Interviews lasted between 9-18 minutes (mean 13.5, SD 2.78). Generally, telephone interviews are shorter than those conducted face-to-face as several factors contribute to the length of an interview such as, the research topic and how much the participant has to say on the research topic or they choose to share, and availability of participant’s time[24]. The thematic analysis of the interview data provided three major themes: Oral health care in general practice settings; Barriers and enablers to oral health care; and Role of diabetes care providers in promoting oral health (Figure 1).
Characteristics of participants
Twelve GPs working in general practices across Sydney South West (n=5), West (n=3) and North (n=2), and the Southern Highlands (n=2) in New South Wales, Australia participated in this qualitative study. Of the 12 GPs, 11 were practicing in group practice settings, 10 were male, and nine were over 40 years old (range 37-70 years old). The mean time that the GPs had worked in their practice was 25 years (range 5-42 years). Half (n=6) of the GPs had a medical fellowship qualification such as Fellowship of the Royal Australian College of General Practitioners (FRACGP), followed by undergraduate (n=4), and postgraduate (Masters) degrees (n=2).
Insert Figure 1 here
Theme 1: Oral health care in general practice
There was general consensus among the GPs that oral health care is important for people living with diabetes.
Perceived importance of oral health care
Most of the GPs highlighted the significance of oral health describing the compromised immunity of people living with diabetes and resulting risk of infections including oral health problems. As one GP mentioned:
Yeah. As you know oral health is very important, particularly in the patient with the chronic medical conditions … for example, if someone has diabetes and is not having good oral health, because diabetic people are not having very good immune system and they have high sugar in their blood, so they become susceptible for infection. Oral health could become a serious issue with these people. (GP-8, 66 years old)
Some of the GPs also recognised the relevance of promoting oral health care in people living with diabetes and expressed willingness to play an active role in this area as part of clinical practice:
I think it's good that somebody has taken an interest [in oral health care]. I would definitely like to learn more and being a proactive GP I would definitely be interested in more activities [training and workshops]. (GP-3, 55 years old)
Perceived incidence of oral health problems
While exploring the incidence of oral health problems in patient with diabetes, most GPs reported seeing between 20 to 30% of patients with diabetes having oral health problems:
Okay, I would probably say about - from my cohort of patients, it's probably about - out of 10, maybe 2 to three the most. [would have dental problems] it's very broad I'm answering that because obviously I don’t have finer details (GP-3, 55 years old)
However, one GP working in Western Sydney mentioned that “seven out of 10 patients would have issues [oral health problems]” (GP-6, 39 years old). In contrast, GPs working in Northern Sydney reported seeing very few patients with oral health problems:
My practice is sort of a middle-class area and there are very, very few people who have bad oral health in my practice. (GP-4, 70 years old)
Current oral care prevention and management practices
Although most of the GPs highlighted the importance of oral health care for people living with diabetes, their current practices in this area were found to be very limited. The discussion around current oral health care practices focussed on risk assessments, patient education, and providing referrals to a dentist.
Risk assessment
Most of the GPs reported that they never assessed their patients with diabetes for oral health risks, except when oral health problems were raised by the patient such as, “patients come in saying I can’t eat because I have rotten tooth” (GP-10, 48 years old).
Another GP mentioned:
So, if a patient complains of oral health issues, then I would certainly make sure that the patient's glycaemic control is good. If that is good then you will want to know - basically take the history as to when these oral health issues started and at the time you proceed to - you can backtrack to see whether you think or suspect that at the time their oral health problems began, the glycaemic control wasn't so good. (GP-5, 67 years old)
In one of the large GP practices, oral health was included in a care plan for the people living with diabetes and practice nurses inquired about oral health as part of the care team approach adopted:
We don't do a formal screening process, but we certainly ask them how their teeth are... All of my patients [with diabetes] get seen four times a year and have a care plan review four times a year. That's actually one of the things that the practice nurse who helps me do the care plans has on their list. It's actually on their form in terms of asking questions about a patient's sleep, a patient's exercise and they ask about their dental health and their last trip to the dentist (GP-11, 61 years old)
Patient education
Most GPs rarely provided oral health education to their patients or discussed oral health issues
I don’t bring it up, no. I'm focused on internal medicine and oral health, I leave to the dentist… my focus of practice is not on oral health (GP-4, 70 years old)
Providing referrals
Most GPs reported they would suggest patients see a dentist if they are experiencing any dental problems:
We see people with diabetic dental abscesses, dental infections. So we treat them with antibiotics and refer - advise them to go and see the local dentist (GP-2, 60 years old)
However, all of the GPs agreed that there is a lack of formal systems in place to provide specific dental referrals. As one participant mentioned “it is not a formal referral. We just say look go and see your favourite dentist” (GP-11, 61 years old).
