A geospatial analysis of factors influencing clinical decision-making of rural and urban dental practitioners in Tiruppur district

INTRODUCTION

The core of dental practice is clinical decision-making. Clinical decision-making has several meanings, but one of the most basic is the process of deciding between multiple treatment possibilities or options. These decisions are rarely simple and involve a complex procedure that necessitates the collection and analysis of clinical and other data to draw conclusions.^[1]

Some of the aspects in medicine and dentistry have been studied in the previous works, and they can be divided into “clinical” (or occasionally “technical”) and “non-clinical” factors.^[1] Clinical factors are aspects of a patient’s health that relates to their current state of illness, their history of symptoms in the past, and the likelihood of developing a disease in the future. Non-clinical factors are elements that affect a clinician’s behavior, such as the amount of time, they spend working in a dental office and other individual traits of the doctor and patient.^[2] Research has shown that dentists’ clinical decisions are influenced by non-clinical factors such as provider age, years of experience, and place of first training.^[3] For instance, Grembowski et al. found that young dentists usually employ more aggressive clinical techniques and carry out more needless treatments than their older counterparts.^[4]

Inadequate dental practitioner distribution between urban and rural locations is the other issue that has an impact on or influences clinical decision-making. Furthermore, regions with concentrated providers are thought to be more competitive.^[5] Due to the concentration of dental professionals in urban rather than rural areas, the oral health of the urban population in India has improved more than that of its rural counterparts.^[6] One of the main reasons of disparities in oral health is access to oral health-care providers, with this issue being exacerbated by the uneven geographic distribution of dental professionals.^[7] Geographic information systems (GISs), which have been utilized in dentistry since the 1960s, can be used to locate the distribution of dental clinics.^[8] Prior research has examined the distribution of dental clinics using GIS and how it may affect the availability of dental treatment in a number of nations, including Australia, Brazil,^[9-11] New Zealand,^[12] and Malaysia.^[13]

To this end, no studies were conducted in India regarding the clinical decision-making of a dental practitioners. Hence, this present study was aimed to assess the clinical decision-making of the dental practitioners in rural and urban areas of Tiruppur district, Tamil Nadu through GIS.

MATERIALS AND METHODS

The Institutional Ethical Committee board in Chennai provided ethical approval for the project (IEC No). This cross-sectional study was conducted in June 2022 across diverse regions of rural and urban area dental practitioners in Tiruppur district.

An online survey with ten questions was created to collect information on practice, patient, and provider characteristics. The survey included inquiries about the respondent’s age, sex, number of years of experience, location, and ownership of the practice. A number of hypothetical case scenarios were used to quantify the result, clinical decision-making. The case scenarios presented typical clinical situations, such as deciding to harvest asymptomatic third molars to cure proximal caries rather than offering a prophylactic treatment. Each scenario offered four alternative options. The treatment options included both very aggressive and very conservative methods. The most conservative approach received a “1,” and the most aggressive one received a “4.” The respondent’s score for treatment intensity was, then, calculated by averaging the results from each question. The dental faculty members at the Ragas Dental College and Hospital helped with the case scenario questions’ development by analyzing the literature. In addition, ten dental professionals were asked to pilot test the questions to determine their face validity. The G-Power software version 3.1 study by Ghoneim et al. in 2020 was used to determine the sample size. Thirty people were determined to be the bare minimum sample size with 80% power and = 0.05. A total of 50 registered dental practitioners (25 urban and 25 rural) participated in this cross-sectional survey. Dental clinics in Tiruppur district that were within a 5–10 km radius of both urban and rural areas were chosen using GIS. Following the receipt of informed consent, the participants were given the questionnaire to complete using a Google form forum to gather information about the factors impacting dental practitioners’ clinical decision-making.

RESULTS

[Table 1] denotes the demographic details of study participants.

