Oral health knowledge deficit: A barrier for seeking periodontal therapy? A pilot study.

CONTEXT: In developing countries many chronic conditions including periodontitis are on the rise. Oral health attitudes and beliefs are important factors affecting oral health behavior. AIMS: The aim of this pilot study was to assess the existing knowledge about periodontal disease and its impact on treatment seeking behavior in a group of population visiting the out-patient Department of Periodontics, Yenepoya Dental College, India. This study also attempted to identify deficit in the knowledge if present. SETTINGS AND
DESIGN: This is a written questionnaire based pilot study. 143 subjects (89 male and 54 female) agreed to participate in the study. Simple random sampling was used for recruitment. SUBJECTS AND METHODS: A written questionnaire consisting of 18 questions was given to the patients. Only one correct answer was present and the score given was + 1. The knowledge of the subjects was reflected by their ability to select a correct answer from the number of distractors (multiple choices, prespecified answers). STATISTICAL ANALYSIS USED: SPSS software version 15.0 is used for all statistical analysis. The Chi-square test was employed to assess the passive knowledge of the participants in relation to their age.
RESULTS: We found a deficit in the knowledge in all the topics investigated. No consistent relationship between age and gender was found. Female respondents had better knowledge about oral hygiene compared to males.
CONCLUSION: We made an attempt to assess the knowledge of periodontitis among the participants of this study. Knowledge deficit was found in the population surveyed. This knowledge deficit could be one of the reasons why patients do not seek periodontal treatment routinely unless there are acute symptoms. There is urgent need to educate the patients about the periodontal disease, the need for the treatment of periodontitis and advanced treatment modalities available.

INTRODUCTION

Good oral hygiene practices, avoidance of tobacco and consumption of a healthy diet are modifiable risk factors that can help maintain periodontal health. The rise in the prevalence of periodontitis, a complex multi-factorial disease, has increased the burden on the oral health care system in India. The prevention and control of this disease need to be addressed at both the population and individual level.[1] This is more relevant in the current scenario where periodontitis is one of the major causes of tooth loss after dental caries.[2] Poor oral hygiene and noncompliance lead to the progression of the periodontal disease and tooth loss.[3] Sufficient knowledge of the oral health behavior and the understanding of the scientific reason for its improvement is an important precondition to improving oral health behavior.[4]

Oral health attitudes and beliefs affect oral health behavior. The motives to seek prompt preventive periodontal treatment could be the belief of increased susceptibility to periodontal disease, the perception that periodontal problems need attention, and acceptance that periodontal treatment is beneficial to overall health. The compliance with oral health care regimens is better among well-informed patients. Misconceptions or incorrect knowledge about oral health may actually lead to harmful behavior.[5] The socioeconomic status, attitude, periodontal awareness, habits, and oral health behavior are the factors that determine the level of periodontal health and oral health in an individual.[3]

Baseline data on knowledge levels are required to determine the areas of oral health education that need to be improved for the vulnerable population. We need to determine those factors that can be amended and are associated with adequacy of oral health knowledge to formulate appropriate educational strategies.[6] In view of this requirement, a questionnaire-based cross-sectional pilot survey was conducted where an attempt was made to understand patient's beliefs, level of knowledge and possible methods to improve the patient-periodontist relationship.

Aims and objectives

The aim of this pilot study was to assess the existing knowledge about the periodontal disease and its treatment in a group of the population visiting out-patient Department of Periodontics, Yenepoya Dental College. This study also attempted to identify deficit in the knowledge if present.

SUBJECTS AND METHODS

This was a written questionnaire based pilot study. The total number of subjects who participated in the study were 143, 89 males, and 54 females. The age group ranged from 14 to 60 years [Tables 1 and 2]. The participants were selected from the outpatient Department of Periodontics, Yenepoya Dental College, Yenepoya University. Simple random sampling was used. Prior to the study, clearance was taken from the institutional ethical committee. Informed consent was taken from the participants.

