Abstract
Background:
The clinical field of periodontology encompasses the prevention, diagnosis, treatment, and long-term maintenance of periodontal diseases. The aim of this study is to explore the perceptions and practices of Greek dentists regarding all aspects of periodontology in their daily clinical practice.
Materials and Methods:
In this cross-sectional, mixed-method survey, an online questionnaire was emailed through the regional dental associations to all active dentists in Greece. The questionnaire addressed demographic characteristics, as well as perspectives and practices related to periodontal diagnosis, treatment, maintenance, and the need for collaboration with periodontists.
Results:
Overall, 522 dentists (50.6% females) participated. Among the 406 general dentists (GD), 81.7% (332) feel quite or very comfortable in diagnosing periodontal diseases; 73.6% (299) perform only steps 1, 2 and 4 of periodontal therapy, while 9.9% (40) also perform step 3 (surgical interventions); 63.1% (253) have an organized recall system; 92.8% (376) give oral hygiene instructions to all patients; 42.6% (173) identify indications for soft and hard tissue grafts; and 75.7% (306) refer patients to a periodontist. The open-ended question regarding the reasons for such a referral revealed the following issues: disease severity, medical history complexity, and small financial incentive.
Conclusions:
GD in Greece are confident in diagnosing periodontal diseases and predominantly provide nonsurgical therapy. Further training is necessary to increase awareness regarding the current classification system for periodontal diseases and the indications for periodontal grafting. Finally, dentists should be encouraged to record periodontal parameters and motivate patients to comply with recall visits.
Keywords: Dentists, Greece, periodontal disease, questionnaire, survey
INTRODUCTION
Gingivitis is a chronic, inflammatory disease of the gingiva, initiated mainly by the accumulation of a microbial biofilm in the gingival crevice. If left untreated, it may progress to periodontitis (PD), which is characterized by clinical attachment loss (CAL).[1] Dependent on the extent of bone destruction, the result may be increased tooth mobility and eventually tooth loss. PD is one of the main causes of tooth loss in adults worldwide.[2] Epidemiological studies have underscored the significant prevalence of PD, ranking it as the sixth most common disease, affecting people of all ages.[3,4]
PD is both preventable and treatable. Consequently, general dentists (GD), periodontists, and dental hygienists play a central role in minimizing the risk of disease onset and in the reestablishment and maintenance of periodontal health.[5] If preventive measures are not successful, GD should be able to diagnose the presence, extent, and severity of PD, perform an individualized periodontal treatment (PT), and finally follow measures to maintain periodontal health.[6] In addition, based on the severity of the disease, the clinician should be able to decide when to treat the patient or refer to a periodontist.[7]
But what are the perceptions and practices of GD regarding PD? Available research data on the topic are limited. Most surveys conclude that GD feel confident in diagnosing PD.[8,9,10,11,12] For severe cases (PD Stages III and IV) and when periodontal surgery is required, they prefer collaborating with a periodontist. In addition, there is only limited data regarding various practices, such as whether and to what extent they record periodontal clinical data (periodontal chart),[11] whether they use the current classification for PD, whether they have an organized recall system, whether patients comply and whether they are familiar with the indications for gingival and osseous grafting. The European Federation of Periodontology (EFP) has recently published guidelines for the treatment of PD,[13] but to what extent do GD follow them? It is important to reveal possible gaps in knowledge or concerns that practitioners have and to incorporate this information in undergraduate curricula and continuous education initiatives.
The aim of this study was to investigate the perceptions and practices of dentists in Greece regarding the management of PD.
MATERIALS AND METHODS
This is a cross-sectional, nationwide survey that employed mixed methodology. The study population consisted of active dentists enrolled in the dental associations of the different prefectures of Greece. All dental associations across the country were contacted by telephone and email to be informed about the aims of the study and were asked to forward the online questionnaire, via email, to their active members. Dentists were asked to participate voluntarily and anonymously. No incentive was given to increase the participation rate. A reminder email was sent from the dental associations 2 weeks after the first online invitation. The study took place from December 2023 to February 2024.
