Attitudes toward and knowledge of collaboration of dental and medical practice among medical students in Southern India: a cross-sectional questionnaire survey

Background: Enhancing oral health care services provided through inter-professional collaboration between medical and dental practitioner is important, and even essential. The purpose of this study is to assess the attitude toward and knowledge of medical-dental collaborative practice among medical students attending colleges in Southern India. Methods: A cross sectional questionnaire survey was conducted among medical students and interns of medical colleges in coastal South India with prior information and permission. The questionnaire consisted of 11 questions to assess attitude toward and knowledge of medical-dental collaborative practice. The demographic backgrounds of participants were also recorded. Chi square test was employed for data analysis. The responses obtained were correlated with age, gender and year of study of participants using Pearson’s correlation test Results: A total 250 questionnaires were distributed and 234 responses were appropriately completed. Most of the students agreed that oral health was an integral part of systemic health, however participants disagreed on attending compulsory rotation in dentistry at a statistically significant level (p<0.05), moreover participants did not agree with physicians having an active role in motivating their patients for regular dental check-up. 82% of the medical students believe that dental check-up should be included in health packages under health insurance. A statistically significant (p<0.05) difference was observed among 3 rd year & 4 thyear students and interns and also it was found that female students provided more positive responses towards medical-dental collaboration. Conclusions: Even though medical students showed fairly positive attitudes and knowledge towards dentistry, the analysis within the study groups showed that knowledge and attitudes regarding the collaborative practice worsened over the academic years among the medical students. In order to destigmatize and foster interdisciplinary collaboration which would contribute to higher resource efficiency and the standard of care, continuing education in both the disciplines would be highly beneficial.


Introduction
One of the commonly neglected health issues globally is oral health, and the impact of oral diseases has significant effects on individuals, communities and global health care systems. 1 The evolution of professional health care education over the years is yet to compete with the demographical challenges and inequalities faced, which causes a burden on the system to fight the disease spread, and utilize the scientific knowledge and advanced technology with increasing complexity in the system.In addition to this, there is existing gap in imparting training to medical professionals about importance of oral health and its impact on general health. 2,3 order to achieve greater resource efficiency and upgrade the standard of care and comprehensiveness by reducing duplication and gaps in services, interprofessional collaboration is a key to success. 4All parties will benefit from improved professional cooperation between medical and dental practitioners and better educate the public.Overlooking underlying health problems while treating a patient is what most dentists do while they focus on the diagnosis and treatment of oral diseases.Likewise, doctors may fail to notice their patient's oral health problems which could result in initiation of a long-lasting medical illness.Enhancing health care services through inter-professional collaboration between medical and dental practitioners is therefore essential. 5An article was published after the First Systemic Health Round Table Discussion to advocate for better medical-dental collaborative practice.Inter-professional collaboration enhances communication and decision-making, enabling a synergistic influence of grouped knowledge and skills. 6Due to limited literature and emphasis on this topic, we decided to conduct this study to improve the understanding and importance of the same.
As per the medical education curriculum in India, medical students have to attend compulsory rotation-ship of about one month in a dental clinic/hospital, which by far many medical colleges follow it routinely.Hence the purpose of this study is to evaluate the knowledge and attitudes of the medical students studying in medical college attached to a dental college, towards collaboration between medical and dental practice in South India to understand the shortcomings and address them with a better strategy.

Ethical approval
Approval was obtained from the Institutional ethics committee (IEC) with protocol reference number-17020, from Manipal College of Dental Sciences, Mangalore.Necessary permissions and the written consent of participants were obtained and all methods were in accordance with relevant guidelines and regulations for carrying out the survey.

Study and questionnaire design
The questions in the questionnaire survey were adapted from the previously published studies and modified as per requirement for this study. 6,7The questionnaire was pretested in pen and paper format(physical format) on a group of 20 medical students selected based on our inclusion and exclusion criteria and the participants were given brief explanation about the study and the feedback was collected.Based on the feedback from participants, minor corrections were incorporated in the questionnaire and updated questionnaire was used in the main study.This cross-sectional study was carried out among the 3 rd year, 4 th year students and interns (5 th year) of four medical colleges with an attached dental college in and around Mangalore, a coastal urban area in the south Indian state of Karnataka.A total of 900 medical students were invited to participate in the study from all the medical colleges, out of which 250 students consented to participation to fill the questionnaire in the pen and paper format (physical format).From 250 responses, 234 questionnaires were appropriately completed and 16 responses were excluded as they submitted incompletely filled questionnaires.Dental students were not considered to be included in the study because the dental curriculum is designed such that dental students has a good exposure to medical college departments throughout the entire course with mandatory clinical postings and University examination when compared to medical students who only have a month of posting in dental college as required by medical curriculum.

