A Questionnaire-Based Survey Investigating the Interest in ... · A Questionnaire-Based Survey Investigating the Interest in Periodontology and Preferences for the Treatment of Localized

BAOJ Dentistry

Besas P,et al. BAOJ Dentistry 2018, 4: 3

4: 046

BAOJ Dentistry, an open access journal Volume 4; Issue 3; 045

Research

A Questionnaire-Based Survey Investigating the Interest in

Periodontology and Preferences for the Treatment of Localized

Gingival Recession by Dentists in the UK: A Pilot Study

Besas P1, Chatzopoulou D1, Islam S2 and Gillam DG1

1Institute of Dentistry Barts and the London School of Medicine and Dentistry QMUL, London EA1 2AD, United Kingdom2 BSMMU Shahabag Avenue Dhaka, Bangladesh

*Corresponding Author: David Gillam, Oral Bio Engineering Institute of

Dentistry Barts and the London School of Medicine and Dentistry QMUL,

London EA1 2AD, United Kingdom, E-mail: [email protected]

Sub Date: September 10th, 2018, Acc Date: September 19th, 2018, Pub

Date: September 19th, 2018

Citation: Besas P, Chatzopoulou D, Islam S, Gillam DG (2018) A

Questionnaire-Based Survey Investigating the Interest in Periodontology

and Preferences for the Treatment of Localized Gingival Recession by

Dentists in the UK: A Pilot Study. BAOJ Dentistry 4: 046.

Copyright: © 2018 Gillam DG . This is an open access article distributed

under the terms of the Creative Commons Attribution License, which

permits unrestricted use, distribution, and reproduction in any

medium, provided the original author and source are credited.

Abstract

Aim

The aim of the present study was to evaluate, using a questionnaire, the interest and preferences of UK Dentists in 1) identifying the pres-ence of lesions associated with periodontal defects in general and gin-gival recession more specifically and 2) to compare the results with respective findings from a previous questionnaire study performed by Zaher et al. (2005).

Methods

Questionnaires were posted to 620 dentists from three regions of the United Kingdom, namely England, Northern Ireland and Scotland. The questionnaire consisted of 17 questions, which assessed the pro-fessional status of the dentists; knowledge and interest in Periodon-tology as well as competence and confidence in assessing and treating periodontal and recession defects.

Results

220 questionnaires were returned indicating a response rate of 35.5%. The mean age of the respondents was 40 years (SD 10.6). Most of the participants were in General Dental Practice (73.6%; n=162) with ‘Periodontics’ (5.5%; n=12) and ‘Prosthodontics’ (5%; n=11) as rec-ognised specialities. Interest and satisfaction in periodontics appeared to be moderate in nature compared to specialist periodontists. Trau-matic tooth brushing was the most popular reported cause of gingival recession (87.4%) whereas aesthetics proved to be the most significant indication for planning treatment for recession defects (81.9%) fol-lowed by Dentine Hypersensitivity (78%). CTG, FTG and CAF pro-cedures had similar percentages of treatment preference in all three

clinical cases although as the clinical cases became more severe in na-ture more dentists choose CTG and FTG than CAF procedures.

Conclusion

Dentists need to be more informed about recent innovations in tech-niques using up-to-dated regenerative materials which can be highly efficient in restoring aesthetics in both recession and periodontal de-fects. The results of the study also validated the questionnaire used in the Zaher et al. study.

Introduction

Traditionally, the aim of medical and dental treatment has been the repair or reconstitution of lost or damaged tissues targeting to a resto-ration of function. Recent advances in medical research however have shifted this paradigm to a direction of providing treatments which apart from restoring function would provide satisfactory aesthetic results. According to Reddy [1] the treatment of periodontal con-


Page 2 of 12Citation: Besas P, Chatzopoulou D, Islam S, Gillam DG (2018) A Questionnaire-Based Survey Investigating the Interest in Periodontology and

Preferences for the Treatment of Localized Gingival Recession by Dentists in the UK: A Pilot Study. BAOJ Dentistry 4: 046.

ditions cannot be excluded from this concept since there have been considerable advances in regenerative materials and techniques over the last two-three decades. The high correlation of teeth and smile ap-pearance to the facial aesthetics anticipated by patients [1] is therefore the main factor determining the application of these materials in peri-odontal defects with these up-to-date surgical techniques. Currently, the patient’s cosmetic expectations have risen to such a level that they constitute a major factor for the dentist when considering planning treatment for patients in which restoration function could lead to out-weighing the aesthetic harmony.

