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INTERNATIONAL DENTAL JOURNAL OF STUDENTS RESEARCH - VOLUME 5, ISSUE 2, JUNE 2017

Pages: 46-50
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Assessing the ability of house surgeons in screening and diagnosis of periodontal diseases – A cross sectional study

Author: Dilshi Ishaan, Harinath Parthasarathy, Deepa Ponnaiyan, Anupama Tadepalli

Category: Original Research

Abstract:

Abstract

Introduction: Diagnosis of periodontal problems in dental colleges are mostly done by the interns and may not be timely diagnosed. The aim of the present study is to assess the knowledge and diagnosis of periodontal disease pathogenesis by the interns of various dental colleges from the southern most states of India.

Materials and Method: 780 participants from 30 dental colleges in South India filled a structured questionnaire consisting of 15 knowledge and 10 practice based questions related to periodontal disease. The variables such as period of internship (0-3, 4-6, 7-9 and 10-12 months) and working status in private dental clinics were recorded. The mean total knowledge and practice scores were calculated and statistical significance was based on probability values of less than 0.05.

Results: There was a statistically significant difference in the knowledge and practice scores among the interns according to their duration of internship (p<0.001, p<0.002 respectively). When the knowledge and practice scores were correlated with the working status, the non working interns had better knowledge scores when compared to the working interns (p<0.001). The knowledge scores were more in the interns during the period of 4-6 months and the practice score were more during 0-3 months.

Conclusion: During the last phase of internship, students showed a decrease in scores of knowledge and practice pertaining to periodontal diagnosis and treatment plan. Hence a short refreshing seminar/course on periodontal diagnosis and treatment planning topics could be recommended to reinforce and facilitate them as good clinicians in future.

Keywords: Periodontal disease, Diagnosis, Treatment plan, Referral, Questionnaire

DOI: 10.18231/2278-3784.2017.0009

Full Text:

Introduction

Periodontal disease is a chronic inflammatory disease resulting in the destruction of tissues and structures surrounding the teeth and is one of the most prevalent dental diseases in Indian population.(1) Diagnosing the periodontal problems at an early stage may prevent further destruction of the periodontium and if left untreated may result in tooth loss.        

The dental professionals are expected to be well conversant with issues of health and disease and must be motivated and knowledgeable to impart appropriate attitudes in their patients. Positive attitudes towards health promotion need to be developed during student days rather than afterward. Diagnosis in dental colleges are often done by house surgeons who have completed four years of academic curriculum. Frequently early periodontitis patients might not be timely diagnosed and hence not referred to periodontology clinics. Furthermore proper oral hygiene instructions may not be given to patients, leading to lack of awareness among the patients regarding their periodontal status and by the time patients perceive symptoms of periodontitis, the disease might have progressed into advanced stages. Regeneration of lost periodontal tissues is still a challenge, hence early diagnosis and prevention of periodontal diseases is desired.

The present study aims to assess knowledge and practicing skills of students pursuing internship in the dental colleges of southern most states of India for diagnosis of periodontal diseases. The objectives were, assessing knowledge, regarding influence of systemic diseases and conditions on periodontal tissues. The diagnostic methods, treatment modalities and preventive measures like oral hygiene instructions were also assessed.

Materials and Methods

The study was approved by the Institutional Review Board (IRB NO: SRMDC/IRB/2015/SP-OS/NO.101) and informed consent was obtained by the willing participants. This was a cross sectional study and the sampling design was a two stage cluster random sampling with a design effect of two. Each dental college across the Southern most states of India (Kerala and Tamil Nadu) were considered a cluster. From the total number of dental colleges, a sample of 30 clusters (dental colleges) was selected randomly and from each selected cluster (dental college) 26 interns were selected randomly. Sample size calculation was done from results obtained by Bader et al. 2005(2) with 5% level of significance. The total sample size was 780.

The participants were provided with full explanation of the study and a written informed consent was obtained following which the willing participants filled the structured questionnaire. The questionnaire consisted of a total of 25 questions comprising of 15 questions assessing their knowledge of etiology, pathogenesis, diagnosis and treatment planning of periodontitis. 10 practice based questions gauging their clinical acumen in identifying signs of periodontal disease and imparting appropriate patient education (Table 2 and 3). The reliability of the questionnaire was assessed using Cronbach α (α=0.8). Once completed, each questionnaire was double-checked to make sure that all the questions were answered and participants were requested to complete any missing data. All the 780 participants completed the questionnaire.

The data were processed by the computer after auditing, reviewing and coding the completed questionnaires for data processing and analysis was done using statistical software (STATA). Students who were in their compulsory rotatory internship programs in various dental colleges were included and students who did not complete the questionnaire were excluded.

Results

The study population consisted of a total of 780 interns from 30 dental colleges across Tamil Nadu and Kerala. The percentage of subjects from state 1 were 60% (n=468) and state 2 were 40% (n=312). 26 interns from 18 colleges in State 1 and 12 colleges from State 2 were selected. 86.3% of participants were almost completing their internship (10-12 months), 4.5% were in the 7-9 months period, 5.9% in the 4-6 months and 3.3% in the 0-3 months of their internship. The percentage of working and non-working interns were 37.3% and 62.7% respectively (Table 1).

