Adoption Issues Associated with a New Periodontal Screening Tool: An Online Survey of Canadian Dentists

Abstract

Objective: To determine barriers and facilitators associated with the acceptance of a new diagnostic screening tool for periodontitis.

Methods: As part of a larger study to examine factors that affect the adoption of new technology by dentists, we piloted an online survey of Canadian dentists through an electronic newsletter produced by the Journal of the Canadian Dental Association. A new oral rinse that screens for the presence of periodontitis by estimating neutrophil abundance in saliva was used for illustrative purposes. The survey included questions about the types of patients for which the test would be beneficial, how the test might be incorporated into practice and how much the dentist would be willing to pay for the test.

Results: As the survey was delivered through a new communication tool, the response rate was low. Nonetheless there appeared to be interest in new periodontal screening tools to complement existing diagnostic tests for periodontitis. The test was seen as a valuable educational tool for patients; however, the cost to administer the test was determined to be an issue.

Conclusions: Despite the low response rate, dentists were interested in new screening tests for periodontitis. A larger study with a more representative sample could provide valuable information for scientists who are interested in taking their research from the bench to chairside.

Although dentists are considered to be innovators in technology,¹ a number of supportive and obstructive factors affect the adoption, non-adoption or rejection of an innovation among this population.² For change to occur, dentists must perceive the need for change³; innovations with no perceived advantage are often rejected.² This consideration may be a factor contributing to the low rate of adoption of microbial root canal sampling^4,5 and the slow acceptance of the dental-operating microscope.⁶ Higher adoption rates have been observed when dentists have been offered educational opportunities⁷ and when opinion leaders and early adopters provide positive feedback on a new technology.²

Traditional diagnosis of periodontal disease involves the use of radiographs and periodontal probing measurements, both of which may be uncomfortable or even painful for some patients.^8,9 Although measurement of pocket depth and clinical attachment level may be important to clinicians, patients may not find the results of a periodontal examination particularly meaningful or relevant.¹⁰ Thus, it can be difficult to convey the significance of such findings to patients and have them commit to recommended therapy. This is further complicated by the fact that, like hypertension, periodontitis is generally a painless condition with few visible symptoms until the late stages of disease. Thus, a rapid, non-invasive test that enables clinicians to screen for the presence of periodontal inflammation may not only provide additional information to the dentist, but could also facilitate uptake of recommended treatment by patients with periodontal diseases.

Screening tests that quantify neutrophils in saliva have been used in research settings.^10,11 However, they are unlikely to be practical in a clinical setting as they require serial rinses, which are cumbersome and time-consuming to administer. A recent study¹² has shown that elevated salivary neutrophil levels, determined during a 30-second mouth rinse, accurately reflect the presence and severity of ongoing loss of periodontal attachment. Further, following initial therapy, oral neutrophil levels returned to those found in periodontally healthy patients. Although, in this study, a microscope was needed to count cells, a new colorimetric adaptation of the same rinse test from the same laboratory is currently being tested.^13,14 The addition of a colorimetric reagent to the oral rinse sample accurately reflects neutrophil levels in the patient's mouth and aids in quickly diagnosing active periodontitis at chairside.

We conducted a pilot survey to examine attitudes of Canadian dentists with respect to this new screening test as part of an ongoing study to determine factors that affect the adoption of new periodontal screening tools into dental clinical practice. This information will inform additional research into the adoption of new technologies by dental professionals.

Methods

A self-reporting, online survey was developed to examine factors that influence the acceptance and adoption of new screening technologies into dental clinical practice. The non-invasive oral rinse test described above¹² was used for illustration.

The survey was developed and tested for face and content validity among a convenience sample of clinical and academic periodontists. The questionnaire included a brief description of the colorimetric screening mouth rinse was provided, and collected demographic data. Respondents were asked about situations in which they might consider using this type of test. All responses were anonymous. Exploratory questions included: for what type of periodontal patients would you use this test (i.e., newly diagnosed periodontal patients, patients on periodontal maintenance therapy or patients with recurrent periodontal disease)? would the test replace or supplement current diagnostics? would the test be helpful to monitor ongoing periodontal status and/or as an educational tool to improve a patient's understanding of their disease status and acceptance of treatment? and how much would you be willing to pay for such a test?