Gingival recession (GR) is one of the two components - consequences of periodontal disease progression; the other one is pocket formation. According to epidemiological studies, exposure of root surface due to apical migration of gingival epithelium may result, as consequence of 1) either aggressive oral hygiene habits [2-4], 2) or progression/ treatment of the disease process to the supporting attachment of the teeth [3, 5-7] Although this condition can progress over time appar-ently unnoticed and symptomless, it at some juncture subsequently may alert the patient, which in turn may cause aesthetic distress, pain and fear of tooth loss [8]. Factors contributing to self-awareness of the condition may be; for example a high lip line combined with / without the development of interproximal tissue recession [1] which may appear as “black triangles” [9], diet acidic factors which may lead to increased severity of pain symptoms [10] and individual patient mentality with regards to oral and general health issues and their in-terrelation with quality of life [11].

Since the patient’s aesthetic values may change over time resulting in an increased cosmetic expectation, dentists need to update and develop their knowledge base and skills in order to respond to those perceived needs. An important aspect of this process is the dentist being able, as a professional health care provider, to recognize conditions where treatment could lead to increased functional and aesthetic satisfaction and if necessary refer patients accordingly to a specialist. Although there is a considerable amount of evidence on the development of ma-terials and procedures with regards to treatment of GR, the interest of research has not been adequately directed into dentists’ opinions and perspectives regarding the various treatment options [12]. Further-more, it was evident from this study that aesthetics was the most pre-dominant indication for treating localized gingival recession defects. More recently a study by Rotundo et al. [13] which explored the aes-thetic perception of a simulated root coverage procedure in patients, dentists and periodontists indicated that complete root coverage was perceived as the most successful outcome by all the participants. Con-sequently, it would be of considerable interest to investigate the level of interest and competence in diagnosing and treating recession defects by dentists in general dental practice.

Aim

The aim of the present study was to evaluate, using a questionnaire, the interest and preferences of UK dentists in 1) identifying the pres-ence of lesions associated with periodontal defects in general and gin-gival recession more specifically and 2) to compare the results with respective findings from a previous questionnaire study performed by Zaher et al. [12].The current study design was assessed by the Re-search Ethics Committee Queen Mary University London (QMREC 0353). It was concluded that it does not present any ethical concerns and it was characterized as “extremely low risk” and therefore would not warrant a full ethics board evaluation.

Materials and Methods

Study Design

A structured questionnaire based on Zaher et al. [12] was used for our study. The original questionnaire template was provided by Professor Mombelli (University of Geneva, Switzerland) and translated into En-glish from the original German (DGG).

The questionnaire consisted of 17 questions and for most of those questions multiple answers were also applicable. Questions 1-5 at-tempted to clarify the professional status of the participant by iden-tifying the age, the amount of years since graduation, the geographic area of clinical practice (England/Wales versus Scotland/Northern Ireland), the specific “areas” of clinical interest (oral surgery, cosmetic dentistry, implantology, endodontics, crown and bridge, periodon-tology, prosthodontics or other) and possible existence of specialisa-tion in dentistry (working in general dental practice, periodontology, crown and bridge, specialist in prosthodontics, specialist in maxillo-facial surgery or other). The number of journal subscriptions by the dentist was also noted.

Three questions (Q.6-8) addressed the interest and satisfaction in periodontics: reading of Periodontology journals (yes/no), interest in periodontics on a numerical scale from 1 (no interest) to 10 (high interest), and satisfaction in periodontics, again on a numerical scale from 1 (no satisfaction) to 10 (high satisfaction).

Questions 9-11 asked the dentists about their knowledge in the classi-fication and aetiology of gingival recession as well as about the general indications of procedures for root coverage (dentine hypersensitivity, aesthetics, prevention of further progression of a gingival recession defect, occlusal stability, and preservation of tooth vitality or other).

