PERIODONTAL SYSTEMIC INTERACTION: PERCEPTION, ATTITUDES AND PRACTICES AMONG MEDICAL DOCTORS IN NIGERIA

Abstract

Background

Periodontal diseases (PD) impact the outcome of some systemic illnesses. Medical doctors’ knowledge and practices regarding this association may influence the effective management of their patients. This has been understudied among Nigerian doctors.

Aim

The study aimed to determine the knowledge, attitudes and practices regarding periodontal-systemic disease interactions among medical doctors in Nigeria.

Methodology

This was a descriptive, cross sectional study by design, while the study setting was at the National Postgraduate Medical College of Nigeria (NPMCN), Ijanikin, Lagos. The study participants were senior resident doctors attending compulsory Research Methodology and Management courses organized by the NPMCN in 2014. Self-administered questionnaires were distributed among the participants to obtain information on their socio-demography, PD knowledge, association between PD and systemic illnesses, attitudes to periodontal health and oral hygiene practices questionnaires. Student t test and ANOVA were used to test associations between variables. The level of significance was set at p < 0.05.

Results

A total of 236 doctors participated in the study with a mean age of 35.8 (± 4.5) years, males being predominant (62.7%). Few doctors (42.1%) knew dental plaque as the main cause of PD, while 16.5% were aware of gum bleeding as earliest sign. Female doctors displayed better knowledge than males (p= 0.044). Majority were aware of an association between PD and chronic kidney disease (88.6%) and diabetes (86.5%). Knowledge of PD as a risk factor for stroke was 33.1%, poor glycemic control (25.4%), and pre-term low birthweight (14.8%). Most doctors had positive attitudes towards patients’ periodontal health, while 33.5% assessed their patients’ oral cavity regularly. All the doctors used tooth brush and paste to clean their teeth, while 43.2% cleaned twice daily. Only 16.5% used dental floss frequently and was associated with higher PD knowledge (p<0.001) and higher attitude scores (p=0.005).

Conclusion

Senior resident doctors in Nigeria have positive attitudes regarding periodontal health. However, poor knowledge of PD and PD as risk factor for some systemic illnesses, coupled with unsatisfactory oral hygiene and dental examination practices are evident among the doctors.

Introduction

The impact of periodontal diseases (PD) particularly periodontitis on the development and outcome of some systemic diseases has been reported1. This association is related to the potential for the microorganisms involved in chronic periodontitis to cause long term release of cytokines into the systemic circulation and the induction of a state of chronic inflammation. Periodontitis causes local damage to the connective tissue apparatus which may progress to tooth loss in advanced stages. In addition, the chronic inflammatory state it induces has been associated with increased morbidity and mortality in conditions such as cardiovascular disease2, stroke3, hospital acquired respiratory infections4, poor glycemic control5 and adverse pregnancy outcomes6. It is therefore pertinent for physicians to identify chronic periodontitis among patients particularly those presenting with chronic medical conditions so as to make prompt referrals to the dentist for appropriate diagnosis and treatment so as to improve outcome.

The knowledge of doctors regarding this association between periodontitis and chronic systemic diseases, their perception of its importance regarding outcomes and their self-care practices are likely to influence their ability to recognize PD among their patients. It may also influence their ability to counsel patients on good self-care practices and the promptness with which they make appropriate referrals to the dentist.

Studies have been conducted among health professionals in Europe, Asia and Nigeria on periodontal disease and systemic disease interaction. Whilst some reported good knowledge7 others found a poor perception and limited knowledge of periodontal and systemic disease interactions8^-11. In the Nigerian context, data is limited and previous studies have been restricted by relatively small sample sizes and inclusion of doctors from one institution or specialty12.

We therefore aimed to assess doctors across all specialties attending a mandatory research training program on their knowledge, attitude and practice regarding periodontal diseases and systemic illnesses. We also aimed to determine their oral self-care practices and the relationship to their PD knowledge and attitudes.

Materials & Methods

Ethical approval

This study was approved by the health research and ethics committee of the Lagos University Teaching Hospital (LUTH) and was carried out in keeping with the Helsinki Declaration of the World Medical Association13. Informed consent was obtained from all participants and confidentiality was ensured.