All dentists, after reading the introductory text outlining the purpose of this study, were asked to consent electronically. They were then granted access to the study’s questionnaire that consisted of six distinct parts, including a total of 30 questions, and one open-ended question. The questionnaire was meticulously developed after a comprehensive review of the relevant literature and agreement among the research team that consisted of experts in the field. The questionnaire [Appendix I] was initially tested on a convenience sample of 10 dentists to confirm comprehensiveness, and feedback was used for refinement.
The first part collected general demographic data, the second information regarding PD diagnosis, the third data on practices related to PT, the fourth information on the maintenance phase, the fifth data on oral hygiene instructions (OHI) and practices, and finally, the sixth part collected more general information related to PD, the awareness of the possible association between PD and systemic diseases, the level of confidence in special aspects of PT, and the interest in following the advances in periodontology. Finally, an open-ended question was used, aiming to explore the reasons for referring patients to periodontists.
The study protocol was approved by the Bioethics Committee of the School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki (protocol number 50/2023/10-11-2023). Following the Declaration of Helsinki and Personal Data Protection Regulation (EUR-Lex– 32016R0679), the study protocol ensured that participants proceeded to the questionnaire completion after giving their online informed consent. No personal data were tabulated or entered into the analytical phase.
The Statistical Package for Social Sciences (SPSS) software, Version 21.0, was used for statistical analysis. Participants were stratified into three groups, i.e. GD, periodontists, and nonperiodontists specialized dentists for a more meaningful interpretation of the data. Participants’ responses are presented in absolute numbers and corresponding percentages within each group. Intragroup comparisons in relation to demographic characteristics and professional profile, such as age groups (24–75), gender, groups according to years of experience (1-51), and practice location, were performed using the Chi-square test. Significance level was set at 0.05 and two-sided.
The qualitative data collected from the open-ended question were subjected to an inductive thematic content analysis to identify recurrent patterns and crucial components, until data saturation was reached. Analysis was performed independently by two researchers (removed for blind review), both health professionals with training and experience in qualitative research. Greek quotations were translated into English (DL-removed for blind review), and the accuracy of the translation of each quotation was checked (ZT-removed for blind review). The quotations were labeled by the serial number of the participants, their gender, and the years of work experience.
RESULTS
Out of the 52 dental associations, 32 (61.5%) forwarded the questionnaire to their active members. A total of 522 dentists participated in the survey, corresponding to a 6.4% response rate, based on the number of enrolled members.
Table 1 contains the demographic characteristics of the participants and their professional profiles. Data regarding the perspectives and practices of dentists on the diagnosis of PD are presented in Table 2. Data regarding the way dentists routinely carry out PT are demonstrated in Table 3. Data regarding the perspective and practices of dentists in respect to periodontal maintenance are presented in Table 4. Data regarding the perspective and practices of dentists with respect to OHI are presented in Table 5. Data regarding the perspective and practices of dentists with respect to general aspects of PD are presented in Table 6.
Table 1.
Demographic characteristics and professional profile of participating dentists
| Demographic characteristics | n (%) |
|---|---|
| Gender | |
| Female | 264 (50.6) |
| Male | 252 (48.3) |
| Prefer not to disclose | 6 (1.1) |
| Specialty training | |
| Yes | 114 (21.9) |
| No | 406 (78.1) |
| Periodontologists | 32 (6.2) |
| Practice location | |
| Urban area | 443 (84.9) |
| Semi-urban area | 54 (10.3) |
| Rural area | 25 (4.8) |
N – Number
Table 2.