Questions 12-14 presented photographs of three clinical recession cases with buccal gingival recession at different stages and offered a




choice of the following procedures: 1) No treatment, 2) Change of toothbrush, 3) Change in tooth brushing technique, 4) Occlusal ad-justment, 6) Nightguard, 7) Referral to a specialist, 8) Coronally Ad-vanced Flap [CAF], 9) Full Thickness Graft [FTG], 10) Connective Tissue Graft [CTG], 11) Guided Tissue Regeneration [GTR] with a resorbable barrier membrane, 12) GTR with a non-resorbable barri-er membrane, 13) Application of tissue stimulating agents, 14) Other procedures, with space to specify. Multiple answers were possible.

A final set of questions (Q.15-17) presented three periapical radio-graphs from patients with severe periodontal disease and the den-tists were asked to indicate their treatment choices. The first case presented with an advanced localized periodontal lesion on a vital mandibular incisor and the following treatments were offered (Q.15): 1) Extraction and replacement with a bridge, 2) Extraction and re-placement with an implant, 3) Root canal treatment, 4) Root planing 5) Local antibiotic therapy, 6) Flap surgery, 7) Bone graft, 8), Other procedures. The second and the third cases (Q.16-17) presented ra-diographs from patients with advanced periodontal disease, involving non-vital multi-rooted teeth, with furcation involvements, endodon-tic and restorative complications. The dentists were simply asked if they considered periodontal treatment to be a reasonable treatment option or not (yes, no, not sure; Q16-17).

Questionnaire (Pilot Study)

A pilot study was initiated within the Barts and London School of Medicine & Dentistry in London, with approximately 100 question-naires distributed to members of staff and postgraduate dental stu-dents within the Dental Hospital and the Institution. The pilot study lasted for two months during January and February 2011. Following its completion the responses were checked to determine whether there was a need to correct any of questions to be included in the main study. As there appeared to be no major issues with these initial responses it was decided to proceed with the main part of the study.

The aim of the present study was to equally distribute a total number of approximately 1000 questionnaires across 4 distinct areas within in the UK, namely, Northern Ireland, Scotland, England and Wales; 250 to each area. Initially it was agreed with the help from a Dental Company (Straumann UK) that 250 questionnaires would be distrib-uted to Scotland and Northern Ireland (500 in total) respectively from the Dental Institute in London, and the remaining 500 questionnaires would be sent by the Sponsor Company to Dentists in England and Wales.

The selection of the practices for the present study was based on available lists of Dentists from NHS Boards and the GDC Register, subsequently a list of 362 and 624 practices in Northern Ireland and Scotland respectively was prepared to enable a final list of practice

addresses. These addresses were subsequently randomised using a randomised number generator (RNG)(Graph Pad Software Inc. 2002-2005) and the questionnaires were sent out to the selected Den-tal practices by Royal Mail during the months of April to June 2011. Each envelope contained an information sheet, the questionnaire and a stamp address envelope for Dentists to return to the dental Institute. Additionally, twenty questionnaires were sent to seven practices in England which were selected on a non-randomised basis.

Statistical Analysis

Data management and analysis was performed using both Microsoft Excel 2007® and SPSS® version 18.0 software. Data obtained from the returned questionnaires were entered and processed using SPSS® ver-sion 18.0 (IBM Portsmouth, UK) software. Frequency distributions and cross tabulation tables were constructed and graphs for this data were plotted using Excel software.

Statistical analysis performed on data from the returned question-naires included both parametric and non-parametric tests and the sig-nificance level was set up at α= 0.05 (95%). Parametric tests were used if the data followed normal distribution demonstrated by a Kolmogor-ov-Smirnov test as well as quantile-quantile plots. For categorical data non-parametric tests were used. Data analysis from the present study was also compared, where possible, to data from the original Zaher et al. study [12]. To describe the data we calculated medians, interquar-tile (IQR) and full ranges (min–max) for continuous measures and proportions for binary data.

Results

The total number of questionnaires that were distributed totalled 620 and these were sent out during the period January to June 2011. 220 questionnaires were returned and included for analysis indicating a response rate of 35.5%.

