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ORIGINAL ARTICLE
Ahead of print publication  

Patient awareness of oral health and periodontal disease before and after comprehensive periodontal treatment


1 General Dentist, Graduate of Dentistry Program, Batterjee Medical College, Jeddah, Saudi Arabia
2 Departments of Periodontics and Clinical Sciences, Periodontics Division, Dentistry Program, Batterjee Medical College, Jeddah, Saudi Arabia
3 Department of Periodontology, Faculty of Dentistry, King Abdul-Aziz University, Jeddah, Saudi Arabia

Date of Submission02-Apr-2019
Date of Decision18-Jun-2019
Date of Acceptance17-Mar-2020
Date of Web Publication07-Aug-2020

Correspondence Address:
Fatimah I Patel,
3448, Abbas Ibn Siddiq, Al Rehab, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_30_19

  Abstract 


Introduction: Periodontal disease (PD), a major health problem, reportedly affects a large percentage of the adult population with multifactorial etiology including awareness and practices from family and/or their treating physician.
Aim: The aim of the study was to assess the patient's oral health as well as PD awareness before and after comprehensive periodontal treatment registered at the Outpatient Department of Batterjee Medical College.
Subjects and Methods: The present cohort study was conducted on 120 adult patients, selectively undergoing comprehensive clinical care by the dental students of the final 2 clinical years (D4 and D5, respectively) and interns (D6) with a self-answered questionnaire.
Results: Among the majority (92%, n = 113), the usage of toothbrush and toothpaste was common before treatment like the previous studies. In addition, there was an increase in the knowledge of the word dental plaque and calculus, where the majority believed calculus to be the causative factor of PD. It was noticed that there was very little difference in the knowledge being given regarding systemic association to their oral health. Postoperatively, 70% of the patients believed that they should visit the dentist annually or biannually, but a larger percentage across all groups (them) believed that dental visits are need based. Moreover, awareness increased postoperatively in patients. As a result, the majority of them acknowledged the deleterious effects of smoking.
Conclusion: A change in the patient's attitude and behavior toward oral health is achieved in a coalition with the practitioner's professionalism, empathy, and delivery of oral hygiene advice.

Keywords: Dental awareness, dental health/care, miswak, oral health behavior, oral hygiene practices, periodontal awareness, periodontal disease, prevention



How to cite this URL:
Patel FI, Khan KA, Abdelrasoul MR, Bahammam MA. Patient awareness of oral health and periodontal disease before and after comprehensive periodontal treatment. Saudi J Oral Sci [Epub ahead of print] [cited 2020 Sep 23]. Available from: http://www.saudijos.org/preprintarticle.asp?id=291609




  Introduction Top


Good oral health is the key to the overall general health of the body and plays a vital role in improving the quality of life. According to the World Health Organization (WHO), “promotion of oral health is a cost-effective strategy to reduce the burden of oral disease and maintain oral health as well as the quality of life.”[1]

Health literacy is defined as “the degree to which individuals can obtain, process, and understand basic health information and service needed to make appropriate decisions.”[2] Oral care, as a part of general health self-care, comprises a wide spectrum of activities ranging from care, prevention, and diagnosis to seeking professional care.[3]

Periodontal disease (PD), a major health problem, reportedly affects a huge percentage of the adult population.[4],[5] It is well known that plaque microorganisms, immunological, and genetic factors play a major role in the etiology of caries and PDs.[6] Dental plaque is a biofilm, clinically defined as a structured resilient yellow-grayish substance that adheres tenaciously to the intraoral hard surfaces including removable and fixed restorations.[7] Although uncalcified biofilms can be removed by routine oral hygiene aids or professional dental instruments, they have the potential to calcify into dental calculus making their removal difficult.[3] Several studies have reported that gender, aging, low educational level, nutritional status, stress, smoking, and inadequate oral hygiene habits are generally associated with PDs.[4],[8],[9],[10],[11]

The clinical concept, maintenance of effective plaque control is the cornerstone of any attempt to prevent and control PDs, has been established since the 1950s, and remains valid.[12] Prevention and treatment of PD depend primarily on professional cleaning, appropriate plaque control, and modification of adverse risk factors.[13] Dentists play a vital role in this regard by providing appropriate dental treatment and encouraging patients to change their behavior and attitude toward oral health.[14]

Several cross-sectional studies are already available which assessed the patients' oral health literacy (OHL) and periodontal health awareness before the treatment on presentation in the office associating with various factors such as gender,[12] education level,[6],[14],[15],[16] knowledge regarding oral health and oral self-care behavior,[2],[5],[13],[17],[18] periodontal status/awareness,[3],[4],[14],[15],[19] and socioeconomic status.[3],[6] However, they failed to show the difference between pre- and post-dental visits.