Perspective and practices of participating dentists, regarding periodontal diagnosis
| Questions and answers on periodontal diagnosis | GD (n=406; 78.1%), n (%) | P (n=32; 6.2%), n (%) | OS (n=82; 15.8%), n (%) |
|---|---|---|---|
| Do you receive periodontal charts? | |||
| Never | 118/406 (29.1) | 0/32 | 27/82 (33) |
| Yes, selectively in some patients | 263/406 (64.8) | 19/32 (59.4) | 44/82 (53.6) |
| Yes, in all patients | 25/406 (6.2) | 13/32 (40.6) | 11/82 (13.4) |
| The periodontal charts you receive | |||
| Are fully supplemented | 88/288 (30.1) | 9/32 (28.1) | 35/55 (63.6) |
| Are selectively supplemented | 200/288 (69.4) | 23/32 (71.9) | 20/55 (36.4) |
| How confident do you feel in diagnosing and assessing the severity of periodontal diseases? | |||
| Not comfortable at all | 3/406 (0.7) | 0/32 | 0/82 |
| A little | 14/406 (3.4) | 0/32 | 6/82 (7.3) |
| Moderately | 57/406 (14) | 0/32 | 15/82 (18.2) |
| Quite | 234/406 (57.6) | 4/32 (12.5) | 38/82 (46.3) |
| Very | 98/406 (24.1) | 28/32 (87.5) | 23/82 (28.2) |
| Are you aware and do you use the current (2017) classification system for periodontal diseases? | |||
| I am not aware of it | 138/405 (34.1) | 2/32 (6.3) | 21/77 (27.3) |
| I am aware of it, but I do not use it | 197/405 (48.6) | 15/32 (46.9) | 36/77 (46.8) |
| I am aware of it and use it | 70/405 (17.3) | 15/32 (46.9) | 20/77 (25.9) |
| What type of X-rays do you use for periodontal diagnosis? | |||
| Do not use X-rays | 10/406 (2.2) | 0/32 | 2/82 (2.5) |
| Only panoramic X-rays | 185/406 (45.6) | 7/32 (21.9) | 30/82 (36.5) |
| Panoramic and periapical X-rays | 211/406 (52) | 25/32 (78.1) | 50/82 (61) |
GD – General Dentists; P – Periodontists; OS – Other Specialists; n – Number
Table 3.
Perspective and practices of participating dentists, regarding periodontal treatment
| Questions and answers on periodontal treatment | GD (n=406; 78.1%), n (%) | P (n=32; 6.2%), n (%) | OS (n=82; 15.8%), n (%) |
|---|---|---|---|
| Do you perform periodontal treatment? | |||
| No, I do not engage at all | 0/406 | 0/32 | 0/82 |
| No, I refer all cases to a periodontist | 67/406 (16.5) | 0/32 | 29/82 (35.4) |
| Yes, but I perform only nonsurgical periodontal treatment | 299/406 (73.6) | 0/32 | 47/82 (57.3) |
| Execute both nonsurgical and surgical treatments | 40/406 (9.9) | 32/32 (100) | 6/82 (7.3) |
| What means do you use during periodontal treatment? | |||
| Curettes only | 7/396 (1.8) | 0/32 | 3/71 (4.2) |
| Ultrasonic device only | 38/396 (9.6) | 1/32 (3.1) | 5/71 (7) |
| Combination of curettes and ultrasonic device | 351/396 (88.6) | 31/32 (96.9) | 63/71 (88.8) |
| Do you use laser devices during periodontal treatment? | |||
| Yes, I use laser devices | 50/398 (12.6) | 8/32 (25) | 4/72 (5.6) |
| No, I do not use laser devices | 348/398 (87.4) | 24/32 (75) | 68/72 (94.4) |
| What is your philosophy regarding periodontal therapy? | |||
| Extract teeth with questionable or poor prognosis | 58/403 (14.4) | 2/32 (6.3) | 6/78 (7.7) |
| Preserve as many teeth as possible | 345/403 (85.6) | 30/32 (93.8) | 72/78 (92.3) |
| Do you recommend implant placement in patients with periodontitis? | |||
| Yes, I recommend | 82/404 (20.3) | 13/32 (40.6) | 16/80 (20) |
| Yes, I recommend, but with caution | 273/404 (67.6) | 19/32 (59.4) | 55/80 (68.8) |
| No, I do not recommend | 49/404 (12.1) | 0/32 | 9/80 (11.2) |
GD – General dentists; P – Periodontists; OS – Other specialists; n – Number
Table 4.