As the data differed significantly from a normal distribution as as-sessed using the Kolmogorov–Smirnov test and normal quantile–quantile plots, non-para-metric tests were used for formal testing of differences between subgroups (Mann–Whitney U-test and Kruskal Wallis test) or for correlations (Spearman rank correlation coeffi-cient). It was also decided that prior to data analysis, variables such as ‘interest’ and ‘satisfaction’ would be categorised into four descriptor bands for example, scale 1-3 was named as “low”, 4-6 as “moderate”, 7-9 as “high” and 10 as “very high” interest and satisfaction. Data des-ignated as missing was coded as “missing values” and as such was not included in the final analysis. The mean age of the participants was 40 years old (SD 10.6). Most of the participants were in General Dental Practice (73.6%; n=162)




with ‘Periodontics’ (5.5%; n=12) and ‘Prosthodontics’ (5%; n=11) as recognised specialities. 15.9% (n=35) were classified as ‘other’ (Ta-ble 1). 56.1% (n=115) of the respondents indicated that ‘crown and bridge’ was a favourite preference of the suggested clinical activities (Q.2). ‘Aesthetic Dentistry’ (43.1%; n=87) and ‘Endodontics’ (34.2%; n=69) were also favourite clinical activities, however only 17.3% (n=35) indicated that ’Periodontics’ was a preferred clinical activity (Table 1). Subscriptions to Dental Journals were relatively low (Table

1) with 19.9% (n=42) of participants indicating that they had read a periodontal journal. Overall both ‘Interest’ and ‘Satisfaction’ in peri-odontics was lower in the General Dentists group compared to the ‘Specialist Periodontists’ group (Table 2) (Q.5-8). When asked which classification system is used to classify gingival recession (Q.9) most of the participants (65.5%; n=135) indicated that they could not remem-ber or had forgotten. 29.6% (n=61) of the respondents indicated that the Miller classification was the classification system in current use.













In response to Q.10 (common causes for the occurrence of gingival recession) 87.4% (n=160) indicated that a traumatic tooth brushing technique was the most common cause for the occurrence of gingival recession. Other causes included tooth malposition (62.8% [n=115]), plaque accumulation (61.2% [n=112]), filling overhang/ill-fitting crowns (54.1% [n=99]), occlusal trauma (45.9% [n=84]) and en-do-perio lesions (22.4% [n=41]). 9.8% (n=18) of respondents provid-ed “other causes” as an option, such as frenal attachment, dehiscences, genetics, pregnancy and smoking. 81.9% (n=149) of the respondents considered aesthetics as the major indication for treatment of gingival recession (Q.11), followed by 78% (n=142) for dentine hypersensitiv-ity, 69.8% (n=127) for prevention of further recession, 16.6% (n=30) for preservation of pulp vitality and 15.9% (n=29) for occlusal stabi-lization.

Q.12-14 required the participants to provide various treatment op-tions to three clinical cases (Q.12-14) as indicated in Tables 3 & 4, based on 1) responses from all dentists and 2) dentists grouped per country.

Responses to Q.15 (a clinical case with an advanced localized peri-odontal lesion on a vital mandibular incisor) indicated that 59% (n=108) of the participants suggested ‘extracting the tooth and re-placement with a bridge’. Other popular responses were ‘extraction and replacement with implant’ (47.5% [n=87]), ‘bone grafting’ (37.2% [n=68]), ‘root planing’ (34.4% [n=63]). Less popular responses in-cluded ‘flap surgery’ (22.4% [n=41]), ‘local antibiotic therapy ‘(19.7% [n=36]) and ‘root canal treatment’ (3.8% [n=7]). Other treatment op-tions suggested by the participants 13.7% (n=25) were categorised as ‘splint/occlusal adjustment’ and/or ‘bite guard’ (n=8), ‘extraction and denture (n=3) dentists and ‘splinting to adjacent teeth’ (n=1).

Participant responses (%) to Q.16 (a clinical case with various treat-ment options for advanced periodontal disease, involving non-vital multi-rooted teeth [mandibular molars], with furcation involvements, endodontic and restorative complications) indicated that only 28.8% (n=53) of the participants considered periodontal treatment as a rea-sonable treatment option for at least one mandibular molar whereas “no” treatment was suggested by 52.2% (n=96) of dentists as their pre-ferred answer and 19% (n=35) of participants were ‘not sure.’