Therefore, the study aimed to assess oral health and PD awareness of the patient before and after comprehensive periodontal treatment registering at the Outpatient department (OPD) of Batterjee Medical College, Dental Clinics (BMC-DC) at Jeddah, KSA.

Accordingly, the hypothesis is that the comprehensive dental care could change the awareness and attitude toward self-practice of their oral health. Furthermore, the dental healthcare provider plays a vital role in this change.


  Subjects and Methods Top


The current cross-sectional study was conducted on patients visiting the OPD of the BMC-DC. Patients presented at the DC reception to be registered with the clinics. The average waiting time for initial assessment and examination by a general dentist (oral medicine and diagnosis department) was 15–20 min depending on the number of patients reporting. This practice is similar to the practice in every dental teaching institution in Saudi Arabia.

A detailed medical and dental history was taken on a structure case-history sheet, and a thorough oral examination was performed. The patients were then distributed between 5th year students (D4), 6th year students (D5) and interns (D6), according to their severity of caries and periodontal conditions, and have to be treated by them under supervision within respective departments.

Using a structured questionnaire, patients were asked to complete a self-answering questionnaire. The questionnaire was formulated by reviewing articles and the guidelines of the WHO as well as translated into the local language, i.e., Arabic by a certified translator. Arabic translation was pretested for validity and reliability and modified accordingly. The targeted patients were screened and referred for comprehensive clinical care by the dental students of the final 2 years (D4 and D5) and interns (D6).

Data were collected over a duration of 10 months (March–December 2015) for patients who visited the periodontal department. Pretreatment data were taken at the first interaction with the patients by the students, while the posttreatment was recorded at a minimum interval of 4–6 weeks from the first periodontal treatment at the BMC-DC.

The ethical clearance was obtained from the Institutional Ethical Committee. The informed nonverbal consent was obtained from the patients who participated in the study. The respondents were assured of their unwillingness to participate in the study that would not affect their treatment.

Adult patients between 18 and 70 years of age who were willing to participate and gave nonverbal consent and understood and answered the questions while attending the periodontal department were included in the study, while handicapped patients, incomplete questionnaires, and discontinued patients (no follow-up of treatment) were excluded from the study.

Procedure of data collection

Copies of the questionnaire were distributed among the patients at their first visit before the comprehensive periodontal treatment and reevaluated with the same questionnaire after a period of 4–6 weeks. Dental students and/or interns providing treatment were present with the patient while the questionnaire was being filled to make sure that the participants were able to understand the questions and respond accordingly. The participants responded to each question according to the response format provided. The questionnaire consisted of 36 close-ended questions including information related to.

  1. Demographic data
  2. Oral hygiene awareness (11 questions)
  3. Periodontal health awareness (12 questions)
  4. Association between PDs and systemic conditions (8 questions)
  5. Awareness about periodontal treatment (5 questions).


Data were entered into Microsoft Excel worksheet and analyzed using IBM SPSS software package version 20.0. (Armonk, NY, USA: IBM Corp). Qualitative data were described using number and percentage as well as using range (minimum and maximum), mean, standard deviation, and median. The significance of the obtained results was judged at the 5% level.

The used tests were as follows:

  1. Chi-square test
  2. Fisher's exact or Monte Carlo correction
  3. McNamara and Marginal Homogeneity test
  4. F-test (ANOVA)
  5. Paired t-test
  6. Kreskas–Wallis test.