The survey was disseminated electronically by the Journal of the Canadian Dental Association (JCDA) through its new electronic newsletter. The JCDA editorial team used Ultimate Survey software (Checkbox Survey Inc., Watertown, Mass., USA) to develop the online version of the survey. The survey was only accessible via a web link included in the electronic newsletter. Distribution occurred in 2 phases: the first in August 2012 and the second in September 2012. The survey was sent to the 14 219 licensed Canadian dentists who are on the membership list of the Canadian Dental Association.

Results

We received 15 responses after the first phase of distribution and an additional 183 responses after the second distribution (response rate = 1.4%). Of the 198 respondents, 74.2% were men (n = 147), 23.2% were women (n = 46) and 2.5% (n = 5) did not disclose their sex. Of the respondents, 86.9% were general practice dentists (n = 172), 12.1% (n = 24) were specialists and 1.0% (n = 2) did not disclose this information. Although the response rate was extremely low, according to data from the Canadian Dental Association¹⁵ this ratio of general dentists to specialists reflects the distribution for Canada. Specialists included oral pathologists (n = 1), periodontists (n = 20), pediatric dentists (n = 1) and orthodontists (n = 2). The average number of years in practice of respondents was 22.25 (standard deviation [SD] 13.50 years, median = 23.00 years). The average number of hygienists working at each practice was 2.0 (SD 1.8).

Just over a third of respondents (38.4%) said that they would use this test on all recall patients, while 37.4% would only use it on patients with new or recurrent periodontal disease, i.e., radiographic evidence of increasing bone loss, increasing probing depths or increased bleeding on probing (Table 1). This was especially true for general dentists: 18.0% would only use it for patients with a history of periodontal disease, and 2.9% would use it only for patients at risk of periodontal disease because of changes in their medical condition. Only 2.5% of dentists said that they would not use this test for recall patients.

Asked how they would use this new screening test, most respondents (90.0%) said that they would use it to educate patients about their periodontal disease status (Table 2): "[I] really like the idea [of this test], since patients often have trouble understanding their periodontal status, especially if they are not experiencing any symptoms." Other uses included monitoring patients' periodontal status (64.6%) and confirming patients' periodontal diagnosis (63.6%): "This would be useful to assist the patient in evaluating/confirming their periodontal situation, as an adjunct to my and my hygienist's evaluation of their disease state." Only 2.0% said they would use the new rinse to replace traditional periodontal diagnostic tests (i.e., periodontal probing and radiographs), suggesting that most would use it to complement existing practices: "The colour change would make this a useful adjunct for patient education and, possibly, a quick screening tool, but proper treatment planning still requires periodontal probing and radiographs." Responses were similar for both specialists and generalists (Table 2).

Dentists were willing to pay an average of $9.5 (SD $10.8) per test (Table 3); however, the range was wide: from nothing to $75 (median $5). Some respondents were concerned about out-of pocket expenses to administer the test. If the cost of the test exceeded their expectations, 36.9% of dentists would not use this method, and 46.5% would bill the patient (Table 4). Among those who chose "other" if the cost of the test exceeded expectations, some said that they would absorb the cost, while others would be more selective about which patients received the test, would discuss the test with the patient first or would try to recover the cost through insurance.

Recorded comments showed that respondents wanted to learn more about the specific screening values of the test, including its sensitivity, false positive rate and the range of neutrophil presence at each colour stage: "The test has only three results: healthy, moderate or severe periodontal disease. I would be interested to see the [range of] levels of WBCs [white blood cells] for each of the three and at what point there is a change from moderate to severe." They were also interested in factors that might affect test results: "As this is a measure of white blood cells, how can you eliminate the increase in white blood cells from other non-periodontal oral infections that may complicate the results of the screening test?"

Respondents also expressed a desire to try this new test to see first-hand how effective it is: "I would not fully implement this test unless I was sure about the accuracy." In the belief that a visual demonstration would help to convince patients of their periodontal disease diagnosis, respondents wondered if this test could be used at home by patients.

Discussion

This pilot study was designed to investigate attitudes toward and factors affecting implementation of new diagnostic and screening tests into clinical practice and not as a definitive survey of attitudes of dentists. The major limitation of this study was the low response rate, which could be explained in part by the fact that the link to the survey was delivered through a communication tool that was new to Canadian dentists. The link was included in a newsletter rather than sent as a separate, directed, personalized email message. Further, this was the first time the Canadian Dental Association had participated in recruitment for a research project. As JCDA newsletters generally focus on information related to clinical practice, some dentists may have perceived this as a marketing survey.