Table 1

Sample characteristics: Number of participants in the study and percentage of population within each gender and age group

Table 2

Passive percentage mean knowledge on the different categories assessed in the questionnaire

The main topics included were knowledge about periodontitis, risk factors associated with periodontitis, knowledge of oral hygiene-related behavior, knowledge of periodontal treatment and advances in Periodontology, knowledge about prevention of periodontitis, knowledge about patient-periodontist relationship.

A written questionnaire consisting of brief case history, chief complaint, and 18 questions was given to the participants [Appendix 1]. It contained both open-ended and closed-end questions. The questionnaire was typed in English. For those participants who did not know English well-trained translators helped them understand the questions. There were no subheadings in the questionnaire. Six yes/no questions under chief complaint were not scored. It was written only to help participants relate to the chief complaint of periodontal disease. However, for the purpose of scoring the evaluators entered the score in different subcategories for closed-end questions (multiple choice questions) only. Only one correct answer was present and the score given was + 1. Question number 17 and 18 addressed source and methods to improve knowledge. Hence, they were not scored. We assessed the percentage of the response.

We recorded the sample characteristic like number of participants in the survey and percentage of the population within each age group and gender wise distribution. According to Deinzer et al., Knowledge can be categorized as active and passive knowledge. Passive knowledge is reflected by the ability of the participants to give the correct alternatives from a given number of distractors.[2] Questions related to ‘Methods to improve knowledge’ was not scored. It was considered as participants possible suggestions to improve the periodontal knowledge. This questionnaire assessed only passive knowledge. Hence, those questions were framed in the multiple choice question format. Overall knowledge is the summative score of assessment of knowledge in all the categories.

Knowledge was graded as very good (score of 90% and above), good (score of 80–89%), moderate (50–79%) and poor (<50%). The knowledge deficit was graded as a complete deficit (0), the severe deficit (<25%), and moderate deficit (25–50%), based on their scorings in each category. We did not try to correlate the passive knowledge of oral hygiene measures, socioeconomic status or educational background of the patient, as this was not the aim of the study.

The knowledge of the subjects was reflected by their ability to select the correct answer from the number of distracters (multiple choices, prespecified answers). Clarity, comprehensibility, the suitability of questions and retest reliability were tested in a student sample that was given the written questionnaire.[7] No oral hygiene examination was done.

RESULTS

Statistical data analysis

Categorical data was analyzed by frequency and percentage. Assessment of knowledge level was obtained by mean, standard deviation and mean in terms of percentage. Karl Pearson correlation coefficient was used to ascertain the correlation between knowledge and age. Man–Whitney test was used to compare the knowledge between the genders. SPSS software version 15.0, IBM SPSS INC., Chicago, Ilinois, USA is used for all statistical analysis. A total of 18 questions were categorized into seven categories:

Knowledge of periodontal disease

Knowledge of the risk factors for periodontal disease

Knowledge of oral hygiene behavior

Knowledge of treatment and advances in Periodontology,

Knowledge about prevention of periodontitis

Knowledge about periodontist-patient relationship and

Over all knowledge [Appendix 1].

Sample characteristics

Total numbers of participants were 143. 37.8% were females, and 62.2% were male participants. 21.7% of the participants were under 20 years of age, 47.6% were in the age group of 20–30 years, 10.5% were in the age group of 31–40 and 20.3% were in the age group of 41–60 years [Table 1].

Knowledge of periodontal disease

Question number 1–5 was used to evaluate the knowledge of the periodontal disease. The mean score obtained by the participants was 0.33 ± 0.79. Mean percentage knowledge was 6.57%. The severe deficit in the knowledge was noted [Table 2].

Knowledge of the risk factors for periodontal disease

Question number 6–8 was used to evaluate the knowledge of the risk factors for a periodontal disease the Mean score obtained by the participants was 0.26 ± 0.63. Percentage mean knowledge was 8.62%. The severe deficit in the knowledge was noted [Table 2].

