A survey on acquaintance, orientation and behavior of general medical practitioners toward periodontal diseases.

BACKGROUND: An association between oral conditions such as periodontal diseases and systemic conditions is noted. As such, periodontal disease is associated with an increased risk of systemic illnesses such as cardiovascular disease, diabetes, adverse pregnancy outcome, atherosclerosis, stroke and hospital acquired pneumonia. The concept of diagnosing and treating a potential patient to minimize the deleterious effects of this chronic infectious and inflammatory condition on systemic conditions represents both an unprecedented challenge and opportunity to our profession. Keeping this in view, the present survey was designed to evaluate the acquaintance, orientation and behavior of general medical practitioners; concerning the effects of periodontal disease on systemic health.
MATERIALS AND METHODS: A typed questionnaire carrying four sets of questions was distributed among general medical practitioners of seven different government and private medical colleges and hospitals. Questionnaire was developed to assess the acquaintance, orientation and behavior of general medical practitioners toward periodontal disease.
RESULTS: Most of the respondents have knowledge regarding the signs and symptoms of periodontal disease and its association with cardiovascular disease. However, majority of them do not know about the potential effect of periodontal disease on other organ systems.
CONCLUSION: General medical practitioners have inadequate knowledge regarding periodontal diseases. Hence, oral health related training should be an integral part of the medical curriculum.

INTRODUCTION

Periodontal disease is a bacterially induced chronic inflammatory infection that affects tooth-supporting connective tissue and alveolar bone in the oral cavity, eventually leading to tooth loss.[1] Periodontitis is common, with mild to moderate forms affecting 30–50% of adults and the severe generalized form affecting 5–15% of adults in the United States.[2] Its prevalence in developing countries is even higher with considerable global variation; although the prevalence of the severe generalized disease appears to be similar in most of the populations.[1]

As with chronic infections elsewhere in the human body, chronic periodontal infections are associated with certain systemic changes. A case-control study in Glasgow observed significant increase in plasma fibrinogen concentration and white blood cell count in patients with chronic gingivitis and periodontitis.[3]

Recently, there has been a resurgence of interest in the interaction between oral conditions and a number of prevalent systemic diseases.[45] The possibility that periodontal diseases might influence the morbidity and mortality of systemic diseases has led to new dimensions of research in periodontal medicine. Evidence for a link between periodontal disease and several systemic diseases is growing rapidly. The infectious and inflammatory burden of chronic periodontitis is thought to have an important systemic impact.

Among these interactions is that between oral infections such as periodontitis and systemic diseases such as cardiovascular disease, cerebro-vascular disease (stroke), peripheral vascular disease, diabetes mellitus, respiratory infections and adverse pregnancy outcomes.[678910] Patients with severe periodontitis are almost twice as likely to have a fatal heart attack and three times as likely to have a stroke as patients without periodontal disease, even after adjusting for known cardiovascular risk factors such as blood lipids, cholesterol, body mass, diabetes and smoking.[1112] Severe anaerobic lung infections can occur following aspiration of salivary secretions especially in patients with periodontal disease. Estimates have been made that 30–40% of all cases of aspiration pneumonia, necrotizing pneumonia, or lung abscess involve anaerobic bacteria, most of which have been associated with periodontal disease. It has also been noted that oral bacteria may also have a role in the exacerbations of chronic obstructive pulmonary disease.[8]

The World Health Organization stated that oral diseases, including periodontal diseases, are a serious health problem and increasing the awareness of oral health worldwide should be considered an important component of general health and quality of life.[13]

A recent consensus statement recommended that patients with atherosclerotic cardiovascular disease should receive a periodontal evaluation and patients with moderate to severe periodontitis should be informed about their potential increased risk of atherosclerosis.[14] Whether general health care providers are applying this information about the link between systemic health and periodontal diseases in their practices, depend on the levels of their knowledge of such valuable fact.

Till date, very few studies have assessed the general physician's knowledge about the awareness of the bidirectional relationship between periodontal and systemic disease. Keeping this in view, the present survey was designed to evaluate the acquaintance, orientation and behavior of general medical practitioners; concerning the effects of periodontal disease on systemic health.

MATERIALS AND METHODS

Source of data

This survey was conducted among general physicians of seven different government and private medical colleges and hospitals in the state of Punjab. A total of 200 doctors participated in this study in the month of April, 2011.