Perspective and practices of participating dentists, regarding periodontal maintenance (step 4)
| Questions and answers on periodontal maintenance (step 4) | GD (n=406; 78.1%), n (%) | P (n=32; 6.2%), n (%) | OS (n=82; 15.8%), n (%) |
|---|---|---|---|
| Do you have an organized recall system? | |||
| Yes | 253/401 (63.1) | 29/32 (90.6) | 49/82 (59.8) |
| No | 148/401 (36.9) | 3/32 (9.4) | 33/82 (40.2) |
| If so, what is the average frequency of the recall visits? | |||
| Every 3 months | 123/253 (48.7) | 17/29 (58.6) | 24/49 (48.3) |
| Every 6 months | 110/253 (43.4) | 12/29 (41.4) | 23/49 (46.7) |
| Every year | 8/253 (3.1) | 0/29 | 1/49 (2.5) |
| Only in case of recurrence | 12/253 (4.8) | 0/29 | 1/49 (2.5) |
| What is the percentage of patient compliance to the recall visits? | |||
| <25 | 73/330 (22.1) | 2/32 (6.2) | 14/63 (22.2) |
| 25–50 | 113/330 (34.3) | 9/32 (28.1) | 17/63 (27) |
| 50–75 | 117/330 (35.4) | 15/32 (46.9) | 23/63 (36.5) |
| 75–100 | 27/330 (8.2) | 6/32 (18.8) | 9/63 (14.3) |
| Do you receive a periodontal chart on the recall visit? | |||
| Yes | 153/401 (38.2) | 24/32 (75) | 35/82 (42.7) |
| No | 248/401 (61.8) | 8/32 (25) | 47/82 (57.3) |
GD – General dentists; P – Periodontists; OS – Other specialists; n – Number
Table 5.
Perspectives and practices of participating dentists, regarding oral hygiene instructions
| Questions and answers on oral hygiene instructions | GD (n=406; 78.1%), n (%) | P (n=32; 6.2%), n (%) | OS (n=82; 15.8%), n (%) |
|---|---|---|---|
| Do you give oral hygiene instructions? | |||
| Never | 1/406 (0.2) | 0/32 | 0/82 |
| Occasionally | 29/406 (7.1) | 2/32 (6.3) | 10/82 (12.2) |
| Always | 376/406 (92.7) | 30/32 (93.8) | 72/82 (87.8) |
| How do you demonstrate oral hygiene instructions? | |||
| Verbally only | 64/405 (15.8) | 0/32 | 14/82 (17.1) |
| I also demonstrate in the patient’s mouth | 341/405 (84.2) | 32/32 (100) | 68/82 (82.9) |
| What type of toothbrush do you recommend? | |||
| Powered toothbrush | 165/397 (41.6) | 13/32 (40.6) | 30/80 (37.5) |
| Manual toothbrush | 232/397 (58.4) | 19/32 (59.4) | 50/80 (62.5) |
| What toothbrush bristle hardness do you recommend? | |||
| Soft | 165/398 (41.5) | 19/32 (59.4) | 37/82 (45.1) |
| Moderate | 229/398 (57.5) | 13/32 (40.6) | 45/82 (54.9) |
| Hard | 4/398 (1) | 0/32 | 0/82 |
| Do you recommend the use of interdental brushes? | |||
| Yes | 399/406 (98.3) | 31/32 (96.9) | 80/82 (97.6) |
| No | 7/406 (1.7) | 1/32 (3.1) | 2/82 (2.4) |
| Do you recommend daily use of a mouthwash? | |||
| Yes | 137/406 (33.7) | 2/32 (6.3) | 31/82 (37.8) |
| No | 269/406 (66.3) | 30/32 (93.9) | 51/82 (62.2) |
GD – General dentists; P – Periodontists; OS – Other specialists; n – Number
Table 6.