Discussion

The original intention of the present study was to equally distribute a total number of approximately 1000 questionnaires across 4 distinct areas in the UK: Northern Ireland, Scotland, England and Wales; 250 to each area. However, due to operative difficulties the questionnaires to England and Wales were not distributed in time by the Company who originally agreed to send them out to dental practitioners and subsequently were not accounted for in the present study.

As a result of this unforeseen change it was agreed to include the 100 questionnaires distributed to participants within the Dental Institute together with the additional, twenty questionnaires that were sent to dental practices in England. The total number of questionnaires distributed totalled 620 and these were sent out during the period January to June 2011). The small sample size (n=220) used for sta-tistical analysis in the present study however may have limited the potential for comparing the results with those of Zaher et al. [12] in a more meaningful manner. Additionally, the present study being a pilot study may not necessarily be a representative sample of dentists practising in the UK. An interesting observation from the present study was that the non-randomised England (including Wales) group had a considerably higher response rate (50.4%; n=111) than the ran-domised Northern Ireland (28.6%; n=46) and Scotland (20.9%, n=63) groups even though 130 less questionnaires were distributed to this group than to Northern Ireland and Scotland separately. The presence of a non-randomised group of respondents subsequently denoted as “England”, however may have limited to some extent the validity of the results and introduced a degree of bias into the study. Subjects within this group were from the Dental Hospital/Institution conducting the study and from seven selected practices in England known to one of the Investigators (PB).

Most of the participants of this group were originally part of a pilot study prior to mailing out the questionnaires for the main study, the results from this initial study were analysed and subsequently includ-ed in the final analysis. Notwithstanding this issue the addition of this group together with the subsequent responses from Scotland and Northern Ireland increased the overall percentage response rate, to levels comparable to Zaher et al. [12], namely 35.5% (220/620) com-pared to 31.7% (1201/3780). The response rate from the present study was, however, lower than rates reported by previous questionnaire studies; 91.2% by Clayton et al. [14], 73% by Choudhury et al. [15], 69% by Ireland et al. [16] 64.6% by Schuurs et al.[17], 61% by Ghiabi & Weerasinghe[18], 60.17% by Gillam et al. [19] and 44.9% by Gillam et al. [20]. However, some of these surveys were not postal surveys [14, 19] and reminders were also sent out by most of the postal sur-veys [15-18] contrary to the present study and Zaher et al. [12] where no further reminders were sent out to the participants. Additionally, there was considerable variation in the topics chosen for these ques-tionnaires surveys.

The aim of both the present study and the Zaher et al. study [12] was to investigate the level of interest in Periodontology by general den-tal practitioners and specialist periodontists by way of a question-naire using specific clinical and radiographic examples. It was also intended that a reference group of specialist periodontists would be used to compare the preferences between the UK general dentists and specialists in periodontology. This choice was justified by the fact that this group naturally and as result of postgraduate qualifications




would demonstrate the highest relevance to up-to-dated knowledge in periodontology Unfortunately, only 12 participants were classified in this status and this made it impossible to compare any differences be-tween the two groups in terms of statistical significance.

Dentists in Switzerland and in the UK as presented by Zaher et al.[12] and in our study respectively appeared to share common percep-tions with regards to recession aetiology and treatment indications. The primary role of traumatic tooth brushing in the development of gingival recession was acknowledged by both studies at similarly high percentages (91.5%-87.4%). Tooth malposition and plaque accumu-lation were also identified as important causative factors in the ini-tiation of gingival recession. Furthermore, incorrect tooth brushing has also been reported to be considered the main causative factor of DH by dentists in questionnaire based postal surveys [17, 20], even though there is inadequate scientific evidence to substantiate the hy-pothesis that tooth brushing (alone without toothpaste) was respon-sible for the initiation of gingival recession [21]. It was evident from the present study that there was a general informal consensus among dental practitioners identifying tooth brushing as the main aggravat-ing factor contributing to the initiation and development of gingival recession. One of the reasons for this misconception may be related to prevalence studies involving populations with good oral hygiene stan-dards with associated localised buccal soft tissue defects and wedge type hard tissue defects [3, 22-24]. The role of highly concentrated abrasives and detergents in toothpaste formulations may however be significant in the initiation of gingival recession [21].