Method of collection of data

A short questionnaire carrying four sets of questions was distributed to 200 general physicians in different hospitals. Questionnaire was developed to assess the acquaintance, orientation and behavior of general medical practitioners toward periodontal disease. Informed verbal consent from all participants was obtained prior to their contribution. The nature and purpose of the study were clearly explained to them. Participation was anonymous to minimize the biasing of data. Its voluntary nature was emphasized, and strict confidentiality assured.

The first part of the questionnaire recorded information about general demographics like doctor's age, sex, educational qualification, name of the specialty (if any), and the name of the institute from where graduated. The second part contained six true and false optional questions regarding the periodontal disease. Third part of the questionnaire carried four questions and inquired about general practitioners orientation toward diagnosis of periodontal disease. For this set of questions, the participants were given the choice of “never”, “occasionally”, “very frequently”, and “always.”

The next part carried five questions regarding acquaintance and attitude of participants toward periodontal diseases. The choices given were “no”, “to some extent” and “yes”.

The last part had six questions, with options of “aware” and “unaware” to assess the awareness of participants about bidirectional relationship between periodontal disease and systemic health.

The respondents were asked to tick the most appropriate answer according to their knowledge from the given list of answers. Filled questionnaires were collected on the same day.

Statistical analysis

Results were analyzed using commercially available Statistical Package for the Social Sciences (SPSS) software for windows version 11.0 IBM corporation. Frequency distribution and descriptive statistics were generated for all study variables. Chi-square analysis was carried out to detect significant associations among categorical variables.

RESULTS

The survey was given to a total of 200 general medical practitioners; out of which 6 respondents filled it wrong, that is, either they filled it incompletely or filled more than 1 option, giving a correct response rate of 97%. Their median age was 35 years: 114 (59%) were males and 80 (41%) were females. Of the responders, 15 were medical interns who were on 1-year compulsory rotatory internship, 90 were medical graduates and 89 were post-graduates from the medicine specialty; thus giving a percentage of 7.7%, 46.4% and 45.9%, respectively [Table 1].

Table 1

Number and percentage of participants based on qualification

Table 2 shows the reported knowledge about periodontal diseases based on a questionnaire carrying true/false options, with the correct answer and the percentage of subjects who answered each question correctly. 100% subjects answered first question correctly. The correct response rate for second and third question was 84.5% and 82%, respectively. However, when it comes to the reverse relationship that is; periodontal medicine; only 45.9% and 19.1% answered the fourth and sixth question correctly. Most of the respondents have knowledge regarding the signs and symptoms of periodontal disease and its association with cardiovascular disease. However, majority of them do not know about the potential effect of periodontal disease on other organ systems.

Table 2

True/false knowledge items with correct answers and percentages of subjects who answered correctly (n=194)

Table 3 shows the distribution of correct responses given by participants based on qualification. Interns have the least knowledge when compared to graduates and postgraduates about the potential effects of periodontal diseases on systemic health.

Table 3

Distribution of correct responses given by participants based on qualification

Figure 1 shows the number of correct answers given for first set of questions by all 194 responders. No subject answered fewer than 2 questions correctly. Only 15 respondents answered all six questions correctly, thus giving a perfect quiz score of 7.7%, which is a very less Figure 40.7% respondents answered four questions correctly, giving a median quiz score of 4 with an interquartile range: 3–5.

Figure 1

Graph showing percentage of respondents giving two, three, four or five correct answers for first set of questions (true/false knowledge)

Figures 2–4 shows the responses to questions exploring the general medical practitioners regarding their knowledge, awareness, orientation and behavior toward periodontal diseases. Only 7.7% (N = 15) of the respondents always inquire their patients that whether they have any periodontal disease whereas only 2.6% (N = 5) always examine their patients for it. 28.4% (N = 55) have never taken any Periodontist's suggestion or have never referred their systemically ill patients for a periodontal evaluation [Figure 2].

Figure 2

Response to second questionnaire exploring clinical practice orientation/behavior

Figure 4

Response to questions exploring awareness toward perio-systemic link (periodontal medicine)

About 47.4% (N = 95) think that to some extent periodontal disease evaluation should be done by general medical practitioners in case of systemically ill patients while 34.5% (N = 67) fully agree to it. Only 30.9% (N = 60) were at an ease while performing a simple periodontal examination like probing. 51% (N = 99) did not acquire any knowledge about periodontal disease and its relation with systemic health while in medical college. Whereas 53.6% (104) agree that medical training should include acquaintance about screening periodontal disease. 43.8% (N = 85) respondents feel that patients expect them to discuss the role of periodontal health and its relation with systemic health [Figure 3].

