Assessment of knowledge, awareness, and attitude among patients with cardiovascular disease about its association with chronic periodontitis.

BACKGROUND: A strong bilateral relationship between cardiovascular disease (CVD) and chronic periodontitis has been established for decades. However, a knowledge gap regarding this association still persists among patients. The main objective of the present study was to assess the knowledge, awareness, and attitude among patients with CVD about its association with chronic periodontitis (CP).
MATERIALS AND METHODS: This observational cross-sectional survey consisted of 500 patients with CVD. Along with information on demographic characteristics, data were collected on knowledge, awareness, and attitude of the interrelationships between periodontal disease and CVD, using a 5-point Likert scale, with 4 and 5 representing "agree" and "strongly agree," respectively.
RESULTS: A significant number of the study population had no knowledge regarding the bilateral association CVD and CP. Other questions revealed limited awareness and ignorant attitude of the patients.
CONCLUSION: Within the limitations of the study, it can be concluded that there is a lack of awareness and an ignorant attitude about the bidirectional relationship between CVD and periodontitis among the CVD patients. Special efforts should be taken by dental as well as medical professionals to increase the awareness in this regard and thereby deliver quality health-care services at earlier stages. Copyright:

INTRODUCTION

Chronic periodontitis (CP) is an inflammatory disease initiated by bacterial pathogens and affected by environmental, physical, social, and host stresses which may modify disease expression through a multitude of pathways. It is a highly prevalent public health problem, contributing to the global burden of chronic diseases.[12] Periodontitis may be a source of systemic inflammation that impacts overall health.[34] Correspondingly, many systemic conditions have been implicated to be the risk factors in periodontal disease. Bilateral associations between periodontitis and a wide range of systemic conditions, such as diabetes mellitus (DM), cardiovascular disease (CVD), chronic renal disease, preterm labor, and low birth weight have been reported. The successful prevention and management of periodontal disease depend to a large extent on awareness and good knowledge of its etiology, early identification of symptoms, and effective treatment.

In addition, periodontal infections are associated with cardiovascular and cerebrovascular diseases through the formation of atherosclerosis. Periodontal infections may play a role in atherosclerotic plaque formation, and periodontal pathogens can be isolated from these atherosclerotic plaques. If atherosclerotic plaque occurs in brain arteries, they can cause a stroke; when plaque occurs in coronary arteries, they can lead to myocardial infarction.[56]

A proposed mechanism for the effect of periodontitis on the development of CVD is systemic inflammation. Periodontal pathogens have been shown to have the ability to adhere to, invade, and proliferate in coronary endothelial cells leading to atheroma formation and impaired vasculature relaxation.[7] Thorough knowledge of the oral and periodontal changes in such patients is essential to diagnose the underlying disease and take precautionary measures to avoid the bacteremia and prevent complications.

Hence, this study aims to assess the knowledge, awareness, and attitude among patients with CVD about its association with periodontitis with the objective of enhancing dental health education for this population, which would upgrade their knowledge and awareness.

MATERIALS AND METHODS

This questionnaire-based study was conducted from March 2019 to October 2019 at the outpatient department of periodontology, of our institute in accordance with the Helsinki Declaration of 1975, as revised in 2013. Written informed consent was obtained from all the participating patients. The study was also approved by the institutional ethics committee of our institute (IEC no. IEC/VSPMDCRC/21/2019). The inclusion criteria were patients with the age range of 45–75 years, with a known history of CVD, those suffering from moderate-to-severe periodontal disease, and those who were willing to participate in the study. However, pregnant and lactating mothers and patients with other systemic diseases were excluded from the study.

Description of questionnaire

The questionnaire was chosen as an appropriate methodology since it can be used to obtain standardized information. It was drafted in English and local language. A structured questionnaire containing a total of 17 questions divided into three sections were designed. The first section included the vital details of the participants [Questionnare 1]. The second section included questions assessing knowledge on the level, source, and need for more information about the association between periodontal disease and CVD. The third section included questions assessing awareness and attitude assessed using a 5-point Likert scale. The validation of the questionnaire was regulated by means of face validation, content validation, reliability, and consistency tests by piloting it on 30 patients. There was a complete anonymity of all the data collected in the study.

sThe sample size was calculated based on the prevalence of the periodontal disease in the previous study[8] with 97% confidence interval which was 336 patients. It was increased and rounded off to 500 patients in the present study.