The participants were senior resident doctors in residency training institutions from all the six geopolitical zones across Nigeria who were attending compulsory Research Methodology and Management courses organized by the National Postgraduate Medical College of Nigeria (NPMCN) in Lagos, Nigeria in March 2014. The NPMCN has the responsibility for postgraduate training of medical doctors and dentists, and this includes the organization of professional training programs and development of curricula14.

Study design and recruitment

This was a cross sectional study in which consecutively consenting doctors were recruited to participate. Each participant completed a self-administered questionnaire. The Self-administered questionnaire used was adapted from a previous study15. Section A was used to obtain the socio-demographic and work-related characteristics of the respondents. Section B had four questions assessing the knowledge of PD. This was based on score 1 for ‘yes’ and 0 for ‘No’, ‘Not sure’ and ‘Non-response’. Total score computed for each respondent was 4. Knowledge of the association of PD with some systemic conditions was tested in Section C. In addition, there were two sections assessing the doctors’ attitudes towards their patients’ periodontal health and their oral hygiene practices. Seven questions were used to evaluate their attitude towards patients’ dental care and referral practices. These were assessed using a 5 point Likert-type scale, with options ranging from Strongly agree, Agree, Neutral, Disagree, to Strongly disagree. Non-response was assigned score 0. The total score was computed for each respondent and 20 was the maximum score attainable.

Data Analysis

Data were analyzed using EPI INFO^TM 7 statistical software (Centers for Disease Control and Prevention (CDC). Means and standard deviation were used to express continuous variables. Univariate analysis was performed and mean knowledge and attitude scores for PD were computed. Student t tests and ANOVA were used to assess the differences in means between PD knowledge score and socio-demographics, PD knowledge score and oral hygiene practices, and attitude score and oral hygiene practices. The level of statistical significance was set at p < 0.05.

Results

Relationship between socio-demographics and PD knowledge

Table 1 shows the total number of respondents (236) following the distribution of 300 questionnaires (response rate of 78.7%). There was a male predominance (62.7%), mean age of 35.8 (± 4.5) years, Yoruba ethnic group being the most (36.0%), with surgery and internal medicine being the leading specialties (28.4%, 23.3% respectively). Mean number of years post- medical school and residency training were 9.7 (±3.9) and 5.0 (±1.9) years respectively. A high proportion (72%) understood ‘periodontal disease’ to be the same as gum disease, only 42.1% correctly identified dental plaque as the primary cause. Gum bleeding was known by 16.5% as the earliest sign, while 47% knew twice daily tooth brushing and flossing of the teeth as the best method for preventing PD. Oral health sources of PD knowledge were from dentists (50.8%), television (47.0%), undergraduate training (45.6%), books/journals (37.7%), continuing medical education (CME) (25.0%), radio (24.6%), newspaper (19.9%), seminars/conferences (16.9%) and family/friends (16.5%). Mean knowledge score was 1.8 ± 1.0 which was low in comparison with 4.0, the maximum score attainable. The knowledge score was significantly associated with the gender of the respondents (p= 0.044). Females had better knowledge than male doctors.

Table 1. Association between socio-demographics and periodontal (PD) knowledge .

Characteristics	Total n (%)	Mean PD knowledge score	ANOVA
Age (years)
28-35	133 (56.4)	1.9 (1.0)	0.062
36-52	103 (43.6)	1.6 (1.0)
Gender
Male	148 (62.7)	1.7 (0.9)	0.044
Female	88 (37.3)	1.9 (1.1)
Ethnicity
Yoruba	85 (36.0)	1.8 (1.0)	0.385
Others	70 (29.7)	1.8 (1.1)
Igbo	59 (25.0)	1.8 (1.0)
Hausa	22 (9.3)	1.4 (1.1)
Specialties
Surgery	67 (28.4)	1.8 (1.0)	0.957
Internal medicine	55 (23.3)	1.8 (1.1)
Pediatrics	41 (17.4)	1.8 (0.9)
Family medicine	35 (14.8)	1.9 (1.1)
O& G	24 (10.2)	1.6 (1.0)
Laboratory medicine	14 (5.9)	1.7 (1.0)
Geopolitical Zone
South west	76 (32.2)	1.9 (1.0)	0.820
North west	51 (21.6)	1.8 (1.1)
South south	42 (17.8)	1.7 (1.1)
North central	38 (16.1)	1.6 (1.0)
South east	27 (11.4)	1.8 (0.9)
North East	2 (0.8)	1.5 (0.7)
Years since graduation from medical school
≤ 8	113 (47.9)	1.8 (1.0)	0.784
> 8	123 (52.1)	1.8 (1.0)
Years in residency training
≤ 5	175 (74.2)	1.8 (1.0)	0.879
> 5	61 (25.8)	1.8 (1.0)