REVISED Amendments from Version 3
The revisions done in the Version 4 of our Manuscript is based on the suggestions and queries by one of the reviewer comments.We hope this version brings more clarity regarding our work published.Conclusion of the study is revised and is concise as per the relevance to the study.More information regarding sample population and participation has been added in methodology section for more clarity.We acknowledge the reviewers' comments and would like to clarify that no students were forced to take part in the study.Questionnaires were distributed only to the participants to give consent to take part in the study and the responses were collected in pen and paper format.
Any further responses from the reviewers can be found at the end of the article Inclusion criteria: 1. Undergraduate Medical Student studying in 3 rd , 4 th or 5 th year of the college.

Students who consent to participate in the survey
Exclusion criteria: 1. Medical student studying in 1 st or 2 nd year of the college 2. Students belonging to paramedical course in the same college

Post graduate medical students
The questionnaire was subjected to face and content validation by both a medical and dental faculty member for its comprehensiveness and simplicity of understanding and each question was tested for content validity.
After obtaining the written consent from the participants, questionnaire to be filled were distributed among the participants.The questionnaire had 2 components: the first component was to collect the demographic data such as age (below 20 years of age, 21-24 years, above 20 years of age), gender (male and female) and year of study (3 rd year, 4 th year, interns) and the second component contained 11 objective questions which were designed to assess their attitude and knowledge.Questionnaire responses were recoded using 5-point Likert scale (1-strongly disagree, 2-disagree, 3-neutral, 4-agree, 5-strongly agree).

Score calculation and interpretation
For the study to be statistically valid and comprehensible, we calculated the mean response score for each question Shapiro wilk test will be used to the test the normality.If the data is skewed, median and inter quartile range will be used for analysis.
The collected data were coded and analysed using statistical package of social sciences (SPSS) version 11.5.Results were expressed as proportion and summary measures (median with inter quartile range) using appropriate tables and figures.
For comparison across the groups Mann Whitney U test was employed.A p value of 0.05 was considered statistically significant.

Results
A total of 900 students were invited to participate in the study, out of which 250 students consented to participate, which amounts to 27.7% of response rate.Although the response rate was less than expected, the statistically calculated required sample size of minimum180 responses was completed.
Reliability analysis was done using Cronbach's alpha and it was found to be 0.769 with no improvement in alpha on deletion of any item in the questionnaire.
Those who returned a blank or incomplete questionnaire were excluded.The mean age of the participants was 21.5 years with 58.36% respondents being female and 41.64% male.Out of total respondents, 43.77% were 3 rd years, 39.9% were 4 th years and rest (17%) accounted for interns.Shipiro wilk test for mormality was performed and the data was found to be skewed (p value<0.001).Thus , statistical analysis was performed using non parametric tests.
There was no statistically significant difference in knowledge and attitude based on gender, except that the female students were significantly more (p value-0.00)aware of interprofessional referral practice before elective medical surgeries (Table 1).Overall analysis of gender-based difference in responses indicated that females are more well informed and have increased positive attitude than males regarding the intended collaboration.
Most of the students agreed that oral health was an integral part of systemic health with analysis leading to median score of 5 (Table 2), but a statistically significant difference in the attitudes of medical students based on study year was seen when asked about attending compulsory rotation in dentistry with senior students showing negative attitude.The majority of participants had adequate knowledge regarding the medical-dental relationship, but almost 47% had very limited awareness about the existing relationship, which was assessed by questions 2, 3, 4 and 5.While comparing the groups     Oral health is an integral part of general health based on study year there was a statistically significant difference in knowledge (Table 2) with p value of 0.003, when asked about importance of salivary bio markers.Moreover when asked about physicians' active role in motivating their patients for regular dental check-up, there was a statistically significant difference (p value-0.013) in responses given by groups based on year of study indicating their negative attitude.However, 82% of the medical students were of the opinion that dental check-ups should be included in the health packages under health insurance.
Most students were aware about the necessity for interprofessional practice but only 61.8% agreed to the foster integral collaboration; 12.8% disagreed and the rest were unsure.Medical students (61%) gave a median score of 4, and agree that regular interaction is required with dental students to mutually exchange knowledge.Interestingly, 25% of them have replied neutrally, which again indicates a lack of interest with regards to the same.
A statistically significant difference based on age was seen (Table 3) with p value of 0.014 when asked about relation of HIV patient and dental treatment.Participants belonging to 21-25 years age groups showed lesser knowledge regarding the same.