Statistical analysis

The statistical analysis was done using Epi info 7 software (Epi info 7 software developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (US). The data were described using frequency counts, percentage, mean, and standard deviation. Comparisons were made using Chi-square test and Yates-corrected Chi-square test and Fisher's exact test applied with probability (P value). The significance level was set as 0.05.

RESULTS

Table 1 represents the demographic structure and gender-wise distribution of the study population where 46.60% were male and 53.40% were female. Table 2 depicts the assessment of knowledge among both the genders regarding the periodontal disease and its systemic interlink. It was revealed that about 192 (82.4%) males and 135 (50.56%) females were aware of the periodontal disease. This was found to be statistically significant with P = 0.001. The fact that gum disease can affect the general body health was known to just 46 (19.74%) males and 37 (13.85%) females. About 3% of males and only 2.62% females were aware of the fact that the gum disease can cause thickening of arteries leading to heart attack and that gum disease is a potential risk factor for myocardial infarction/stroke/heart attack. The differences were not significant. Around 15.87% of males and 2.62% of females were of the view that loosening of teeth is due to the underlying systemic disease. Chi-square test showed the differences to be statistically significant with P = 0.000. Table 3 shows that of the 500 patients, 26 patients had physician as the source of information that they are suffering from periodontal disease, while 89 of them were told about it by the dentist. However, about 125 got the information from the mass media and 260 stated others but nonspecified source of information about periodontal disease.

Table 1

Gender-wise distribution

Gender	Frequency (%)
Male	233 (46.60)
Female	267 (53.40)
Total	500 (100)

Table 2

Assessment of knowledge

	Male (n=233)	Female (n=267)	χ2	P
Q1	192	135	10.731	0.001*
Q2	46	37	0.08	0.77
Q3	7	7	0.066	0.98
Q4	7	7	0.066	0.98
Q5	37	7	27.25	0.000*

*Statistical significance. P – Probability of occurrence; n – number of patients; χ2 – Chi Square test; Q1 – Question 1; Q2 – Question 2; Q3 – Question 3; Q4 – Question 4; Q5 – Question 5

Table 3

Source of information regarding the periodontal disease

Gender	Physician	Dentist	Mass media	Others	Total
Female	11	20	44	158	233
Male	15	69	81	102	267
Total	26	89	125	260	500

Table 4 shows the awareness and attitude assessed on Likert scale. About 60.20% agreed that bleeding gums and loose teeth requires immediate dental therapeutic assistance. Chi-square test showed a statistically significant difference with P = 0.0003. While just 14 participants agreed to the fact that the patients with CVD are more prone to gum infection than normal people. P value was found to be statistically significant (0.001). Of 500, only 80 females and 109 males agreed that they should be extra careful of oral health and visit a dentist often because they have CVD. About 369 patients (171 females and 198 males) agreed that it is necessary to inform the dentist about history of CVD and regarding the medications currently taking if any. About 317 patients, of which were 139 females and 178 males, agreed that change in the lifestyle, diet, and exercise can help improve the severity of CVD and thereby gum disease. Only 11 females and 8 males were of the view that patients with periodontal disease have an increased prevalence and incidence of coronary heart disease.