Theme 2: Barriers and enablers to oral health care
GPs reported several barriers to promoting oral health care from both the care providers and patients’ perspective. Major barriers for care providers included lack of time and absence of dental referral pathways, while cost of dental care and limited awareness of the link between diabetes and oral health were the barriers for patients.
Barriers for care providers
Time
Most GPs reported time constraints as a major barrier for not including oral health as part of their routine care for patients with diabetes. As one participant mentioned “…. time restriction, you're focusing more on medication, very rare I talk to patients about dental” (GP-12, 40 years old).
Unfortunately, we don’t have time. Apart from a simple, just a glance at the teeth and then request them to go to dentist” (GP-9, 57 years old).
However, some GPs pointed out that they do “…invest a lot of time into chronic health conditions so time is not an issue [for oral health] (GP-6, 39 years old). As one GP expressed:
Well a brief inspection of the mouth only takes 15 or 20 seconds. Do you see any rotten teeth? Do you see [caries]? Do you see severe gingivitis? I don't think there's any reason why a GP can't do that [discuss oral health]. It doesn't take long, but it's one more burden on top of all of the other things that a GP is expected to do. But, for me, it's part of a standard diabetic check. (GP-11, 61 years old)
Referral pathways
Most of the GPs perceived that most of their patients cannot afford the cost of private dental care and indicated the unavailability of public dental care services to address the dental care need of people the eligible people. They reported unavailability of a referral system to prioritise these patients on these public dental services, as an additional barrier to discussing oral health concerns with their patients. As several GPs highlighted:
I suppose it's more to do with the fact that it is a lot of the time not covered by the Medicare Benefit Scheme [Government benefit to GPs]. So that if we do pick something up, what do we do about it? what can the patient do about it in the public system? There isn't much back up because there's such a huge queue in the system (GP-2, 60 years old)
I don't think I can even send people to my local hospital, because you've got to be in grave health kind of danger before they take you on. That's unfortunate. (GP-10, 48 years old)
Having a well-established network of dental services would be useful. Understanding how the dentist would operate, also having the dentist as part of the team would be useful as well. Like if we think of the diabetic patient. We think of the podiatrist or the kidney specialist, or the cardiologist; well they have an established role. They are - they communicate to us, they recognise their role. Similarly, I think the dentist has to establish their role in that team. (GP-9, 57 years old)
Oral health knowledge
There was divided opinion among participants regarding their knowledge about oral health. Few GPs perceived they had adequate knowledge on this topic and “don't think knowledge is a big deal” (GP-12, 40 years old). Some of the GPs explained the association between diabetes and oral health:
I’m not speaking for all GPs, but I think most of us the association is with infection. So that's pretty much how much we know and anything other than that we palm off to the dentist (GP-6, 39 years old)
I recognise that a good dentition is necessary for good oral health. A bad dentition can be the source of inflammation. It can increase inflammatory markers in the body. This can be detrimental to the body generally, but also to any other chronic condition that you are trying to manage. So diabetes can be adversely affected by poor dentitions, broadly speaking (GP-9, 57 years old)
However, a few others perceived they “…do not have enough knowledge about oral health” (GP- 6, 39 years old) and this was a barrier in providing oral health care to their patients. None of the GPs had received training on oral health as part of their undergraduate course:
Generally, we're poorly educated about teeth. We learn very little about teeth in our undergraduate and postgraduate. We try and get around that by every year, at least, we have one or two registrar training sessions to teach them about dental emergencies. But on the whole, we know very little about teeth and that's probably the major barrier (GP-11, 61 years old)
Almost all of the GPs were unaware of the bidirectional link between diabetes and oral health and none were familiar about any diabetes guidelines that address oral health care:
No, there's no guidelines that I could think of that would - that actually tells on the area of oral health with diabetics. I don't think there is. Maybe I've missed it. (GP-5, 67 years old)
Barriers for Patients
GPs also perceived high cost for dental care, limited awareness about oral health and dental anxiety as barriers for patients and contributed to their poor oral health status and lower dental visits.