Knowledge of periodontal-systemic relationship among the doctors

Most participants knew of the association between PD and chronic kidney disease (88.6%), diabetes mellitus (86.5%), rheumatoid arthritis (84.3%) and smoking (80.9%) as seen in figure 1. figure 2 indicates that PD was identified as a risk factor for coronary heart disease by 50.8% of the doctors and preterm low birth weight by 14.8%. Proportion of doctors correctly affirming an association between PD and some drugs were; phenytoin (51.9%) cyclosporin (35.0%), oral contraceptives (24.1%) and nifedipine (9.3%).

Fig. 1. Knowledge of PD-Systemic illnesses/conditions link among doctors .

Fig. 2. Knowledge of PD as a risk factor for systemic illnesses among doctors .

Attitude regarding periodontal health among the doctors

Table 2 reveals that most doctors had positive attitudes regarding their patients’ periodontal health, as 94.1% affirmed the need to assess their patients’ regularly for PD while 84% would refer them for routine dental checkup. Their mean attitude score was 15.8. (Maximum score attainable was 20).

Table 2. Attitude of doctors regarding their patients’ periodontal health .

Variable	Strongly agree	Agree	Neutral	Disagree	Strongly Disagree	Non- response
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
They should refer their patients for routine dental check up	81 (34.3)	117 (49.6)	25 (10.6)	9 (3.8)	1 (0.4)	3 (1.3)
They should refer their patients for dental care only when they have complaints	14 (5.9)	35 (14.8)	26 (11.0)	107 (45.3)	51 (21.6)	3 (1.3)
They should refer their patients only on patients’ request	7 (3.0)	20 (8.5)	33 (14.0)	120 (50.8)	52 (22.0)	4 (1.7)
It is important to assess their patients regularly for periodontal disease	100 (42.4)	122 (51.7)	9 (3.8)	1 (0.4)	0 (0.0)	4 (1.7)
Dental visits should be once every 6 months	140 (59.3)	58 (24.6)	15 (6.4)	15 (6.4)	3 (1.3)	5 (2.1)
Dental visits should be once every 12 months	48 (20.3)	75 (31.8)	37 (15.7)	51 (21.6)	19 (8.1)	6 (2.5)
Dental visits should be once every 2-3 years	13 (5.5)	9 (3.8)	23 (9.7)	84 (35.6)	98 (41.5)	9 (3.8)

Relationship between oral hygiene practices and PD knowledge of the doctors

Table 3 reveals that 90.3% of the doctors used tooth brush and tooth paste to clean their teeth, 43.2% practiced twice daily cleaning (that is morning before/after breakfast and bed time), with only 16.5% regularly using dental floss for interdental cleaning. Nearly two thirds (65.3%) had previously visited the dentist, with 12.7% visiting in the preceding six months. Those that had visited more than six months ago were 52.6%. Reasons for not visiting the dentist were a perceived lack of dental problem (66%), being too busy at work (18%), fear of dental treatment (5%), procrastination (5%) and practice of self-medication (5%). Approximately 5% did not indicate their reasons. About a third of the doctors (33.5%) regularly assessed their patients’ oral health, while 30.1% were indifferent. The regular use of dental floss was significantly associated with a higher mean knowledge score (p<0.001).

Table 3. Association between oral hygiene practices and periodontal (PD) knowledge .