A total of 50 registered dental professionals participated in this cross-sectional survey, of which 25 (50%) were urban and the remaining 25 (50%) were rural. With a mean experience of 6.98 ± 4.57 years and an average age of 28.4 ± 5 years, all 50 (100%) of the certified dental practitioners were working in clinical practice individually. Of these, 35 (70%) were men and 15, (30%) were women. [Table 2] denotes the clinical decision-making among dental practitioners in rural and urban areas.

More than half of the study participants 26 (14 [56%] urban and 12 [48%]) rural practitioners chose the most conservative treatment approach of coronoplasty for asymptomatic impacted mandibular 3^rd molar. Similarly, most of the dental practitioners 30 (17 [68%] urban and 13 [52%]) rural practitioners preferred the conservative treatment plan of removal of caries followed by GIC restoration for class I dental caries in a 7-year-old child. In both these clinical scenarios, there is no statistical difference in treatment choice of urban and rural practitioners. For the case scenario relation to class I malocclusion with spacing, 16 (64%) of urban dental practitioners preferred aligner-based treatment rather than fixed orthodontic appliance. This treatment choice differs statistically between urban and rural practitioners. Furthermore, all the 50 (100%) participants (25 urban and 25 rural dental practitioners) selected the conservative approach of class I GIC or composite restoration for class I dental caries management in a 19-year-old patient.

DISCUSSION

The present study discovered an association between many non-clinical features and clinical decision-making in a representative sample of dental practitioners in the Tiruppur area. Clinical decision-making is a complex process that is impacted by both clinical and non-clinical factors. The findings are supported by previous research. Studies by Traebert et al. and Zadik and Levin found that older dentists chose more conservative treatments.^[3,14]

Dental professionals may now be competent to assess clinical cases more accurately due to their increased competence from recent years of practice. Others believe that senior dentists are less swayed by financial incentives and more inclined toward ethics when recommending treatments.^[15]

Holden et al. 2020 state that dentistry is referred to as a profession, with the professional’s “profession” being to protect and advance the “public good.” Dentists are often viewed as either business people or members of the health-care profession, which has led to some controversy. This implies that the interests of the patient are always put ahead of those of the dentist.^[16] However, some claim that because dentistry is a health profession, its values and conventions frequently conflict with those of its other culture, which is business, which prioritizes profit and high income. This can occur when dentists prioritize patients who desire pricey procedures (veneers) above those who require simpler procedures (basic restorations) to increase revenue. This may aid in explaining the differences in clinical decision-making between those who identify as predominantly business people and those who identify as health-care professionals.^[17] In contrast to the previous study by Ghoneim et al., which found that most dental practitioners in urban areas prefer to use aggressive treatment methods over conservative ones,^[1] the majority of dental professionals in our present study chose conservative methods over aggressive ones for the majority of clinical scenarios. However, most metropolitan dental professionals recommended aligner-based treatment rather than a fixed orthodontic device for the management of class I malocclusion with spacing, crediting the association between location and clinical decision-making. One possible explanation for the aforesaid scenario is that dentists practicing in cities may prefer the aligner due to the socioeconomic status and affordability of their patients in cities rather than rural locations.

The majority of dentists may have a propensity to intervene more forcefully when in doubt, because they worry that patients won’t have access to proper follow-up in the future, according to previously published literature by Ghoneim et al. This can be very important when opting to remove an asymptomatic third molar rather than taking a “watch and see” approach or when choosing to treat an early carious lesion rather than waiting to treat it if it progresses to the dentin.^[5]

Clinical decision-making by dental practitioners has previously been studied. Radiographic images appear to be the most commonly used tool for determining the depth of a carious lesion, where a dentist would perform restorative treatment.^[18] Another technique involves the “ethical” calibration of offered treatment choices to a hypothetical setting^[19,20] and contrasting discrepancies between procedures suggested and performed by dentists under various payment regimes.^[21]

CONCLUSION

This study shows an association between non-clinical characteristics and the self-reported treatment choices of dental professionals. This is the first study to investigate the factors influencing dental practitioners’ clinical decision-making in the Tiruppur district. Furthermore, it serves as a foundation for future studies that will employ a novel measurement approach to study characteristics that are believed to impact dentists’ clinical decisions.