Knowledge of oral hygiene behavior

Question number 9–10 was used to evaluate the knowledge of oral hygiene behavior. The mean score obtained was 1.33 ± 0.94. Percentage mean knowledge was 66.43%. The knowledge level was moderate [Table 2].

Knowledge of treatment and advances in periodontology

Question number 11–12 was used to evaluate the knowledge of treatment and advances in periodontology. The mean score obtained was 0.29 ± 0.71. Percentage mean knowledge was 14.69%. Severe knowledge deficit was noted [Table 2].

Knowledge about prevention of periodontitis

Question number 13–14 was used to evaluate the Knowledge about prevention of periodontitis. The mean score obtained was 0.50 ± 0.50. Percentage mean knowledge was 25.17%. The moderate deficit in the knowledge was seen among the participants [Table 2].

Knowledge about periodontist-patient relationship

Question number 15–16 was used to evaluate the Knowledge about the periodontist-patient relationship.

The mean score obtained was 0.28 ± 0.45. Percentage mean knowledge was 13.99%. Severe knowledge deficit was noted [Table 2].

Over all knowledge

Overall knowledge is the summative score of assessment of knowledge in the above-mentioned categories. Scores for the Questions 1–16 were included to obtain the overall knowledge [Appendix 1]. The minimum possible score was 3 and the maximum score was 16. The Mean score was 2.99 ± 1.98. Percentage mean knowledge was 18.71%. Severe over all knowledge deficits were noted among the participants [Table 2].

Passive knowledge in relationship to the age

There was no correlation between age and the passive knowledge [Table 3].

Table 3

Passive percentage mean knowledge on the different categories assessed in the questionnaire

Passive knowledge in relationship to the gender

A significant difference in the knowledge of oral hygiene behavior was noted. Females had a mean knowledge score of 1.556 ± 0.839 compared to 1.191 ± 0.987 score of males. Mean percentage score of females was 77.78% and in males the score was 59.55%. P < 0.05. There was no statistically significant difference between gender and other topics investigated [Table 4].

Table 4

Correlation of gender and passive Knowledge of the participants

Percentage response to source and methods to improve knowledge

Questions 17 and 18 were included in this category. No scores were allotted. We did not want to judge the source and methods of existing passive knowledge. 42% of the participants felt that their source of knowledge is dental camps. 20.3% felt that advertisements on television are their main source of knowledge. 14.7% felt that online sources like internet provide them knowledge and 23.1% felt that health care professionals like doctors and nurses provide them the information about periodontitis.

Nearly, 38.46% felt that the government should take measures to improve their knowledge. 23.07% felt that dentists can update their knowledge. 10.5% felt that improvement in knowledge can be achieved by sharing the responsibilities between themselves, dentists and health department. 27.97% felt that tooth paste manufacturing companies can update their knowledge [Table 5].

Table 5

Percentage response to source and methods to improve knowledge

DISCUSSION

A questionnaire study evaluating the knowledge about periodontitis, risk factors associated with periodontitis, knowledge of periodontal treatment and advances in periodontology, knowledge about prevention of periodontitis, knowledge about patient periodontist relationship was conducted. In this study, we noticed knowledge deficit in all the topics investigated. These results were in agreement with Deinzer et al.[2] They considered percentage knowledge below 80% as a bench mark to establish knowledge deficit. There were several differences in our study population compared to the German population investigated. There were differences in ethnicity, culture, socioeconomic status, access to oral care and treatment. In our previous study, we noted that even health care professionals like physiotherapists and physicians had knowledge level of 50.29% and 68.37% respectively.[8] Health care professionals have better education, exposure, access to dental professional colleagues and hence improved awareness about the periodontal disease than the general population. Considering the results of our study and difference in the level of knowledge among health care professionals and the general population, we set 50% knowledge level as the benchmark. We considered knowledge level below 50% as knowledge deficit. We assessed passive knowledge in our study. Active knowledge can be better assessed in the interview format.