Figure 3

Response to questions regarding inclusion of periodontal examination in medical training

Finally, Figure 4 shows the response to questions exploring awareness toward Perio-systemic link. Majority of respondents 88.1% (N = 171) were aware that diabetes affects periodontal health adversely. However, when it comes to potential effects of periodontal disease on other organ systems such as coronary heart disease, premature rupture of membrane (PROM), preterm low birth weight (PTLBW), Preeclampsia and hospital acquired pneumonia, the knowledge was limited. 66% (N = 128) were aware that patients with poor oral hygiene have 2 fold increased risk for coronary heart disease. Majority of the respondents (54.6%, N = 106) were unaware that periodontal disease can result in PROM and PTLBW. Only 38.4% (N = 74) knew the fact that periodontal disease contributes to more PTLBW babies than smoking and alcohol use during pregnancy. Majority (56.2%, N = 109) were unaware that periodontal disease may increase the risk of preeclampsia to 2–2.5-fold. 40.2% (N = 78) did not know that periodontal disease may at as a risk factor in hospitalized patients to cause hospital acquired pneumonia.

DISCUSSION

Few studies have evaluated the attitude and behavior of general medical practitioners toward periodontal diseases.[111] Most of these studies showed; that a very low number of dentists communicate with the physicians of their patients and vice-versa.[1516] To the best of our knowledge, this is the first study of its type, in this region of the country that documents the acquaintance, orientation and behavior of general medical practitioners toward periodontal disease.

There is growing evidence that identifies a strong association between periodontal disease and systemic health. These associations pose a compelling reason for general physicians to increase their role in inquiring about oral health care and screening for oral problems and lead to a call for greater collaboration between dentists and physicians.[1] In our survey, we found that there is limited knowledge of general medical practitioners about periodontal diseases and their impact on overall health.

Our results show that there is an underestimation of the extent, severity and outcome of periodontal diseases and their effects on systemic health. Most of the respondents have the basic knowledge about the signs and symptoms of periodontal disease and its relationship with myocardial infarction but they are less aware of the fact that periodontal disease has potential effect on many organ systems of the body. The low awareness of periodontal complications could be explained by the medical curriculum and practice focus, which is mainly concerned with systemic conditions, and lack of knowledge and interest toward oral diseases and their possible bidirectional link.

Few respondents expect that they should discuss with their patients the potential role of periodontal health and its reciprocal relation with systemic health, while majority of them think that their main role is to focus on systemic health conditions rather than on oral health, which comes within the vicinity of dental specialists. The reason may be that the majority of the physicians did not acquire any knowledge about periodontal disease and its relation with systemic health while they were in medical college. They do not feel at ease while performing simple periodontal examination like probing, given the reason that they have not been trained about oral health in the medical college. More than half of the respondents are of the opinion that medical training should include some acquaintance about periodontal disease.

Based on the findings of this study, it can be interpreted that training in medical schools does not cover all aspects of oral/periodontal health which is very necessary based on today's need. Given the high prevalence of periodontal disease, its deleterious impact on oral health and its association with systemic disease, patients seeing internal medicine physicians may not be receiving the education and guidance needed.[17] There is an urgent need for new information to enable the medical profession to identify who needs periodontal treatment and how to treat such patients.

In order to improve general physicians capability to diagnose and intervene the periodontal health related issues, at least a basic curriculum should be added in their medical training program. Reducing the systemic risk associated with periodontitis requires new diagnostic tools and a set of clinical guidelines for treatment. In essence, a new standard of care needs to be created.

CONCLUSION

Through the findings in this study, it may be concluded that general medical practitioners have inadequate knowledge regarding periodontal diseases. Hence, oral health related training should be an integral part of the medical curriculum. Increasing the knowledge of general physicians about the oral health and its bidirectional link with systemic health will undoubtedly improve their attitude and behavior toward oral diseases. It appears highly likely that the new knowledge being gained in the discipline of periodontal medicine will serve as an impetus to further coalesce medicine and dentistry. On the other hand, dentists will need to assume a larger responsibility for the overall health of patients, and eventually periodontal care may become a medical necessity. Knowledge of relevant systemic conditions needs to be more extensive to enable dentists to interact more meaningfully with their medical colleagues. This will place new educational goals on the profession.