  Results Top


A total of 128 patients agreed to participate and responded with the treating doctors for follow-up visits in this study. However, eight of them did not complete their treatments. Hence, the response rate was 94% (n = 120 out of 128). The 6th year students had 59 patients for the comprehensive care, whereas 32 patients with 5th year and only 29 patients were treated by the interns [Figure 1], [Figure 2], [Figure 3].
Figure 1: Distribution of patients among different batches

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Figure 2: Gender and nationality distributions

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Figure 3: Education level

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  Oral Hygiene Awareness Top


Preoperatively, 94% (n = 113) of all participants agreed that oral hygiene is important for the overall health of the body and were already using toothbrush and toothpaste, while only 51% (n = 61) of them cleaned twice per day and 35% (n = 42) brushed for a minute; 6% (n = 7) among them used miswak.

Although during pretreatment 27% (n = 32) thought that hard brushing would clean better, only 8% (n = 10) were using a hard toothbrush. Thirty-five percentage (n = 42) did not use any interdental cleaning aids.

Among the 59% (n = 71) who cleaned their tongue, 65% (n = 46) of them cleaned it with a toothbrush. Moreover, 46% (n = 55) of the patients were smokers, while 14% (n = 17) used smokeless tobacco [Figure 4].
Figure 4: Smokers versus nonsmokers

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Periodontal health awareness

Fifty-two percentage (n = 62) and 28% (n = 34) patients had not heard the terms dental plaque and calculus, respectively, while 26% (n = 31) thought that PD is caused by calculus. Thirty-nine percentage (n = 47) acknowledged of having gum disease, while only 17% (n = 20) had previous treatments before attending the BMC-DC.

Significantly (P < 0.001) posttreatment, 60% (n = 72) accepted the cause to be an accumulation of bacteria, while 10% (n = 11) still thought the cause to be either hard brushing, accumulation of food, or still did not know why.

Periodontal and systemic disease association

Genes play a role in PDs were believed by 22% (n = 26). Pretreatment, 38% (n = 46) and 16% (n = 19) acknowledged diabetes to be a risk factor for PD and PD as a risk factor for coronary heart disease, respectively. Twenty-two percentage (n = 26) were aware that pregnancy affects gingival health, whereas only 12.5% (n = 15) were aware of the gingival swellings during pregnancy. Seventy-eight perecentage (n = 94) were unaware of the correlation between PD and preterm low birth weight deliveries pretreatment. Furthermore, awareness about the effect of smoking in the healing of periodontal tissues significantly increased from 66% (n = 79) to 88% (n = 106) (P < 0.001).

Periodontal treatment awareness

Posttreatment, 92.5% (n = 111) believed in the dental visit necessity, 51% (n = 61) agreed on visiting biannually, and only 14% (n = 17) still thought that scaling would damage the teeth. Pretreatment, 73% (n = 88) thought that gum diseases are preventable, but 42.5% (n = 51) did not know how.


  Discussion Top


In this study, patients were distributed among three levels of students, who were treating patients of oral diagnosis and periodontal department. The patients were evaluated twice, once upon their first visit with the dental students and later after completion of Phase I therapy, where the aim was to reestablish a healthy functioning periodontium. The aim could not be achieved if the treating doctor was not able to provide the motivational education or if the patient is noncompliant. Overall, oral health awareness is multidimensionally dependent across the population and hence requires to be re-evaluated periodically.

Oral hygiene awareness

This study supports evidence from the previous observations[3],[4],[18],[20],[21] regarding the use of toothbrush and toothpaste. Using miswak to clean the teeth is not surprising, as it is a common practice among Muslims worldwide.[22],[18] Significantly, brushing frequency for the three groups had increased from once a day to twice per day by about 20% (n = 26) (P = 0.035), while the duration of brushing increased to 2 min by about 31% (n = 37) (P < 0.001). This is contrary to the Japanese study by Saito et al.[15] which reported 45% brushing three times per day, whereas only 34% twice a day.

