Periodontal disease status and associated risk factors in patients attending a Dental Teaching Hospital in Rawalpindi, Pakistan.

BACKGROUND: Investigators have identified an association of socio-demographic and medical factors with periodontal risk. This study observed status and association of periodontal disease and associated risk factors/indictors.
MATERIALS AND METHODS: All patients attending a dental teaching hospital were interviewed for socio-demographic and medical information through a structured questionnaire. Participants were examined for periodontal status using the community periodontal index (CPI), by a single examiner during September to November 2012. An association of age, gender, smoking habit, systemic conditions, and oral hygiene measures with periodontal status ([periodontitis CPI score ≥3]/nonperiodontitis [CPI score ≤2]) was analyzed by applying Chi-square test and forward selection stepwise regression analysis.
RESULTS: One thousand nine hundred and eighteen patients were examined during the study period. The findings revealed that 63.5% of the subjects had CPI score ≤2 (nonperiodontitis), while 34.5% were found with CPI score ≥3 (periodontitis). Age, gender, occupation, smoking, diabetes, arthritis, cardiovascular disease, kidney disease, stress, medications, and oral hygiene habits of using tooth powder or tooth brushing were significantly (P ≤ 0.037) associated with periodontal status. Regression analysis showed a significant association of age, occupation, and smoking with periodontitis.
CONCLUSION: This study observed prevalence of periodontitis in one-fourth of study sample. The study confirmed various socio-demographic risk factors/indictors associated with increased risk of periodontitis.

INTRODUCTION

Prevalence of the periodontal disease varies in different regions of the world, and a higher prevalence and severity of periodontal disease in Asian countries is reported.[1] Periodontal diseases are chronic infectious diseases that results in the inflammation of specialized tissues that surround and support the teeth. It can lead to a progressive loss of connective tissue attachment and alveolar bone. This tissue destruction is characterized by the formation of periodontal pockets that act as reservoirs for bacterial colonization of the dento-gingival environment.[23] Periodontal diseases can be divided into two major categories: (a) Gingivitis – nondestructive and reversible gingival inflammation related to a nonspecific bacterial challenge; and (b) periodontitis – destructive inflammation of teeth supporting tissues (periodontal ligament, cementum, and alveolar bone) related to some specific periodontal pathogens.[4]

Many risk factors and risk indicators have been identified that are associated with increased risk of periodontal disease. Socio-demographic factors of age, sex, education, income, occupation, medical conditions such as diabetes, cardiovascular disease (CVD), arthritis, kidney disease, respiratory disease, stress and habits of smoking, tobacco use, alcohol, and oral hygiene practices have shown significant relationship with periodontal disease.[567] Majority of the population are suffering from moderate grade of periodontitis that initiates at an early age, and clinical manifestations of the disease appear after 35 years of age, which if left untreated will ultimately result in loss of tooth.[8] The identification of a relationship between periodontal disease and some systemic conditions or events can improve care and attention to systemic health, either as a preventive or therapeutic strategy. The prevalence of periodontal diseases varies in different regions of the world according to the definition of periodontitis and study population, and there are indications that they may be more prevalent in developing than in developed countries.[191011]

National oral health surveys have assessed periodontal health in America[12] and it was noted that 82% of adolescents in United States have overt gingivitis. The National Health and Nutrition Examination Survey III conducted during 1988–1994[11] have demonstrated that 50% of the adult population has gingival inflammation. The national survey also reported that 19.9% of subjects aged 30 years and 7.3% of those aged 90 years had a clinical attachment level ≥5 mm and 7 mm, respectively.

From a study in UK,[13] it was reported that moderate periodontal disease remains commonplace amongst UK adults and that the associated risk factors of plaque and calculus are in abundance, even among those who profess to be motivated about their oral health and attend the dentist regularly. The continued high prevalence of disease needs to be seen in the context of the far larger number of people who are now potentially at some risk, particularly in the older age groups.