Discussion
This study was used to evaluate the knowledge and attitudes of medical students towards the collaboration of medical and dental practice.As per Zhang the dental students would be more aware collaborative efforts than medical field as dental students are exposed to medical colleges from 1 st year to 3 rd year of their curriculum, contrary to the medical students who spend only a month in dental college postings.
Overall, medical students showed fairly good knowledge and positive attitude towards medical and dental collaboration in congruence with the results obtained from the study by Zhang.But analysis of groups within each parameter showed a significant difference.Based on year of study, it was found that students from third and final years of study had more positive attitudes than the interns, unlike results obtained by Zhang. 7More than half the participants, particularly the interns, did not agree to attend compulsory rotation in dentistry (p value 0.017), contrary to finding in which Hendricson and Cohen concluded this rotation-ship was not only beneficial but essential. 8though nearly 50% participants had fair knowledge regarding the oral-systemic link, many participants were confused when asked if it was mandatory to undergo an oral check-up before pregnancy.Sufficient research has shown that severe periodontal disease in pregnant women predisposes them to a higher risk of delivering preterm and/or low-birth weight of the new born. 9,10Offenbacher found mothers with periodontal disease are at a risk seven times more than mothers without. 11When asked about a link between diabetes and oral health, students seemed to have limited knowledge regardless of year of study.In addition, previous investigations have established an association between either type 1 or type 2 diabetes and periodontal diseases to the extent that periodontitis has been called the "sixth complication of diabetes". 12,13Interestingly, analysis among gender revealed a statistically significant difference with more knowledge among female participants with regard to questions about criteria to undergo treatment among HIV patients.Though it does not provide any supporting evidence to prove poor knowledge, it does indicate the need for further education among medical students about HIV patients and dental treatment.
While assessing the attitude of the students, we found significant data that junior students advised and motivated their patients to undergo dental check-up regularly, compared to senior students who gave a more of neutral response.One of the reasons for such an attitude from senior students can be because of the concept of social hierarchy which can be due to lack of interprofessional communication and patient management. 4 the United States, utilization of oral health care services and the incidence of oral disease are strongly linked to dental insurance coverage. 14In contrast, in India the dental insurance sector is less prevalent, 40-50% of the medical students strongly feel that dental check-up and some part of treatment must be covered in general health packages.
Around 60% of participants responded positively towards the integral collaboration and interprofessional communication, although 30% students were not sure and the rest disagreed with it.Analysis showed that the third and final year students were more positive than interns which is in contrast to results obtained from a study by Zhang. 7The exposure medical students undergo at clinics along with their interest in the subject affects their perception of oral health and its importance on general health.The Indian health education system, which often displays egocentric power relations among healthcare professionals, whereby medical professionals may not consider oral health as an integral part of general health due to a false perception, is threatening this interprofessional collaboration. 15tudents' attitude is associated with factors such as gender, knowledge of regular dental check-up, and curriculum.
Results of a previous study reported that gender could affect a student's attitude towards medical dental collaboration. 9,16uestions pertaining to the attitude towards collaboration such as insurance benefits for dental treatments received a more positive response from females than males.When asked about importance of interprofessional communication for exchange of knowledge and better patient care, females gave a greater positive response than males, which can be attributed to higher ego among males. 15 clinical practice, interprofessional continuing education is a useful means of regulating and stabilizing a professional's identity and improving teamwork. 4Guidelines must be set to improve confidence in a provider's ability with regard to cases pertaining to both fields and have access to updated knowledge about the collaboration between medical and dental practice. 17,18The existing body of medical and dental professionals play an important role since they have the ability to lay the guidelines.They can set guidelines for the indications, timing, protocols, and responsibilities of referral and consultation among physicians and dentists.Patients and the community should be made to understand the relationship between oral and systemic health by means of awareness campaigns. 19In doing so, national health goals can be achieved by reducing these kinds of healthcare disparities.
Apart from this, studies with larger sample size should be considered in future, to extrapolate the study results to a larger professional population.Even para-medical healthcare providers can be included as a part of the study to seek better understanding.

Limitations of the study
While we attempted to assess the attitude and knowledge of medical students, there are few confounding factors which may affect the responses of the participants such as participants personal interest in the subject, Interaction with para medical and dental peers which may affect their perception.Future studies can be structured to eliminate such bias.