The knowledge, awareness and attitude studies can be used to understand the existing knowledge level and enhance educational efforts to reduce the deficit. We found that age did not influence the level of knowledge as there was no correlation between age and the knowledge of the topics investigated. Deinzer et al. made similar observations and noted that there was no rationale for restricting educational efforts to specific target groups. The whole population must be addressed.[2] However, we noted that mean percentage knowledge of oral hygiene behavior was significantly different in females compared to males. This finding was in agreement with Rahman et al.[9] This has been explained by the fact that the females were more esthetically conscious, better informed and interested in visiting dentist.[10]

The respondents had a severe deficit in knowledge of risk factors that could predispose individuals to the periodontal disease. Improving the awareness of the risk factors could benefit those individuals who are at a higher risk. Knowledge of oral hygiene behavior was moderate. This may be due to the impact of the mass media and the efforts of various oral hygiene awareness campaigns carried out. The Severe deficit was noted in the knowledge of treatment and advances in periodontology. This could be explained by respondents’ belief about visiting periodontists regularly.

51.7% of the respondents believed that visiting periodontist regularly was not necessary. Several reasons can be attributed to this finding. This could be due to the misconception and incorrect information that periodontal treatment is not essential as it does not cause acute symptoms, unlike pulpal disease that warrant immediate attention. There is also a lack of awareness about periodontitis and systemic disease link despite large data establishing bidirectional relationships. Overall knowledge is the summative score of the scores obtained in the various categories. The severe deficit was noted in the overall knowledge as most of the topics investigated had knowledge deficit.

We did not subject two topics, the source of the existing knowledge and methods to improve knowledge, that is, question number 17 and 18 [Appendix 1] to statistical analysis. Within the limitations of our existing questionnaire format, it was not possible to quantify this knowledge. While assessing the source of the existing knowledge, 42% felt that the dentist is the only source of knowledge. 18.2% believed that their knowledge could be improved by organizing regular dental camps. All the health care providers need to be educated about periodontitis and recent advances in the field of periodontology. They interact with the larger population and could serve as an important source of information for the general population.

Respondents felt that periodontal disease could be prevented by sharing the responsibilities of educating, preventing, treating and modifying oral hygiene-related behavior between the dentists and the patients. This highlights the need for an improved communication system to disseminate knowledge about the periodontal disease and its associated risks. It also points out that the subjects are open-minded to the changes in their oral health related behavior. Deinzer et al. made similar observations. Educational efforts are a fundamental step in a more general approach to improving public oral health.[2]

Health behavior models are complex involving different aspects such as self-efficacy expectations, decisional balance, perceived susceptibility and normative beliefs.[411] Knowledge is one of the factors affecting these issues. However, it can be considered as one of the preconditions for additional measures to improve oral health behavior. Hence, most interventions aimed to improve oral health include measures to improve oral health-related knowledge.[12]

The limitation of this research is that evaluation of results is based on the self-reported data. The Misinterpretation of questions and memory errors can cause measurement error.[1314] To overcome this problem, the questions were worded in simple English. This study shows that there is a knowledge gap in the general population. The study was a nonexperimental cross-sectional design. Hence, evidence of prediction of causal relationships cannot be provided. Interpretation of the results should be done with caution because of limited sample size and further longitudinal studies with a larger population size are needed. There is an unmet need for improving the oral health of the general population. Oral health education should also emphasize on the recent advances in the periodontal therapy and cater to the need of both urban and rural population alike.

CONCLUSION

We made an attempt to assess the knowledge of periodontitis among the participants of this study. Knowledge deficit was found in the population surveyed. This knowledge deficit could be one of the reasons why patients do not seek periodontal treatment routinely unless there are acute symptoms. However, the study sample is not large enough to generalize the results to a larger population. Within the limitations of the study, we feel there is a need to educate the patients about the periodontal disease, advanced treatment modalities available and the need for the treatment of periodontitis. However, a study with larger sample size and encompassing different respondents with varied cultural backgrounds is needed to validate the conclusion.