Perspective and practices of participating dentists, regarding general aspects of periodontal disease
| Questions and answers regarding general aspects of periodontal disease | GD (n=406; 78.1%), n (%) | P (n=32; 6.2%), n (%) | OS (n=82; 15.8%), n (%) |
|---|---|---|---|
| Are you aware of the association between periodontal disease and systemic diseases? | |||
| Yes | 383/406 (94.3) | 32/32 (100) | 81/82 (99.1) |
| I do not know | 0/406 | 0/32 | 0/82 |
| No | 23/406 (5.7) | 0/32 | 1/82 (0.9) |
| Are you able to identify indications for gingival and bone grafts? | |||
| Yes | 173/406 (42.6) | 32/32 (100) | 40/82 (48.8) |
| I am not always sure | 186/406 (45.8) | 0/32 | 31/82 (37.8) |
| No | 47/406 (11.6) | 0/32 | 11/82 (13.4) |
| Do you attend continuous education courses on periodontology? | |||
| Yes | 120/406 (29.6) | 28/32 (87.5) | 26/82 (31.7) |
| No | 57/406 (13.9) | 0/32 | 18/82 (22) |
| I would like more | 229/406 (56.5) | 4/32 (12.5) | 38/82 (46.3) |
| Do you collaborate with a periodontist? | |||
| Yes | 306/406 (75.7) | 0/32 | 79/82 (96.3) |
| No | 100/406 (24.3) | 32/32 (100) | 3/82 (3.7) |
GD – General dentists; P – Periodontists; OS – Other specialists; n – Number
Intragroup comparisons with the Chi-square test in relation to demographic characteristics and professional profile, such as age groups, gender, groups according to years of experience, and practice location, did not reveal significant correlations of these parameters with any of the specific perspectives or practices toward PD.
The last question of the questionnaire was an open-ended question where dentists had the opportunity to elaborate on the reasons why they do not perform part or the entire PT themselves and prefer to refer their patients to a periodontist. The thematic content analysis revealed the following three main issues summarizing the viewpoints of GD:
Periodontists are more effective in treating severe cases
It was very common for GD to refer to periodontists patients with severe PD (Stages III and IV) because their perception is that these cases will have a better outcome if treated by a specialist. Moreover, GD feel that they are not adequately trained and lack specialized equipment to perform periodontal surgical procedures, so they refer patients to periodontists.
Complex medical history
Patients with a complex medical history are often referred to a specialist, since GD do not feel comfortable in managing these patients and the complications that may arise during or following PT.
Treatment is time and cost-ineffective
Many GD believe that PT is time-consuming, with unpredictable results, and underpaid, so they would rather refer their patients to a periodontist.
DISCUSSION
This cross-sectional, mixed-method, nationwide survey was designed to shed light on the perceptions and practices of dentists in Greece regarding the management of patients with PD. The two genders were equally represented in the study, and this is in accordance with the Greek dental population.[14] In addition, there was a relative balance among dentists with different levels of experience. The vast majority of the responders practice dentistry in urban areas, which again represents reality in Greece.
Information on periodontal chart collection is shown in Table 2. Most GD and periodontists record part of the data included in a periodontal chart. This is consistent with an Australian study reporting that a high proportion of GD did not perform full mouth probing.[11] Incomplete data collection results in an underestimation of disease severity, and therefore, early stages of PD may pass “under the radar” and get detected only after more severe disease has been established.[15] Information on the use of panoramic and periapical X-rays is also displayed in Table 2. Although panoramic X-rays are efficient in detecting marginal bone loss, periapical X-rays are more successful in detecting periodontal osseous destruction and more accurate in assessing it.[16,17] Despite the lack of full mouth charting and the use of only panoramic X-rays by a significant proportion of dentists, eight out of ten GD feel quite or very comfortable in diagnosing the severity of PD. This is in agreement with the results from 3 studies performed in Australia,[11] Scotland,[10] and Australia/Tasmania.[8] However, even though 65.9% of GD are aware of the current classification system for PD, only 17.3% use it. Interestingly, 46.9% of periodontists use this classification. Data regarding the acceptance of the current classification among GD and periodontists are scarce. A study by Hegab et al. 2020 showed that only 24.2% of Egyptian periodontists apply the new classification.[18] In a more recent study by Malmqvis et al. 2024, although 70% of Swedish dental hygienists use this classification, 33% considered their knowledge of the new system to be poor or non-existent, while many feel that it presents difficulties.[19]