Conclusion
• Medical students showed fairly good knowledge and positive attitude towards dentistry, the analysis within the study groups showed that knowledge and attitude regarding the collaborative practice declined over the academic years among the medical students.
• There is a need for improved healthcare education curriculum for interprofessional management of patients with stress on significance of effects of oral health.

Umesh Wadgave
Bharati Vidyapeeth Dental College, Pune, Maharashtra, India How was the sample size calculated? 1.
What were the results of content validation? 2.
Was the reliability of the questionnaire tested?3.
Check the sentences for language errors.Past tense should be used while framing the sentence in the manuscript.

4.
What was the purpose of categorizing age into three different categories?Does it make any sense?The age groups were closely related (<20,20-25,>25).

5.
The authors have not presented the reasoning for questions showing significant differences.

If applicable, is the statistical analysis and its interpretation appropriate?
Partly Are all the source data underlying the results available to ensure full reproducibility?Yes Are the conclusions drawn adequately supported by the results?Yes Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Public Health Dentistry
We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Introduction
The authors can highlight what learning and other initiatives are undertaken at their institution to promote interprofessional education and collaboration.

○
Why did the authors not study the attitude of dental students?For collaboration, both parties involved should have a favorable attitude.

Methods
Ethical approval was obtained over five years ago in 2017.What is the duration of the approval provided by the ethical committee?

○
The study was done in 2019.It may be interesting to study the impact of COVID-19 on student attitudes.

○
How exactly was the data collected?Where were the questionnaires completed?○ I am confused about which colleges were involved in the study.What percentage of students from each college had participated?How were these colleges selected?○ Page 8: Can the authors clarify the statement that they avoided including dental students to avoid positive response bias?

○
In the limitations section, can the authors elaborate on how upbringing can affect interprofessional collaboration?○ Many of the statements in the questionnaire deal with dental complications of diseases and are not related to collaboration between medical and dental practitioners in my opinion.
Can more details about the validation process of the questionnaire be provided?

Conclusion
The conclusion about continuing dental education does not seem to be based on data gathered during the study.
○ A big limitation is not including the dental students and not having any idea about their perception of collaborative care.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound?Partly

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? No
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Health professions education I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
Thank you for the suggestions.
I would like to share with the reviewer that in India dental schools are not involved in teaching oral or dental healthcare-related topics among medical students.As per the curriculum, medical students have approximately a month of internship in dental school to shadow a dental faculty to observe cases.On the contrary, dental students are actively taught by faculty from the medical college and even have clinical postings for an entire year.Hence, the reason for not including dental students in this survey was that they have more exposure to possible interdisciplinary collaboration when compared to medical students.Although this doesn't guarantee a positive bias, the questions designed for the questionnaire are pertaining to how oral health affects general health, for which, we decided to assess medical students for their knowledge, attitude, and practice and avoided the dental students.
Ethical approval was obtained in 2017 and the study was completed in 2019, once the study was completed, we submitted the report to the institutional ethical committee, after which the validity of ethical approval is over.
I have mentioned in the methodology section about how and where the data was collected.We visited the medical colleges in and around Mangalore and collected responses in pen and paper format to meet the calculated sample size.
The authors repeated that the students were assessed for their knowledge and attitude using a 5-point Likert scale.Please check the last two paragraphs under 'Study and questionnaire design'.

2.
The authors calculated the mean response score for each question and conducted the statistical analysis with the median of scores received as a measure of central tendency and evaluated the statistical significance.Why were the mean and median calculated at the same time?One of these central tendencies should be used according to the normality distribution.In addition, the authors compare the three age groups and education levels and mentioned the wrong test, Mann Whitney U test.It was appropriate to use ANOVA (if scores are normally distributed) with post hoc analysis to compare the three groups.

3.
The authors used 'interdisciplinary' and 'interprofessional' interchangeably, consistency in using one of these terms is preferable unless there was an obvious reason(s).

4.
This study has a number of limitations that should be mentioned in the discussion section.5.

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate?Partly Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Dentistry
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Reviewer
Report 04 July 2023 https://doi.org/10.5256/f1000research.151858.r181922© 2023 Shankar P.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Pathiyil Ravi Shankar IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia I have no further comments Is the work clearly and accurately presented and does it cite the current literature?Yes Is the study design appropriate and is the work technically sound?Yes

Table 1 .
Responses based on gender.

Table 2 .
Responses based on study year.

Table 3 .
Responses based on age group.