National research on periodontal disease is scanty in Pakistan; however, national oral health survey[14] and few other studies provides some information on status of periodontal disease and report prevalence up to 98%[151617] and showed 31% with advanced periodontitis. This study was designed to evaluate periodontal disease prevalence and observe demographic and other risk factors/indicators associated with periodontal disease in the general public of a city in Pakistan.

MATERIALS AND METHODS

Study sample and design

Periodontal patients of any age, gender, socioeconomic status attending Margalla Dental Teaching Hospital Rawalpindi, Pakistan during September–November 2012 were included in the study. 2435 patients were reported in the department during this period. 1918 patients who gave consent were observed during the study period. Participants were interviewed and examined for periodontal status. Demographic characteristics and known risk factors/indicators and periodontal status were noted on a Performa prepared for the study.

Oral examination

Community periodontal index (CPI) component of CPITN index[18] was used to assess periodontal status. The index teeth (11, 16, 17, 26, 27, 31, 36, 37, 46, and 47) were examined at mesial and distal proximal sites on buccal and lingual/palatal sides. CPI was applied in six sextants as per laid down criteria by WHO. Periodontitis was defined as a CPI ≥ “code 3,” which indicates that more than one site had a 3.5 mm pocket or larger in the index teeth. All study parameters were analyzed with respect to periodontitis (CPI scores ≥3) and nonperiodontitis (CPI scores ≤2).

Statistical analysis

Statistical analysis was performed using the Chi-squared test for comparison of periodontitis and nonperiodontitis patients, and forward selection regression analysis was applied to explore association among study variables. A P = 0.05 was considered statistically significant. Ethical approval for study conduction was obtained from the competent authority of the Margalla Teaching Dental Hospital, Rawalpindi, Pakistan.

RESULTS

Demographic/medical information of study participants are shown in Table 1. 67% were males, 86% nonsmokers, 97% or more without any systemic disease. Majority (36%) was from labor class, and 55% were from age group 21 to 40 years. Table 2 presents the distribution of study subjects with CPI scores ≤2/≥3. Mean age of patients was 24.2 ± 9.8 years of nonperiodontitis and 37.5 ± 14.7 years of periodontitis group. The findings revealed that 64.5% of the subjects had CPI score ≤2 (nonperiodontitis), whereas 35.5% were found with CPI score ≥3 (periodontitis). Age, gender, occupation, smoking, diabetes, arthritis, CVD, kidney disease, stress, medications, tooth powder, and tooth brushing habit were significantly (P ≤ 0.037) associated with periodontal status. Forward stepwise regression analysis showed a significant association of periodontitis with age, occupation, and smoking [Table 3].

Table 1

Demographic/medical data of study participants

Table 2

Status of CPI and risk factors/indicators associated with periodontitis

Table 3

Forward stepwise regression analysis, using CPI scores ≤2 and ≥3 as dependent variables

DISCUSSION

This study reports the periodontal status of the general population that visit a dental hospital for a self-perceived periodontal problem or on referral by a dentist. Prevalence of periodontal diseases is based on disease definition or diagnostic criteria. Majority of cross-sectional surveys to assess prevalence of periodontal disease have used CPI of CPITN for being simple, inexpensive, less time consuming;[8] therefore, we also used CPI component of the index to estimate prevalence of periodontal disease in sample population. More than half of the study population was middle-aged comparable with regional data;[19] subjects with CPI score ≤2 were four times higher in ≤20 year age-group whereas subjects aged 40 years and above were four times higher with CPI score ≥3. Among subjects with CPI score ≥3: Percentage of females, laborers was higher in their respective groups; smokers were six times higher; CVD patients were 4 times higher, patients with respiratory disease, kidney disease, stress, and arthritis were 2 times higher than the nonperiodontitis group. Although exhibiting a significant difference between periodontitis and nonperiodontitis groups, subjects using tooth powder and toothbrush were equal in all respective categories. The prevalence of periodontitis with 82% of aged 60 years and above in this study are comparable with the national survey that reports 93% prevalence in the same age group[14] and other studies conducted in Pakistan such as Chaudhry et al.[15] have reported prevalence of 98% with 31% with advanced periodontitis in army juniors aged 18–52 years that is concordant with the current study.