Regarding PT, 73.6% of GD perform only nonsurgical PT, while 9.9% execute periodontal surgical procedures as well. Similar results derive from a study in India, where 70% of GD felt more confident in performing nonsurgical PT.[12] In addition, a study from Australia and Tasmania reports that GD were not confident in performing surgical procedures, and 94% stated that they had never performed a regenerative procedure.[8] Regarding mechanical debridement, around 88% of GD prefer the combination of hand instruments (curettes) and ultrasonic devices and do not use laser devices supplementary. This is in accordance with the guidelines for the treatment of PD Stage I–III by the European Federation of Periodontology (EFP).[13]
Data on perspectives and practices regarding PT are shown in Table 3. Dentists in Greece are aware that PT may increase the survivability of periodontally compromised teeth, and that implant placement in untreated patients or patients with a history of PD may increase the risk for implant complications.[20] Similarly, Lanning et al. found that 84% of GD did not place or suggest implant placement in PD patients.[21]
Table 4 contains data on periodontal maintenance (Step 4). The percentage of periodontists maintaining an organized recall system is higher (90.6%) than that of GD, as is patient compliance. Periodontal maintenance is fundamental for the long-term preservation of restored periodontal health.[22] Although the ideal time between recall appointments is not something set[22,23,24] and should be patient-dependent, the reported time between recall visits in our study agrees with the EFP recommendations.[13] The relatively low (8.2%) rate of patient compliance in the group of GD could be attributed to patients’ financial issues or lack of available time by the dentists, since in Greece, dental hygienists are not widely available. ?he study by Agrawal et al., including 1,000 GD, reported that half of them had 3-month recall visits; however, patient compliance was a major problem.[25] In addition, in the study by Fenol and Mathew, 34.6% of the patients reported that they were not sufficiently motivated and informed by their dentist about the recall visits.[26] Table 5 contains data regarding OHI. Interestingly, only 6.3% of periodontists recommend the use of a daily mouth rinse, which corroborates with the notion that mechanical plaque removal is the most effective method of biofilm control.[27] In any case, all recommended oral hygiene measures fall within the EFP guidelines.[13]
Our study demonstrates that the majority of GD (94.3%) are aware of the association between PD and systemic diseases and presumably use this knowledge in their clinical practice. Moreover, only 42.6% of GD reported confidence in identifying indications for gingival or osseous grafting procedures. Therefore, specific types of gingival recessions or osseous defects that could benefit from grafting procedures may remain untreated. This underlines that dentists are not sufficiently educated on this topic; diagnosing a recession is one thing but recognizing which one is treatable requires additional training.
Finally, three-quarters of GD in Greece collaborate with a periodontist. The open-ended question reveals that GD refer to periodontists’ more severe periodontal cases that require surgical intervention since they believe that periodontists are better trained and have specialized equipment. Moreover, GD feel insecure about managing patients with complex medical histories that could affect PT. Another reason for referral to a periodontist is the belief that PT is often time-consuming with unpredictable results and is not always appreciated by the patient since the outcome is not always obvious to them. In addition, the need for a strict recall system and the possibility of recurrence facilitate the decision toward a referral. Several studies in other countries also confirm the close collaboration between GD and periodontists.[12,28] The low level of comfort in treating advanced PD cases and the lack of training to perform surgical procedures are shown to be the most common reasons for a referral to a periodontist.
The questionnaire was intended to be distributed to all 13,904 dentists in Greece through local dental associations. However, only 32 out of the 52 associations forwarded the questionnaire to their active members. Out of the 8,120 dentists that received the questionnaire, 522 responded, representing 3.8% of Greek dentists (6.4% response rate), which is adequate, since data estimates remain reliable even with a 5%–10% response rate in a sample larger than 500.[29]
Another limitation of the present study is that data derived from self-reports rather than observed. Therefore, a “social desirability bias” may be present.[30] Since this is the first survey of its kind in Greece, the goal was to address the main aspects of the topic, and in the future, design a more in-depth questionnaire based on the current findings.