Cost (Finance) of oral health care
The cost of dental care was clearly a major barrier perceived by GPs in accessing oral health care. As one GP stated “we just say look go and see your favourite dentist. Often the answer is I can't afford it” (GP-2, 60 years old). Another GP recalled his recent experience:
Because recently I've had - this is just an example - a type 1 diabetic who has not been to a dentist in the last eight years purely because he has five children, he doesn't have private health and he can't afford it. (GP-6, 39 years old)
Limited oral health awareness
Some GPs also perceived lack of awareness as an additional barrier to patients maintaining their oral health care.
Education I guess, patients will not have the knowledge of the link between diabetes and oral health” (GP-3, 55 years old)
Dental fear or anxiety
One of the GPs also indicated that patients often perceive fear to see the dentists because of the discomfort or pain on oral health care.
The other major barrier is the perception of the actual dental management. See, most patients regard going to the dentist as a painful episode. They’re really worried about the pain they may have to endure, so that is also a factor. (GP-9, 57 years old)
Enablers to oral health care
Several enablers to oral health care were also explored with the GPs which included education/training, risk assessment tool and patient education resources.
Education/Training
Generally, all of the GPs were receptive to education/training on oral health and most believed it would encourage them to provide oral health care to their patients. One GP emphasised the need for “Education of doctors, education of practice nurses (in oral health). I think they're the main ones (GP-11, 61 years old)
I think that probably more education [oral health] for us [GPs] regarding diabetic oral health is needed and that will actually then [assist] - because I think that's one area that we're not really that well alerted to, or educated to, or knowledgeable enough to know and look for things. (GP-5, 67 years old)
Considering their busy schedule, GPs preferred a short session on oral health “may be a two-hour session, one-day session may be too much” (GP-7, 61 years old), preferably in the evening “at my age I quite like evening sessions (GP-11,61 years old) and conducted on online mode “I'm exceptionally busy in this practice here, but I would be more than happy just to do, if it's online, like an evening course (GP-8,66 years old). GPs were also attracted to education sessions that contributed to continuing professional development (CPD) points and a few also suggested that it could be integrated in the diabetes training module:
The only way to attract GPs to training of some sort is if they get something out of it in terms of…may be CPD points. But… if you did a training module on diabetes and slotted in a presentation on oral health, I would say there'll be bigger takers than if you just did a course only on oral health in diabetes. But I think this is a big scope for oral health to be put into here [health pathways- it is an online portal for GPs and healthcare professionals which has clinical and referral material for GPs to use on their day-to-day consultation with patients] because this would be the best education. Health Pathways is taking on brilliantly well with registrars and junior doctors and registered nurses in hospitals and in training. (GP 6, 39 years old)
Risk assessment tool
GPs highlighted the need for appropriate assessment tools that could assist screening and risk assessment:
“A questionnaire would be good, but don't make it too complicated or long” (GP-10,48 years old)
Patient education resources
All of the GPs wanted to have patient education resources such as brochure:
“We'd like to get brochure and save the time. We can just give patients and that will - at least remind us to talk about, then after giving a brief discussion we can give it to them” (GP-7, 61years old)
Theme 3: Role of diabetes care providers in promoting oral health
Role of GPs
Despite time constraints, a majority of GPs perceived they do have some role in promoting oral health.
“…such a good idea [reviewing oral health] because it'll trigger us to think about it more at least, more than we should. (GP-1, 37 years old).
In a busy practice it can be quite challenging to focus on oral health. But we need to make a point - I do try my best within the restraint” (GP-3, 55 years old)
One GP though believed that GPs have limited or no role to play in promoting oral health:
… looking after oral health is such a basic function like going to the toilet and wiping your backside that it's sort of - it’s a little bit too peripheral for GPs to tell people I think. I mean, public health education maybe if you want pamphlets and all that, but it’s not a big issue as far as I can see. (GP-5, 67 years old)
Role of diabetes educators
Some GPs also acknowledged that other diabetes care providers such as diabetes educators could also play an important role “… because they actually help to outline some of the things that we GPs don't have time for” (GP-5, 67 years old). However, the capacity of diabetes educators needs to be assessed while scoping this new role as one GP highlighted:
I'm not sure. Depending on their level of education and their understanding of pathophysiology of the disease. I guess I'm not sure. I guess I'd be more comfortable with a GP talking about it (GP-1, 37 years old).