Table 4

Assessment of awareness and attitude

Questionnaire	Response	Frequency (n=500)	Males	Females	Percentage	P
P1	Agree	301	165	136	60.20	0.0003*
	NAND	120	75	45	24.00
	Strongly agree	79	27	52	15.80
P2	Agree	14	7	7	2.80	0.001*
	Disagree	100	37	63	20.00
	NAND	386	223	163	77.20
P3	Agree	189	109	80	37.80	0.000*
	Disagree	80	0	80	16.00
	NAND	217	151	66	43.40
	Strongly agree	7	7	0	1.40
	Strongly disagree	7	0	7	1.40
P4	Agree	369	198	171	73.80	0.00*
	Disagree	19	0	19	3.80
	NAND	87	51	36	17.40
	Strongly agree	18	18	0	3.60
	Strongly disagree	7	0	7	1.40
P5	Agree	317	178	139	63.40	0.00*
	Disagree	30	0	30	6.00
	NAND	118	71	47	23.60
	Strongly agree	18	18	0	3.60
	Strongly disagree	17	0	17	3.40
P6	Agree	19	8	11	3.80	0.0017*
	Disagree	467	252	215	93.40
	Strongly agree	7	7	0	1.40
	Strongly disagree	7	0	7	1.40
P7	Disagree	91	91	0	18.20	0.00*
	NAND	409	176	233	81.80
P8	Disagree	58	58	0	11.60	0.00*
	NAND	442	209	233	88.40
P9	Agree	30	11	19	6.00	0.00*
	NAND	450	248	202	90.00
	Strongly agree	12	0	12	2.40
	Strongly disagree	8	8	0	1.60
P10	Agree	13	13	0	2.60	0.0024*
	Disagree	469	246	223	93.80
	Strongly agree	18	8	10	3.60
P11	Agree	13	13	0	2.60	0.0027*
	NAND	470	246	224	94.00
	Strongly agree	17	8	9	3.40

*Statistical significance. P – Probability of occurrence; NAND – Neither agree nor disagree; n – number of patients; P – Question assessing awareness and attitude

None of the females and 91 males disagreed that oral bacteria play a significant role in the initiation and progression of atherosclerosis. Similarly, none of the females and 58 males disagreed about the association of myocardial infarction with an increased load of oral bacteria, while 442 patients neither agreed nor disagreed about it. Nineteen females and 11 males agreed that antihypertensive drugs cause gingival enlargement, while 450 patients neither agreed nor disagreed. None of the females and 13 males agreed, while 469 patients disagreed that treatment of periodontitis helps to improve your biochemical profile in cases of CVD s. P value was 0.0024. About 470 patients neither agreed nor disagreed to the fact that there is an association between gum disease and CVD, DM and chronic renal disease. Only 13 male patients agreed, while 470 patients neither agreed nor disagreed of this fact. The difference between males and females was found to be statistically significant with P = 0.0027.

DISCUSSION

Poor oral health maintenance may affect general body health. However, the awareness regarding this bidirectional association between CVD and periodontitis is crucial for prevention of severe periodontal tissue destruction. Hence, this study aimed at assessment of knowledge, awareness, and attitude among patients with CVD and their association with periodontitis.

Periodontal microorganisms present in dental plaque appear in the bloodstream in direct proportion to the severity and extent of periodontal infection and can impact distant sites. They have been hypothesized to cause systemic inflammation.[9] Porphyromonas gingivalis counts are higher in subgingival plaque in periodontal disease where it causes inflammation and periodontal destruction.[10] The organism has been shown to enter the bloodstream following toothbrushing and has been found in the intima of distant blood vessels including in coronary arteries, where it proliferates, initiating an inflammatory cascade leading to apoptosis and consequent endothelial dysfunction, which is associated with hypertension. It also stimulates foam cell production in the intima leading to atherosclerosis.[11]

Literature reveals cardiovascular disorders and CP exacerbating each other, which forced the dental practitioners to contemplate its bilateral association and create awareness among the general population. Hence, the purpose of this study was to assess the knowledge, awareness, and attitude among patients with CVD about its association with periodontitis which would augment the understanding need to control the disease progression and increase the quality of life. In the present study, majority of participants belonged to the age group of 50–60 years. Gender-wise distribution of the participants included majority of females (53.40%) as compared to males (46.60%). Assessment of knowledge revealed that males had significantly more knowledge about periodontal disease and its CVD interrelationship. This finding is in contrast with the survey done by Shanmukappa etal.[12] where they found that females had significantly lack of knowledge regarding the association of DM and periodontal disease. Most of the study population got the information about periodontal disease from mass media and other sources. While Taşdemir and Alkan[13] in their study on assessing knowledge of Turkish medical doctors about relationship of periodontal disease and systemic health found that for 28% of these doctors, this information was obtained from lessons or workshops and only 24% of them got information from daily media and Internet.