There are several reasons why patients may attend for dental treatment namely dental pain and aesthetics which is supported by the partici-pants’ responses in both the present study and in the Zaher et al. [12] study. Aesthetics however was considered the major indication in the treatment of gingival recession in the two studies with pain from den-tine hypersensitivity and preventive strategies for limiting any further gingival recession as other key indications. It is also apparent from clinical practice that patients’ aesthetic standards have become more demanding and as such there is a desire by both dentists and patients for a more aesthetically pleasing result from any surgical procedure particularly when dealing with defects associated with aesthetically important areas. It is also important for a clinician to acknowledge the patient’s perceptions about his/her own appearance to avoid any pos-sible dissatisfaction with the final treatment. Furthermore, to avoid such disappointment dentists should consider combining different surgical techniques with or without regenerative materials to cover the exposed root surface. One of the problems however when assess-ing the results from these surgical procedures was that most studies assess the percentage coverage of the exposed root surface rather than consider other factors such as marginal tissue contour, texture and co-lour. To resolve this problem, the Root Coverage Esthetic Score was proposed by Cairo et al.[25] to assess the aesthetics achieved following

surgical root coverage procedures.

Although dentine hypersensitivity also appeared to be considered as an important indicator for treatment, the published literature indi-cates that clinicians lack the confidence to treat and manage the condi-tion [26-27]. According to Orchardson & Gillam [27] this may be due to the observation from various studies that dentists do not appear to fully understand the aetiology of the condition or successfully manage dentine hypersensitivity. It is also important to recognise the impor-tance of removing of any pre-disposing factors in preventing further damage of both hard and soft tissues by the patient as part of the man-agement of dentine hypersensitivity rather than simply providing de-sensitising toothpaste for home care or applying desensitizing agents in the dental surgery.

One of dental conditions that was not addressed in the questionnaire was the prevention of root caries following gingival recession defect surgical procedures which in retrospect was an unfortunate omission since useful data regarding its diagnosis and subsequent treatment following gingival recession procedures could have been obtained. A further observation was that most dentists could not remember the classification system to be used when assessing and treating gingival recession with only 29.6% (n=61) of the respondents indicated that the Miller classification [28] was the classification system in current use.

In the present study and the Zaher et al. study [12] both variables ‘in-terest’ and ‘satisfaction’ in practising periodontics appeared moderate for general dentists with a tendency to reach high levels for specialist periodontists (Table 2), although the preference for periodontics as a professional activity was lower than most of the other clinical activi-ties. As expected, interest and satisfaction were higher for periodon-tists than for general dental practitioners and a high correlation was observed between these two subjective variables. When comparing the responses from the three clinical cases it was evident that ‘changing the tooth brushing technique’, ‘no treatment’ and ‘change of toothbrush’ were the three favourite treatment options in the first clinical example in both studies, with ‘changing the tooth brushing technique’ identified as the most important factor. This choice remained significant in the second and third clinical examples although as the clinical examples increased in defect severity more dentists either would 1) recommend surgical procedures, 2) refer the patient to a specialist. A further observation revealed that fewer dentists would advise against treatment as the severity of the clinical problem increased.

Further comparison of the three clinical cases indicated that there was relatively poor general confidence and belief in using GTR procedures for covering gingival recession defects with both gingival graft and




coronally advanced procedures preferred by the dentists in the three clinical examples. Several reviews would tend to support this tenden-cy that CTG was superior to GTR procedures [29-32]. However, the advantages of adding enamel matrix derivatives such as Emdogain (EMD) in CAF procedures [32-33] have not been widely understood by dentists despite the available evidence-based literature which have reported that enamel matrix proteins are safe and effective in stimu-lating new periodontal soft and hard tissue as well as the long-term clinical benefits [33-39]. These observations from the published lit-erature were not reflected in the results obtained from both the pres-ent and Zaher et al. [12] studies. It should however be acknowledged that GTR procedures have been successfully used for the regeneration of periodontal infrabony and furcation defects for the last three de-cades [40-42]. These observations also raise an interesting point as to whether general dentists are exposed to adequate under-graduate and post-graduate education in terms of periodontal surgical concepts, materials and techniques compared to those dentists with a special-ised knowledge of periodontology. This would appear to be supported by the relatively low percentage of respondents reading periodontal journals particularly in the present study, although the frequency of reading journals was unknown. Swiss dentists in the Zaher et al. study [12] however appeared to be slightly more interested in reading spe-cific periodontal journals (36.5%-19.9%) although the exact number of dental journals was not published in the study.

