Perceptions of general practitioners towards managing dental presentations in Australia: a qualitative study

Theory

In this study, we applied the Theoretical Domains Framework (TDF; Michie et al. 2005) and the COM-B model to inform data analysis (Michie et al. 2011). This framework was chosen as a behavioural approach is needed to understand GPs’ perceptions when managing dental presentations. This can then inform researchers and guide future research to develop better interventions. The TDF consisted of 14 theoretical domains derived from 128 constructs. This framework has been used to design research studies, such as treatment pathways (Scott et al. 2013), improving uptake, and understanding behaviours around vaccinations (Painter et al. 2010; Biezen et al. 2018) and antimicrobial stewardship in general practice (Biezen et al. 2017). The COM-B model is centred around how the three essential conditions (Capability, Opportunity and Motivation) are needed to change behaviour (Michie et al. 2011).

Design

This was a cross-sectional qualitative study comprising semi-structured interviews with GPs in Victoria, Australia. Ethics approval was obtained by The University of Melbourne Human Ethics Sub-Committee (2022-25002-33041-3).

Participants and recruitment

GPs were recruited through advertisements using the Victorian primary care practice-based Research and Education Network (VicREN), and through the research team’s professional network and snowball sampling technique.

GPs were included if they currently worked in general practice in Victoria, and see patients presenting with a dental complaint at least once per month. A purposive sample of GPs was selected to ensure a range of demographics was included, including sex, range of years of clinical experience, varied socioeconomic index for areas (SEIFAs) and locality of urban or rural workplace locations.

Procedure

Interview questions were developed from literature reviews (Cope et al. 2015, 2018), as well as the clinical experience of the research team to identify key themes around antibiotic prescribing and GPs’ management of patients presenting with dental issues (interview guide in Supplementary Data 1). Interview questions were around the knowledge of management of dental conditions, education and training, thoughts on strategies to improve oral health, and their perceptions on why patients attend medical care for dental treatment. The interview questions were piloted with two GPs and refined based on their feedback. These pilot data were not included in the final analysis.

Interviews (ranged between 12 and 38 minutes) were conducted between October 2022 and January 2023, over the video conferencing platform, Zoom, by LT and AL. Written consent was obtained prior to the interview. GPs were reimbursed for their time with a gift voucher (valued at 100 AUD) upon the completion of the interview. Interviews were conducted until data saturation was achieved.

Analysis

Interviews were digitally recorded and transcribed verbatim by AL. Two researchers (RB and AL) read the first transcript independently, and generated initial codes and themes. The researchers then compared and refined the codes and themes until consensus was reached through discussion. A further two transcripts were coded, compared and refined. The process was repeated until all transcripts were analysed. The codes were matched to the domains within the TDF and mapped to the COM-B model where the themes were generated. Data were managed using NVivo (ver. 12, QSR International).

Theme 1: Capability – knowledge

All GPs acknowledged that dental treatment by a dental practitioner is needed to resolve most dental issues. Therefore, GPs would often provide temporary treatment to alleviate symptoms, but refer patients to seek dental care. Antibiotics were usually prescribed, in addition to the recommendation and referral to attend a dentist.

I would always emphasise that … even if the pain goes away with antibiotics, it is not necessarily the end of it. There may still be an underlying problem that needs sorting out through the dentist. (GP2)

I’ll usually prescribe them antibiotics and ask them to see a dentist after kind of they started the antibiotics to kind of sort out any kind of presumed dental infection(s). (GP3)

Amoxicillin was the most common antibiotic prescribed by GPs in this study, with pain relief also prescribed in some cases.

The national Australian dental guidelines, Therapeutic Guidelines and HealthPathways (a local Australian resource aimed for general practice; Therapeutic Guidelines 2019; HealthPathways 2023), were the most commonly cited resources that GPs use for guidance on managing dental conditions.

Theme 2: Motivation – beliefs about capabilities

Although guidelines were often used, and considered as important to manage dental conditions, GPs thought they only had basic knowledge of oral health, as they received limited training regarding oral and dental conditions.

There hasn’t been a lot of dentistry done, a little bit in my GP training … about the kind of acute presentations and emergencies things that we should know and do, but that I don’t feel like I have a great understanding of this part of the mouth … the teeth. (GP7)

GPs believed that dental treatment is usually required by a dentist, and acknowledged they had limited treatment options available to them, therefore reporting having reduced confidence in managing dental presentations.

GP is not able to manage anything else about it anyway and provide a script. (GP2)

And then … it’s the question about antibiotics or not, which I think a lot of GPs find a bit tricky. And … I don’t always feel 100% confident in making that judgement. (GP7)

Communication between GPs and dentists was limited, with some GPs stating that they would prefer to have better communication pathways with dentists to improve the management of their patients’ overall health conditions, similar to their interactions with other allied health professionals.

I suppose just have better communication with the dentist, perhaps have the sense of the dentist and us being part of the same care team for a patient … certainly we’d benefit from … there’d be a lot that I could learn from dentists … the dentist might benefit from some information from me about my patient’s health … I think it makes sense that we should be communicating and calling on each other for advice. (GP7)

Furthermore, some GPs reported that patients were advised by their dentist to obtain antibiotics from their GP first, prior to seeing the dentist. The initiation of antibiotics from the dentist was expressed by several participants in this study.