A same level of the prevalence of periodontitis has been reported from Bangladesh, Burkina Faso, Kenya, Libya, and Nepal.[20] The prevalence of periodontitis (34.5%) in the present study matches the prevalence (27%) reported by Joseph and Cherry[21] in Trivandrum, India and with another Asian study for 32.3% prevalence of periodontitis (CPI score ≥3).[22] The main reasons for matching of individuals may be the age of the population and oral hygiene habits. 90% of the population studied was using toothbrush once or more times daily, only 6% using occasionally and 11% not using a tooth brush. Participants above the age of 40 years had more periodontitis that is in agreement with other regional studies.[1923] Age has been shown to be a risk factor for periodontal disease. Age itself does not affect the periodontal status, but it is the cumulative effect of untreated disease reflecting the effect of the age on disease severity.[24] The extent and severity of periodontal diseases were shown to be different in different age groups and the general trend observed in the majority of the studies was increasing severity with increasing age.[122425262728] Aging is a natural process and changes are there in host immunity against disease process but if one can practice optimum oral hygiene, he or she can maintain teeth throughout life. Increasing severity may be because of the untreated cumulative effect of disease process over the period of time.

The significant difference of periodontal status was observed on the basis of gender for defined score categories that disagree with another study.[21] Our results demonstrated that quite a higher number of males were with score ≤2, which may be attributed to poor attitude toward oral health and smoking. Habits like smoking, pan with tobacco chewing was shown to be a significant risk factor for more prevalence of periodontal diseases.[293031] Tobacco has been shown to affect gingival and periodontal diseases by several means like increased colonization of shallow periodontal pockets by periodontal pathogens and increased levels of periodontal pathogens in deep periodontal pockets. Smoking may alter neutrophil chemotaxis, phagocytosis and oxidative burst. It can also increase the secretion of tumor necrosis factor alpha, prostaglandin E2, neutrophil collagenase and elastase in gingival crevicular fluid.[32] The prevalence of periodontitis was also higher among smokers, in agreement with other studies[33] but not in tobacco users. The male to female ratio of patients with periodontitis (1.7:1) is in agreement with other studies.[193435] Higher prevalence of nonperiodontitis and periodontitis in low-income category corresponds with one study[36] but differs with another study.[37]

Significant prevalence of periodontitis is reported to be associated with systemic conditions such as diabetes mellitus,[173839] arthritis, CVD, respiratory diseases, kidney disease is in concordance with other studies[4041] and the current study has also confirmed this association.

Toothbrush and toothpaste used to maintain day to day oral hygiene and good oral hygiene status was found to be significantly correlated with better periodontal health[2142] and this notion was confirmed in the current study as the number of patients without tooth brushing habit showed more periodontal disease.

Regression analysis of the data of this study showed that with increasing age the odds of having periodontitis increased and aging is reported to be associated with an increased incidence of periodontal disease[43] however, it has been suggested that increased level of periodontal destruction observed with aging is the result of cumulative destruction rather than a result of increased rate of destruction. Current knowledge has shown that periodontitis does not present a linear progression and is not age dependent. Moreover, its distribution and severity are strongly influenced by host susceptibility and risk factors.[44]

Untreated chronic periodontitis is responsible for tooth loss in the majority of the cases. Foreseeing the bad effects of periodontal diseases on oral as well as general health, the prevention of these diseases should include in national health program and national oral health survey should be conducted to get meaningful data for different oral diseases and plan around preventive/curative measures. Further studies will likely be focused on understanding the relationships between different factors and also on the rapid and practical identification of at-risk individuals and will allow us to tailor therapy to more closely suit the needs of our patients as individuals and the achieve better result.

CONCLUSION

As periodontal diseases and their management have been a major concern of research in dental sciences, this study provides an insight into a number of factors that significantly affect periodontal disease status and need to be addressed during periodontal management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.