CONCLUSION
This study provides clear trends of the perceptions and practices of Greek dentists in the management of PD. In general, dentists are confident in diagnosing PD. In addition, they collaborate with periodontists in more severe periodontal cases and when periodontal surgery is required. Most practices regarding PD fall within the EFP guidelines, while others need improvement to enhance the effectiveness of PT in everyday clinical practice. The main topics that need to be further addressed include:
Encouragement to perform complete periodontal charting
Familiarization with the current PD classification
Motivation to enhance patients’ compliance with recall visits
Further training to increase awareness regarding indications for gingival and osseous grafts.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 world workshop on the classification of periodontal and peri-implant diseases and conditions. J Clin Periodontol. 2018;45(Suppl 20):S162–70. doi: 10.1111/jcpe.12946. [DOI] [PubMed] [Google Scholar]
- 2.Benjamin RM. Oral health: The silent epidemic. Public Health Rep. 2010;125:158–9. doi: 10.1177/003335491012500202. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Jin LJ, Lamster IB, Greenspan JS, Pitts NB, Scully C, Warnakulasuriya S. Global burden of oral diseases: Emerging concepts, management and interplay with systemic health. Oral Dis. 2016;22:609–19. doi: 10.1111/odi.12428. [DOI] [PubMed] [Google Scholar]
- 4.Jepsen S, Blanco J, Buchalla W, Carvalho JC, Dietrich T, Dörfer C, et al. Prevention and control of dental caries and periodontal diseases at individual and population level:consensus report of group 3 of joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017;44(Suppl 18):S85–93. doi: 10.1111/jcpe.12687. [DOI] [PubMed] [Google Scholar]
- 5.Kornman KS, Giannobile WV, Duff GW. Quo vadis: What is the future of periodontics?How will we get there? Periodontol 2000. 2017;75:353–71. doi: 10.1111/prd.12217. [DOI] [PubMed] [Google Scholar]
- 6.Plessas A. Nonsurgical periodontal treatment: Review of the evidence. Oral Health Dent Manag. 2014;13:71–80. [PubMed] [Google Scholar]
- 7.Lee JH, Bennett DE, Richards PS, Inglehart MR. Periodontal referral patterns of general dentists: Lessons for dental education. J Dent Educ. 2009;73:199–210. [PubMed] [Google Scholar]
- 8.Kraatz J, Hoang H, Ivanovski S, Ware RS, Crocombe LA. Periodontal diagnosis, treatment, and referral patterns of general dental practitioners. J Investig Clin Dent. 2019;10:e12411. doi: 10.1111/jicd.12411. [DOI] [PubMed] [Google Scholar]
- 9.Zemanovich MR, Bogacki RE, Abbott DM, Maynard JG, Jr, Lanning SK. Demographic variables affecting patient referrals from general practice dentists to periodontists. J Periodontol. 2006;77:341–9. doi: 10.1902/jop.2006.050125. [DOI] [PubMed] [Google Scholar]
- 10.Chestnutt IG, Kinane DF. Factors influencing the diagnosis and management of periodontal disease by general dental practitioners. Br Dent J. 1997;183:319–24. doi: 10.1038/sj.bdj.4809486. [DOI] [PubMed] [Google Scholar]
- 11.Darby IB, Angkasa F, Duong C, Ho D, Legudi S, Pham K, et al. Factors influencing the diagnosis and treatment of periodontal disease by dental practitioners in Victoria. Aust Dent J. 2005;50:37–41. doi: 10.1111/j.1834-7819.2005.tb00083.x. [DOI] [PubMed] [Google Scholar]
- 12.Halemani S, Sanikop S, Patil S, Jalli V. Perception regarding factors related to periodontal therapy among general dental practitioners of Belgaum city –A questionnaire survey. Oral Health Prev Dent. 2014;12:183–9. doi: 10.3290/j.ohpd.a31665. [DOI] [PubMed] [Google Scholar]
- 13.Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Beglundh T, et al. EFP workshop participants and methodological consultants. Treatment of stage I-III periodontitis. The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47(Suppl 22):4–60. doi: 10.1111/jcpe.13290. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Survey on Physicians and Dentists. ELSTAT Website. [[Last accessed on 2017 Dec 20]]. Available from: https://www.statistics.gr. Published 2017 .