They say, I tried to get hold of them, and they say, come in to see the GP for some antibiotics first. (GP1)

So often a common story … and they been instructed [by the dentist] … I don’t know how true it is, but they say they were told to go and get some antibiotics, and then book into the dentist. (GP10)

Theme 3: Motivation – emotion

GPs expressed that dental anxiety and phobia were reasons behind patients’ delay and/or avoiding seeing a dentist. Due to this, GPs were unsure if patients would seek dental care, despite recommend patients to see a dentist after GPs’ treatment.

I have patients who have dental anxiety, and are afraid to go and see the dentist. (GP10)

Phobia is definitely, there are one or two patients that really don’t want to see the dentist, but they always say that they’ll book in to see the dentist, but I know that they won’t. (GP3)

Negative past experiences and poor oral health were reasons GPs suggested why some patients were unwilling to see a dentist. Some of these might have resulted in patients having preconceived assumptions as to the treatment that will be provided.

You know, I think for some people who … perhaps don’t have great oral health … they’ve potentially had experiences where they’ve been made to feel quite ashamed, or, you know have had quite difficult experiences with dentistry. So … I suspect that some patients are a little reluctant to go to the dentist, and perhaps coming to the GP … can feel a little bit safer. (GP7)

It’s the people that don’t have a regular dentist that may be afraid of the dentist or have preconceived ideas that ‘if I go to the dentist, they are going to pull my tooth out’. (GP2)

Theme 4: Opportunity – environmental context and resources

GPs reported dental care access is an issue for patients, particularly those working in locations with lower SEIFAs or requiring dental care from community public dental practices. Long patient waiting lists and the inaccessibility of timely dental care were common barriers.

I think that’s really pretty big for, for a lot of patients and the public dentistry is just so limited … the community dentistry … there are quite long wait times … the access could still be better, I think. (GP7)

Even access to community dentists … in any health services is very difficult as well … access to the dentistry I think is a significant issue in Australia and certainly in my experience as a GP. (GP9)

Cost was also a factor identified by several GPs that presented a barrier for patients seeking dental care.

… I really get the impression that a lot of it is around cost … people not seeing them … because it’s another thing that you have to pay … (GP6)

I’m dealing with a lot of … people who have a Health Care Card and pension card, living in public housing, can’t afford to see a dentist, don’t have money to have private insurance. (GP5)

GPs reported that the structure of dental care provision in comparison with primary medical care may also influence patients attending the GP instead of the dentist. This is due to the subsidisation of primary general medical care under the federal Medicare scheme, whereas most dentistry is provided by private dental clinics.

If it was under like a bulk billed Medicare, then I think a lot more people will be flocking to dentists. (GP6)

No Medicare rebate to see a dentist, so I think significant proportion of my patients with dental pain have been on Health Care Cards and haven’t got … sufficient funds to be able to pay for a private dentist, and so they will try and manage it themselves with seeing a GP… getting analgesics and antibiotics. (GP9)

However, for GPs who worked in more affluent locations, cost was not a major consideration that influenced dental management for patients.

Cost can be a barrier, I guess, for a few patients. Generally not too much. I’m lucky in that my clinic has a good socioeconomic kind of basis for its patients. (GP3)

Theme 5: Opportunity – social influences/social professional role and identity

Patients’ past experiences influenced their perception that antibiotics were necessary to cure their dental ailments. Some GPs reported that they encountered patients who believed antibiotics were an appropriate treatment for their dental infection.

They might test it out and see if antibiotic makes it better or not. Hopefully not, but if the pain gets better, they’d believe that antibiotics cure the infection. Therefore, when they have pain the next time, they will ask and come in again for antibiotics. So, it is like a reinforcement. (GP5)

I’ve actually had quite a few issues with patients in the past been quite insistent on wanting antibiotics. Because, you know, they’ve had this before … and was given antibiotics. Or I know I have an infection; I need some antibiotics. (GP6)

Patient expectations for antibiotics were also another factor leading to GPs feeling pressured to prescribe antibiotics. This misconception by patients regarding the use of antibiotics for other types of infections also applied to dentistry.

I think there is an expectation. But I think people often equate pain to infection, which is often the case in other parts of the body. If you have pain or swelling on the skin, it might be an infected boil or abscess that might need an antibiotic. So, they probably have that expectation when it comes to dental issues as well. (GP2)

Additionally, GPs reported that some patients would self-manage their dental infection and pain with antibiotics, similar to other medical conditions.

I suspect there would already be some self-treatment for dental pain that goes away or might have gone away without the antibiotic anyway … they definitely do that for other medical illnesses, so there’s no reason why they wouldn’t. (GP3)

GPs realised that patients would rather seek help through their GP, or even self manage their dental problems, than go to a dental practitioner to resolve their dental issues. They were therefore inclined to manage their patient care as much as possible.