CTG, FTG and CAF had similar percentages of treatment preference in all three clinical cases and it was interesting to note that as the clin-ical cases became more severe in nature more dentists would rather choose CTG and FTG than CAF procedures (Table 3) in agreement with the Zaher et al. study [12]. It is reasonable to speculate that the ‘years after graduation’ may have a major impact on the choice of treatment, however, as with the results from the Zaher et al.[12] study no association was observed between ‘years after graduation’ and opt-ing for either CTG or FTG procedures.

The low number of responses in selecting CAF with/without EMD may reflect the lack of continuing education courses for general den-tists whereas specialists in periodontology would have been aware of the new concepts, materials and techniques as well as the reported successful outcomes of the procedure in the published literature [25]. Although this may have had an impact in the present study it should be recognised that exposure to innovative regenerative products and procedures are initially limited to specialists in periodontology rath-er than dentists in general practice. Nevertheless, it is important for dentists to be aware of these novel products and techniques to enable them to inform their patients of the various treatment options avail-able to them. It is also evident from the dentists’ responses to the three clinical cases that as the periodontal condition depicted in the clinical photographs increased in severity the referral rate for specialist care increased (Table 3). There was a similar trend observed when analys-

ing the responses per region with ‘England & Wales’ presenting the lowest “no treatment” preference percentages for every clinical situa-tion as well as providing the highest referral preference in the second clinical case compared to the other regions (Table 4). Although there may be some merit in suggesting that dentists from the ‘England & Wales’ region indicated a greater awareness of the significance of gin-gival recession defects in causing patient symptoms and conditions it should be noted that there was a risk of bias in that part of the group was not randomised as previously indicated. Furthermore, a high pro-portion of this group consisted of professionals working in a hospital/university environment rather than in general dental practice which would also introduce a risk of bias.The last three questions related to three radiographic images of clinical cases that have been successfully treated and maintained for 14-15 years although for the purposes of the study the participants were not aware of these outcomes. In the first clinical case with an advanced localized periodontal lesion on a vital mandibular incisor (Q.15) most dentists would either extract the tooth and replace it with a bridge or implant than maintain the tooth in situ. The second and third clinical cases involved non-vital mandibular and maxillary teeth (Q.16-17) and it was evident from the responses that the participants did not consider periodontal treatment a viable option. In both clinical cases most dentists would not pro-vide periodontal treatment, and relatively few dentists would consider periodontal treatment as a reasonable treatment option.

Due to the relatively small sample size in the present study it was dif-ficult to make a meaningful comparison with the Zaher et al. study [12]. It was therefore evident from the results that most dentists did not have confidence in the effectiveness of periodontal therapy when treating what appeared to be a complex case despite the evidence from the published literature of the success of both non-surgical and surgi-cal procedures in the management of periodontal disease [43-44].The results from the present study would indicate that there was a higher trend among the dentists to consider extraction as the main option for treating teeth with extensive loss of the tooth supporting appartus (e.g., periodontium). It can be argued therefore that with the appropri-ate post-graduation education (continuing professional development courses) the general dental practitioner could be updated on the cur-rent innovative techniques and materials for periodontal regeneration procedures. This knowledge base would enable dentists to have more confidence in treating apparently ‘hopeless’ teeth with the appropriate periodontal treatment or in severe cases refer to a specialist periodon-tist.

Conclusions

Dentists need to be more informed about recent innovations in tech-niques using up-to-dated regenerative materials which can be highly efficient in restoring aesthetics in both recession and periodontal de-fects. The results of the study also validated the questionnaire used in




the Zaher et al. study.

Acknowledgements

The Authors would like to acknowledge and thank Professor Andrea Mombelli (School of Dental Medicine, University of Geneva, Switzer-land) who provided the original questionnaire template from the Za-her et al. study [12] which was used in the present study.

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