- 15.Salvi GE, Roccuzzo A, Imber JC, Stähli A, Klinge B, Lang NP. Clinical periodontal diagnosis. Periodontol 2000. 2023;00:1–19. doi: 10.1111/prd.12487. [DOI] [PubMed] [Google Scholar]
- 16.Pepelassi EA, Diamanti-Kipioti A. Selection of the most accurate method of conventional radiography for the assessment of periodontal osseous destruction. J Clin Periodontol. 1997;24:557–67. doi: 10.1111/j.1600-051x.1997.tb00229.x. [DOI] [PubMed] [Google Scholar]
- 17.Pepelassi EA, Tsiklakis K, Diamanti-Kipioti A. Radiographic detection and assessment of the periodontal endosseous defects. J Clin Periodontol. 2000;27:224–30. doi: 10.1034/j.1600-051x.2000.027004224.x. [DOI] [PubMed] [Google Scholar]
- 18.Hegab MM, Abdelkawy M. Classification of periodontal diseases –Old is gold or new is bold?A survey study in Egypt. Perio J. 2020;41:11–23. [Google Scholar]
- 19.Malmqvist S, Strandberg P, Victorin I, Boberg E, Johannsen A. The new system for classification of periodontal and peri-implant disease: A questionnaire study of implementation by Swedish dental hygienists. Int J Dent Hyg. 2025;23:625–31. doi: 10.1111/idh.12816. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sarafidou K, Lazaridi I, Gotsis S, Kirmanidou Y, Vasilaki D, Hirayama H, et al. Tooth preservation versus extraction and implant placement in periodontally compromised patients: A systematic review and analysis of studies. J Prosthodont. 2022;31:e87–99. doi: 10.1111/jopr.13560. [DOI] [PubMed] [Google Scholar]
- 21.Lanning SK, Best AM, Hunt RJ. Periodontal services rendered by general practitioners. J Periodontol. 2007;78:823–32. doi: 10.1902/jop.2007.060391. [DOI] [PubMed] [Google Scholar]
- 22.Costa FO, Miranda Cota LO, Pereira Lages EJ, Vilela Câmara GC, Cortelli SC, Cortelli JR, et al. Oral impact on daily performance, personality traits, and compliance in periodontal maintenance therapy. J Periodontol. 2011;82:1146–54. doi: 10.1902/jop.2011.100515. [DOI] [PubMed] [Google Scholar]
- 23.Laleman I, Cortellini S, De Winter S, Rodriguez Herrero E, Dekeyser C, Quirynen M, et al. Subgingival debridement: End point, methods and how often? Periodontol 2000. 2017;75:189–204. doi: 10.1111/prd.12204. [DOI] [PubMed] [Google Scholar]
- 24.Ng MC, Ong MM, Lim LP, Koh CG, Chan YH. Tooth loss in compliant and non-compliant periodontally treated patients:7 years after active periodontal therapy. J Clin Periodontol. 2011;38:499–508. doi: 10.1111/j.1600-051X.2011.01708.x. [DOI] [PubMed] [Google Scholar]
- 25.Agrawal C, Parmar M, Shah F, Patel B, Upadhyay T, Gohil S. Knowledge of diagnosis, treatment protocols, and periodontal treatment procedures among dental care professionals of Gujarat: A cross-sectional study. J Res Adv Dent. 2022;13:1–4. [Google Scholar]
- 26.Fenol A, Mathew S. Compliance to recall visits by patients with periodontitis –Is the practitioner responsible? J Indian Soc Periodontol. 2010;14:106–8. doi: 10.4103/0972-124X.70829. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Figuero E, Nóbrega DF, García-Gargallo MD, Tenuta LM, Herrera D, Carvalho JC. Mechanical and chemical plaque control in the simultaneous management of gingivitis and caries: A systematic review. J Clin Periodontol. 2017;44(Suppl 18):S116–34. doi: 10.1111/jcpe.12674. [DOI] [PubMed] [Google Scholar]
- 28.Mali A, Mali R, Mehta H. Perception of general dental practitioners towards periodontal treatment: A survey. J Indian Soc Periodontol. 2008;12:4–7. doi: 10.4103/0972-124X.44086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wu M, Zhao K, Fils-Aime F. Response rates of online surveys in published research: A meta-analysis. Comput Human Behav Rep. 2022;7:100206. [Google Scholar]
- 30.Bergen N, Labonté R. “Everything is perfect, and we have no problems”: Detecting and limiting social desirability bias in qualitative research. Qual Health Res. 2020;30:783–92. doi: 10.1177/1049732319889354. [DOI] [PubMed] [Google Scholar]