Further, Section C consisted of questions assessing awareness and attitude. The fact that symptoms of periodontal disease should not be ignored and require immediate therapeutic assistance was agreed by majority of males as compared to females and the differences were statistically significant (P = 0.0003). This suggests that males were more aware and had a positive attitude to get it treated.

Only 2.8% of the total study population agreed on the fact that patients with cardiovascular disorders are more prone to periodontal diseases. This indicates a lack of knowledge and awareness regarding the disease susceptibility. Visiting the dentist for dental checkup because of having CVD was neither agreed nor disagreed by a majority (43.40%) of the study population and which indicates that they found it least important to be careful about oral health and visit the dentist. These findings are similar to those of the previous study.[12]

Several barriers prevent patients with CVD from seeking dental care which includes lack of knowledge about the need for dental checkup, economic condition, fear of dental treatment, misconception, ignorance, and educational status of patients. Several questionnaire studies have been carried out on medical and dental undergraduates to assess the extent of knowledge, awareness, and attitude regarding periodontal disease in patients with diabetes and other systemic disorders. However, very few studies[14] have explored the attitude of patients with CVD toward periodontal health. In the present study, we found that only 6% of the study population was aware of this bilateral relationship. Similar results were found in previous studies.[1214] Khakre etal.[15] assessed the level of awareness about the mutual relationship between DM and periodontitis among 302 high-risk diabetic patients and found that majority of the patients were unaware of this relationship. Bhatia et al.[16] in 2013 explored the patients views on their periodontal conditions and their attitudes toward oral health and treatment expectations and knowledge toward oral-systemic disease link.[16] They found that almost two-third of the study population (68.9%) was unaware of the oral-systemic disease interlink.

The lack of oral health awareness among CVD patients is likely due to the limited amount of dental care information provided by their clinicians. Some of the cardiac care providers even though being aware of the interlink might ignore the periodontal needs of the patient, as they are more concerned about the cardiovascular condition. Cardiac care providers could play an important role in promoting oral health in the postacute phase of CVD provided they are formally trained in this area. Correspondingly, many dental health-care providers do not educate the patients regarding the systemic and periodontal interlink, as it is a time-consuming process. Likewise, the patients' attitude needs to be changed through counseling and oral health education programs.

CONCLUSION

This study highlights the lack of awareness and an ignorant attitude about bidirectional relationship between CVD and periodontitis among the CVD patients. It also highlights the disparity of knowledge and awareness among males and females regarding the association between CVD and periodontal health. This study brings into focus the need of proper counseling by health-care professional among high-risk population about maintaining proper oral hygiene and regular dental checkup. Awareness regarding the bidirectional relationship between CVD and periodontal disease can help in diagnosis at earlier stages and can aid in providing screening services and advice to seek immediate dental care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

	Questions	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
P1	Bleeding gums and loose teeth requires immediate dental therapeutic assistance
P2	Patients with cardiovascular disease are more prone to gum infection than normal persons
P3	You should be extra careful of oral health and visit a dentist often because you have cardiovascular disease
P4	It is necessary to inform your dentist if you have cardiovascular disease and regarding the medications you are currently taking
P5	Change in the lifestyle, diet and exercise can help improve the severity of cardiovascular disease and thereby gum disease
P6	Patients with periodontal disease have an increased prevalence and incidence of coronary heart disease
P7	Oral bacteria play a significant role in the initiation and progression of atherosclerosis
P8	Increased load of oral bacteria is associated with myocardial infarction
P9	Antihypertensive drugs cause gingival enlargement
P10	Treatment of periodontitis help improve your biochemical profile in cases of cardiovascular diseases
P11	There is an association between gum disease and cardiovascular disease, and other systemic diseases like diabetes, chronic kidney disease