An insignificant increase in the frequency of changing the toothbrush once in 3 months was observed by about 63% (n = 76) of the patients which is consistent with the literature,[1],[3],[12] contradicting the study by Jain et al. which had 60% of the patients changing toothbrushes only when they became redundant [Table 1].[20] In our study, the brushing movement shifted from combined to vertical, whereas the majorities were brushing horizontally in the previous studies.[12],[20]
Table 1: P value for the questions related to oral hygiene awareness

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Contrary to expectations, the use of interdental aid increased from 35% (n = 42), not using any aid to 39% (n = 47), and started using floss (P < 0.001). This outcome is contrary to the research conducted by Al-Sunaidy,[13] Oberoi,[12] and Tubaishat et al.,[18] hence confirming our hypotheses.

More than 75% (n = 93) (P ≤ 0.001) started cleaning their tongue among all the three groups and 70% (n = 67) of them did it using toothbrush, while 26% (n = 24) (P = 0.134) used the tongue cleaner. On the contrary, the study by Oberoi et al.[12] reported that 21% used toothbrush and 36% used tongue cleaner to clean their tongue, whereas Jain[20] reported that 20% of the patients were only cleaning their tongue. A possible explanation of this could be the oral care advice given at the dental visits.

The industrialized parts of the world have entered a “postmedical” era, in which physical well-being is undermined by certain types of individual behaviors (e.g., smoking), economic factors (e.g., poverty and overeating), and factors influencing the physical environment which are not amenable to medicines.[6] Hence, these results can be independent of the literacy rate of the population, as being educated does not guarantee a higher OHL[2] just as previous studies have associated dental health with tobacco smoking, alcohol consumption, and physical activity.[6]

Surprisingly, the prevalence of smokers either nicotine or smokeless tobacco was similar to other studies[13],[23] where more than 40% (n = 55) were smokers and did not quit during or after treatment.

Periodontal health awareness

The oral cavity is an open growth system with an uninterrupted introduction and removal of microbes and their nutrients. It offers diverse habitats, where in different species of microorganisms can prosper. Biofilms have been implicated as the chief culprit in the etiopathogenesis of dental caries and PD.[24]

In 2002 only 16% of the Jordanian adults knew the meaning of dental plaque[25] which increased to 26% by Tubaishat et al, [Table 2].[18] In our study, there was an increase in the knowledge of the word dental plaque (58%, n = 70) and dental calculus (97.5%, n = 117) where the majority (73%, n = 88) believed calculus to be the causative factor of PD (P ≤ 0.001) and only a few believed plaque to be the cause. Having an educated group of patients in our study, our results contrast that of the previous study population (medical professionals and teachers) where 80% believed plaque to be the cause.[1],[16]
Table 2: P value for the questions related to periodontal health awareness

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In our research patients, generalized plaque-induced gingivitis was the most common diagnosis, followed by generalized moderate and localized severe chronic periodontitis [Table 3], [Figure 5]. Inconsistency has been observed regarding being knowledgeable about having the periodontal (gum) disease. In 1999, Gilbert[23] reported 14%, Dietrich et al.[19] reported 30%, and Tubaishat et al.[18] reported 40%. What stands out is that our study testified 61% (n = 73) (P < 0.001), hence proving that the health-care provider is highly influential on the OHL rate of their patients. Moreover, a significant improvement was seen in the knowledge of periodontal pockets and bone loss (P < 0.001) disparate the literature (34% and 12%, respectively[19]).
Table 3: Percentage of the periodontal diagnoses among our study group (n=120)

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Figure 5: Periodontal diagnosis

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The study by Tubaishat et al.[18] reported that 44% of the patients believed poor brushing technique to be the cause of bleeding. Postoperatively, the majority of our patients attributed the cause to be due to the accumulation of bacteria, while only 12% believed the same for Tubaishat et al.[18] There was no significant change in the report of having bad breath sometimes, before or after treatment for the majority of the population analogous to the previous studies.[18],[20],[25]

Although the increase in the level of awareness and the obtained results were significant, they were far from promising to completely prevent oral and PDs, which is definitely dependent on the OHL.

