Dental Referral Patterns at a JKN Primary Care Clinic in Indonesia: An Encounter-Based Sentinel Condition Analysis

Abstract

Introduction: Indonesia's tiered referral system under the National Health Insurance (JKN) evaluates primary care performance mainly through non-communicable disease referral indicators, leaving dental referral patterns largely unexamined. Objective: To quantify the contribution of dental services to overall vertical referral burden and analyze referral variation across the pulp disease continuum at JKN primary care clinic in Indonesia. Methods: A retrospective cross-sectional analysis examined 873 dental encounters from 5,435 routine P-Care visits within February 2025–March 2026. Two sentinel dental conditions, pulp necrosis (ICD-10 K04.1) and impacted teeth (K01.1), were analyzed against the internal contrast of pulpitis (K04.0) versus pulp necrosis, with vertical referral as outcome. Results and Discussion: Dental encounters accounted for 16.1% of all visits (873/5,435) but generated 17.0% of all referrals; referral proportion within the dental subgroup itself was a distinct 16.2% (141/873). Referral proportion rose sharply across the pulp continuum, from 12.7% for pulpitis to 35.5% for pulp necrosis (crude prevalence ratio 2.79; 95% CI 1.91–4.07). Impacted teeth showed the highest referral proportion (56.1%). Conclusion: Dental services represent a disproportionate, previously unrecognized contributor to referral burden at this clinic, with the pulp disease continuum revealing a referral gradient not attributable to differences in operator, unit, or study period.