In general, health professionals are known to exhibit low rates of response to surveys,¹⁶ particularly to electronic surveys.^17–19 Flanigan et al.¹⁹ concluded that, although Internet-based surveys present an attractive alternative to mail and telephone surveys, postal surveys are preferred by health professionals. Although there are no data on dentists per se, response rates among other health professionals (nurses, physicians, pharmacists) are highly dependent on the target audience and response rates range from 8% to 42%.^18,20

It is unlikely that our survey sample is representative of the underlying population. In addition to the low response rate, participants in electronic surveys are more likely to be computer literate²¹ and thus are more likely to be early adoptors of new technologies.

There is a dearth of literature regarding factors that affect the uptake of new clinical technologies — so-called "technology transfer" or "diffusion of innovation" — particularly in dentistry. The unified theory of acceptance and use of technology²² is based on a model used in the field of information technology, but it can also be applied to health care technology. This theory postulates that adoption of new technologies depends on 4 major factors: performance expectancy (how well does the technology perform?); effort expectancy (how difficult is it to use?); social influence; and facilitating conditions (what barriers exist to implementation?).

These factors were reflected in the qualitative data collected in our study. Several respondents questioned the test's performance, including its diagnostic properties (i.e., sensitivity and specificity) and its ability to differentiate between gingivitis and mild active periodontal disease. It was suggested that this test be combined with DentoRisk (Dentosystem Scandinavia AB, Stockholm, Sweden), a Swedish software program that exhibits reasonably high prognostic value.²³ Most generalists said that combining diagnostic tools might give more credibility to their specialist referrals and could assist them in determining which patients should see a periodontist.

Clinicians generally welcome technologies that facilitate communication with periodontal patients and help to convey the importance of treatment in ways that patients can understand and internalize. One of the major benefits of sharing visual aids, such as a radiographic image or a colorimetric screening test, is that these tools can provide concrete evidence to the patient of the presence of disease (at the initial appointment) and evidence of potential improvement following active therapy and during maintenance.²⁴ Although not tested, visual cues provided by this colorimetric test could ultimately improve compliance with periodontal therapy and maintenance.

In adoption of a new screening or diagnostic tests into clinical practice, cost is an important consideration. Ultimately, dental professionals have 3 choices when it comes to managing such costs: look into third-party coverage (although these tests are often not billable through insurance), bill the patient for the test or absorb the cost. Many dentists are uncomfortable charging additional fees for already expensive procedures and, therefore, cost often becomes a significant factor when they are deciding whether to adopt new technologies. In our sample, there was a fairly even split between dentists who would bill for the test and those who would not use the test if it was expensive or find other means to cover the cost (Table 4). Cost and ease of implementation are important factors affecting the adoption of new technologies and should be considered in the design of new screening tools for periodontal diseases.

Conclusion

Although the response rate to our survey was low, dentists who did respond showed an interest in new screening and diagnostic technologies for patients with periodontitis. A larger study with a more representative sample could provide valuable information for scientists who are interested in taking their research from the bench to chairside.

The next step in this research study is to conduct focus groups and structured interviews with clinicians, representatives of the dental industry and periodontal patients. Information from this project will contribute to our overall knowledge of facilitators and barriers to the uptake of new technology in the field of oral health.

THE AUTHORS

	Dr. Matthews is professor and assistant dean research, faculty of dentistry, Dalhousie University, Halifax, Nova Scotia.
	Ms. McNeil is research associate, Nova Scotia Health Research Foundation. At the time of writing this article, she was research coordinator, Atlantic Health Promotion Research Centre, Dalhousie University, Halifax, Nova Scotia.
	Dr. McCulloch is professor, faculty of dentistry, University of Toronto, Toronto, Ontario.
	Dr. Glogauer is professor, faculty of dentistry, University of Toronto, Toronto, Ontario.

Acknowledgements: The authors thank Dr. John O'Keefe, editor-in-chief of JCDA for his assistance with the development and distribution of the electronic survey. This work is supported by a team grant from the Canadian Institutes of Health Research (TBO 122068).

Correspondence to: Dr. Debora Matthews, Faculty of Dentistry, Dalhousie University, 5981 University Ave., Box 15000, Halifax NS  B3H 4R2. Email: debora.matthews@dal.ca.

The authors have no declared financial interests.

This article has been peer reviewed.