Periodontal and systemic disease association

Periodontitis has been implicated as an emerging risk factor for several major systemic diseases or conditions, including cardiovascular disease, stroke, and diabetes, as well as for preterm, low-birth weight infants. Prevention and early intervention of PDs are critical, and oral hygiene education is central to all stages of treatment. In addition to professional care, successful management of the PD depends on the capacity of the patient's oral self-care.[3],[5]

The study by Pralhad and Thomas[8] reported 48% attributing genes as a cause of PD [Table 4]. Although smaller, our study had a significant improvement in believing the same concept. Similar to the study by Swati et al.,[16] in our study, about 83% (n = 100) of the patients of all groups agreed on diabetes as a risk factor for PD.
Table 4: P value for the questions related to periodontal and systemic disease association

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While the awareness regarding the effect of pregnancy having on PD increased marginally, the majority were unaware of the gingival swellings during pregnancy. On the contrary, 60% were aware of the same in Swati's study. Minimal increase in acknowledgment of PD as a risk factor for preterm low birth weight in our study is observed which is contrary to Swati's study (67%).

Apart from pregnancy being a cause of the gingival enlargement, bacterial deposits are the main culprit as well as including the effects of drugs. Hence, awareness regarding bacteria raised, but the majority were still unaware of the effect of certain drugs. Among them, about one-third agreed on drugs being a cause and mentioned cocaine or blood pressure medications.

It can be noted that there is very little difference in the knowledge being given to the patients regarding systemic association with their oral health. This difference prominently may be attributed to the patient to be having the disease (e.g., diabetics were informed of the deleterious effects, but nondiabetics did not receive any knowledge regarding the same). Hence, doctors have to be more proficient in discussing all or common parameters affecting oral health.

Although the smoker's habits were not significant to cessation, but awareness increased from pre- to post-operatively among the majority, believing that smoking affects the healing of the periodontal tissues parallel to Swati's study, but unlike the study by Gilbert where only 32% strongly believed that there is no association of smoking to oral and PD.

Periodontal treatment awareness

Prevention and treatment of chronic periodontitis depend primarily on professional cleaning, appropriate plaque control, and modification of adverse risk factors.[4] Thus, information gathered about the patient's demographics and behavioral aspects related to chronic periodontitis are essential for designing successful preventive and treatment measures.[13]

Following the studies by Pralhad and Thomas,[16] Shah et al.[15] and Sekhar,[1] there was an increase in the belief that PDs are preventable by brushing and flossing, and bleeding gums need the attention of dentist across all groups of patients [Table 5]. The majority started to believe that the dental visit could be annually or biannually, but there was a huge percentage across all groups believing that dental visits were need based, as with the studies by Tubaishat et al.[18] and Taani.[25]
Table 5: P value for the questions related to periodontal treatment awareness

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We observed significant positive changes throughout our study. However, one possible limitation was the small size of the population which does not necessarily represent the whole population. Therefore, a larger, more representative sample has to be studied for more direct correlations. Furthermore, the use of clinical periodontal parameters and indices before and after clinical setup in correlation with the questionnaire is a point worth considering for future studies.


  Conclusion Top


Both of our hypotheses were accepted by this study [Figure 6]. Patient's perception of the quality of dental care providers and their intent on re-accessing a dental service may be associated with a practitioner's professionalism, empathy, and delivery of oral hygiene advice. Certain people (5% in our study), probably from the low-income group, still do not believe in prophylactic visits to a dentist, thus giving them poorer dental health behavior.
Figure 6: Impact of groups on each section of the questionnaire

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The maintenance of periodontal health requires preawareness in public and patients. Treatments will fail and in fact will not even start if individuals are not aware of the differences between periodontal health and disease, the significance of these differences, and the role they play in prevention and control.

Therefore, dental campaigns should run all over the kingdom to educate and motivate a large group of population with materials that are written and explained in the patient's native language, especially in remote areas where access to professional plaque removal including regular follow-up combined with patient oral hygiene instructions is difficult.

Thus, any periodontal care program intended to prevent PD among Saudi adults is required to focus on their demographic characteristics and current oral hygiene habits.

Acknowledgements

The authors gratefully acknowledge the continuous support of Dr. Nadeem Ikram with data analysis, as well as the support of all participants. The authors are also thankful to all the personnel in any reference that contributed in/for the purpose of this research, along with special thanks to the Saudi Society of Periodontology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
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Results
Oral Hygiene Awa...
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