The mean knowledge and practice scores of the interns from State 1 were 11.6 ± 2.4 and 7.69 ± 1.9 and that of the interns from State 2 were 11.41 ± 1.9 and 7.69 ± 1.8 respectively. The overall mean knowledge and practice scores of the interns according to their duration of the internship were 10.03 ± 0.1 and 8.92 ± 0.3 during 0-3 months, 12.08 ± 2.0 and 8.17 ± 1.4 during 4-6 months, 11.11 ± 2.5 and 7.57 ± 1.8 during 7-9 months and 11.57 ± 2.2 and 7.6 ± 1.9 for the interns who were almost completing their internship (10-12 months) which was statistically significant (p<0.001 and p<0.002 respectively) (Table 1).

The interns who worked in a private clinic had a mean knowledge and practice score of 11.15 ± 2.4 and 7.54 ± 2.1 where as the interns who were not associated with a private dental clinic had a mean knowledge and practice scores of 11.75 ± 2 and 7.78 ± 1.6 respectively. The knowledge scores among the working and the non working interns alone showed a statistical significance (p< 0.001) (Table 1).

 

Table 1: Over all study population Frequency Tables

Study population (n=780)

N

%

Knowledge score

(Mean ± S.D)

P value

Practice score

(Mean ± S.D)

P value

State

State 1

468

60.0

11.60 ± 2.4

T-Test

0.226

7.69 ± 1.9

T-Test 0.981

 

State 2

312

40.0

11.41 ± 1.9

7.69 ± 1.8

 

Internship duration

0-3 months

26

3.3

10.03 ± 0.1

ANOVA

0.001*

8.92 ± 0.3

ANOVA

0.002*

 

4-6 months

46

5.9

12.08 ± 2.0

8.17 ± 1.4

 

7-9 months

35

4.5

11.11 ± 2.5

7.57 ± 1.8

 

10-12 months

673

86.3

11.57 ± 2.2

7.62 ± 1.9

 

Working in private dental clinics

Yes

291

37.3

11.15 ± 2.4

T-Test

0.001*

7.54 ± 2.1

T-Test 0.113

 

No

489

62.7

11.75 ± 2.0

7.78 ± 1.6

 

(* indicates statistical significance)

Table 2: Knowledge based questions

 

Knowledge Questions

N

%

Q1

What is the initiating factor of periodontal disease?

Bacterial plaque

655

84.0

Calculus

104

13.3

Malnourishment

21

2.7

Hereditary

0

.0

Q2

Which instrument do you use for diagnosing periodontal status/condition?

Periodontal probe

722

92.6

Straight probe

32

4.1

Tweezer

7

.9

Explorer

19

2.4

Q3

Which one of the following is the first clinical sign of periodontal disease?

Bleeding on probing

729

93.5

Gingival over growth

12

1.5

Pain in gums

14

1.8

Bad breath

25

3.2

Q4

Do we get rid of bad breath by using mouth washes?

Yes

418

53.6

No

362

46.4

Q5

What do you understand by gingival recession?

Movement of gingiva coronally

42

5.4

Movement of gingival apically

187

24.0

Exposure of root

6

.8

Both b and c

545

69.9

Q6

In case of periodontal pocket, what sulcus depth defines a pocket?

Sulcus depth >3mm

700

89.7

Absence of sulcus depth (0mm)

29

3.7

Sulcus depth 2 mm

31

4.0

Sulcus depth 2 mm with gingival recession

20

2.6

Q7

What instrument do you use to assess furcation involvement?

CPITN probe

56

7.2

Nabers probe

530

67.9

Explorer

72

9.2

Williams periodontal probe

122

15.6

Q8

Are radiographs essential for periodontal diagnosis?

Yes

688

88.2

No

92

11.8

Q9

What type of radiographs are ideal for periodontal diagnosis?

IOPA

392

50.3

CBCT

14

1.8

Bitewings

56

7.2

OPG

318

40.8

Q10

 

Do you feel periodontal problems have significant impact in causing systemic diseases like diabetes, heart diseases etc?

Yes

696

89.2

No

84

10.8

Q11

Do you think diabetes can influence the periodontium?

Yes

766

98.2

No

14

1.8

Q12

Do you think smoking can have an impact on the periodontium?

Yes

762

97.7

No

18

2.3

Q13

Healthy periodontal tissues are recommended in a pregnant woman to prevent

Pregnancy tumors

224

28.7

Pre-term delivery

73

9.4

Low birth babies

67

8.6

All the above

416

53.3

Q14

What is the most effective measure to prevent periodontal disease?

Regular use of tooth brush and dental floss

670

85.9

Regular use of mouthwashes

37

4.7

Have a sugar free diet

16

2.1

None of the above

57

7.3

Q15

Do you keep yourself updated with any periodontal journals?

Yes

361

46.3

No

419

53.7

Total

780

100.0

 

Table 3: Practice based questions

 

Practice Questions

N

%

Q16

Do you examine the oral cavity for gingival recession?

Often

579

74.2

Sometimes

169

21.7

Rarely

18

2.3

Never

14

1.8

Q17

Do you routinely examine the lingual/palatal regions for gingival recession

Yes

595

76.3

No

185

23.7

Q18

Do you check for mobility while examining the oral cavity?

Yes

732

93.8

No

48

6.2

Q19

How do you assess a periodontal pocket clinically?

Visual examination

48

6.2

Probing the sulcus using appropriate instrument

706

90.5

Radiographs

8

1.0

By checking for mobility

18

2.3

Q20

Do you perform a full mouth probing while examining the oral cavity?

Often

258

33.1

Sometimes

342

43.8

Rarely

96

12.3

Never

84

10.8

Q21

Do you check for any furcation involvement during periodontal examination?

Yes

724

92.8

No

56

7.2

Q22

How often are you educating patients regarding OHI?

All patients

552

70.8

Only for periodontitis patients

160

20.5

Rarely

59

7.6

Never

9

1.2

Q23

Do you suggest interdental cleansing aids such as floss, inter dental brushes etc to the patients

Often

399

51.2

Sometimes

312

40.0

Rarely

49

6.3

Never

20

2.6

Q24

In case of any habits causing harm to the periodontium and oral health, do you educate the patient to quit the habit?

Yes

738

94.6

No

42

5.4

Q25

In case of periodontitis, do you refer the patient to a periodontist?

Yes

721

92.4

No

59

7.6

Total

780

100.0

 

Discussion

The present study was the first to assess the ability of the interns in screening and diagnosing periodontal disease in the south India. More than 80% of the participants had adequate knowledge regarding the etiology, pathogenesis, symptoms and diagnosis of periodontal diseases.

When the patients were asked regarding the association of bad breath and mouth washes, 46.4% of participants did not respond correctly. Only 67.9% of participants assessed furcation involvement and 50.3% responded for the use of IOPA as ideal radiograph for periodontal diagnosis. 53.3% of interns were aware about the consequences/complications regarding poor periodontal health during pregnancy. American Academy of Periodontology (AAP) has recommended that pregnant women or women planning pregnancy should undergo periodontal examination and receive appropriate treatment if indicated because of the likelihood of its positive effects on pregnancy outcomes.(3) In a recent study by Tarannum et al, only 56.4% of general dental practioners reported awareness of the association between periodontal status and pre-term low birth weight.(4) Nettleton et al. emphasized the need for offering patients accurate information so that they can make an educated decision about their own behaviour and actions.(5) Nasir et al. in a study on medical interns concluded that the level of awareness regarding systemic effects of periodontal disease is limited and hence this aspect should be included in the curriculum to improve the medical practioners ability to contribute towards oral health.(6) Among the subjects, 46.3% updated themselves with periodontal journals. Pacauskiene et al. in a study concluded that the attitude of dental students should be further improved by initiating a comprehensive program that would emphasize the importance of oral hygiene before the start of the clinical program.(7)

A paradigm shift from a ‘surgical approach’ to a ‘medical prevention strategy’ in the management of preventable oral problems was emphasized by Mani et al.(8) In this context, educating and motivating patients gain the importance for which care providers form the role models. 70% of the participants educated all the patients regarding OHI, but only 51.2% often suggested interdental cleansing aids to their patients. 94% of the interns educated the patients to quit habits causing harm to the periodontium.

Lee et al. observed that general dentist may be underdiagnosing periodontal disease in its early stages.(9) In the present study, 74.2% participants often examined the oral cavity for gingival recession, whereas 76.3% participants examined the lingual and palatal regions for gingival recession. Majority (90%) of the participants checked for periodontal pockets using appropriate instrument and mobility, but only 33.1% often performed full mouth probing while examining the oral cavity leading to misdiagnosis about the distribution and extent of periodontal disease.

92.4% of the interns referred the patients to periodontist. Dockter et al.(10) and Cobb et al.(11) stated in their study that general dentist may not be referring their patients early enough for successful periodontal intervention. Williams et al. found that only 40% of dental students reported confidence in diagnosing, treating and appropriately referring patients with periodontal diseases.(12) It was observed that the patients were referred to the specialist too late which could have negative effects on the specialists ability to treat the disease. Patients at risk for periodontal disease can often be overlooked during a routine dental examination because they appear in a state of periodontal health.

In the present study, the knowledge scores were more in the interns who belong to the 4-6 months where as the practice scores were higher in the interns during the first three months of their internship. The practice scores then decreased and was the least among interns in their 7-9 months of completion. Knowledge of risk factors, identification of systemic conditions and medication affecting the periodontium, increased with advanced training. The knowledge scores were higher in the interns who did not work in any private dental clinics. This could have been due to their involvement in preparing for their post graduation programmes. A limitation of the study could be the uneven distribution of the sample according to their duration of internship and working status.

Conclusion

Dental interns at the time of completion of their professional course, do not possess the required knowledge and awareness regarding periodontal diagnosis and treatment. Hence, a comprehensive dental program highlighting the importance of various local and systemic effects of periodontal disease could be included in their internship program.

Acknowledgement

We would like to acknowledge SRM Dental College and all the house surgeons of various dental colleges across south India who participated in the study.

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