Variables	n (%)	Mean knowledge score	ANOVA
Tooth cleaning aid used
Toothbrush and toothpaste	213 (90.3)	1.8 ±1.0	0.555
Toothbrush/toothpaste and chewing stick	23 (9.7)	1.7 ±1.1
Frequency of teeth cleaning
Morning alone before breakfast	125 (53.0)	1.8 ± 1.0	0.377
Morning alone after breakfast	9 (3.8)	1.9 ± 1.2
Morning before breakfast and at bedtime	79 (33.5)	1.6 ± 1.0
Morning after breakfast and at bedtime	23 (9.7)	1.9 ± 0.9
Technique used in tooth cleaning
Vertical	160 (67.8)	1.9 ± 1.0	0.193
No particular direction	37 (15.7)	1.6 ± 0.9
Roll technique	22 (9.3)	1.8 ± 1.0
Scrub	17 (7.2)	1.4 ± 1.0
Regular use of dental floss
No	197 (83.5)	2.3 ± 1.0	<0.001
Yes	39 (16.5)	1.7 ± 1.0
Previous dental visit
Yes	154 (65.3)	1.8 ± 1.0	0.402
No	82 (34.7)	1.7 ± 1.0

Relationship between attitude regarding periodontal health and oral hygiene practices of doctors

In Table 4, there was a significant association between their oral hygiene practice and attitude towards periodontal health (p=0.005). Medical doctors with positive attitudes regarding periodontal health utilized dental floss regularly, shown by higher mean attitude scores.

Table 4. Association between oral hygiene practices and attitude regarding periodontal health .

Practices	Mean attitude score	ANOVA
Tooth cleaning aid used
Toothbrush and toothpaste	15.9 ±2.9	0.126
Toothbrush/paste and chewing stick	14.8 ±4.1
Frequency of teeth cleaning
Morning alone before breakfast	15.6 ± 2.7	0.163
Morning alone after breakfast	14.1 ± 2.8
Morning before breakfast and at bedtime	16.2 ± 3.3
Morning after breakfast and at bedtime	15.4 ± 4.1
Technique used in tooth cleaning
Vertical	15.5 ± 3.1	0.144
No particular direction	15.6 ± 3.6
Roll technique	16.8 ± 2.3
Scrub	16.8 ± 1.9
Regular use of dental floss
Yes	17.0 ± 2.5	0.005
No	15.5 ± 3.1
Previous dental visit
Yes	16.0 ± 2.8	0.062
No	15.2 ± 3.4

Discussion

Despite the growing strength of evidence linking periodontal disease (PD) with several systemic conditions, there is still a dearth of documented studies assessing the knowledge, attitude and practices of medical doctors in Nigeria regarding this link. The main findings were poor knowledge of PD, poor awareness of PD as a risk factor for systemic illnesses, inadequate oral hygiene practices and irregular assessment of patients’ oral cavity by the doctors. The good outcomes were positive attitudes regarding their patients’ periodontal health and good knowledge of PD association with some systemic conditions. The present study had several strengths; doctors were from different medical disciplines, located in various health institutions across the geopolitical zones of Nigeria. In addition, several systemic illnesses/conditions were evaluated and the doctors had adequate post-graduation and residency year experiences.

Table 1 shows the limited knowledge of PD displayed by the doctors which has been reported in similar studies15,16. This could be attributed to the paucity of dentistry topics in the curriculum content at both undergraduate and postgraduate levels in Nigeria as the bilateral link between these two disease entities, an emerging topic may not yet have been fully incorporated into the medical curriculum.

figure 1 revealed that most of the doctors knew PD to be associated with several systemic diseases. However, the role of PD as an emerging risk factor for systemic illnesses was poorly understood in this study as coronary heart disease was the only systemic illness identified by at least half of the doctors (figure 2). This obvious deficiency in their knowledge has also been reported in other studies8,10. Drugs such as nifedipine and cyclosporin are often prescribed by doctors in the course of managing hypertension and chronic kidney disease respectively. It was surprising therefore to note the limited awareness of its association with PD by the doctors. The poor perception of the periodontal systemic relationship has been partly attributed to the isolation of medical doctors by their specialization17. This is supposed to encourage collaboration rather than isolation. The location of majority of the tertiary health institutions within university complexes is an avenue for regular academic activity through seminars, and update courses. It is of concern to note the low proportion of doctors in this study whose sources of oral health information were CMEs and seminars which could have been readily available means of raising awareness of PD-systemic health.

The positive attitudes observed by the resident doctors towards their patients’ periodontal health as shown in Table 2 were quite impressive. This healthy disposition should be encouraged and further reinforced among the doctors. A similar finding was reported in a recent study among medicine residents in Nigeria15. Their positive attitudes should place them in a vantage position to promote periodontal health amongst their patients as they may be the first to encounter them. In order to do this effectively, doctors must pay close attention to their own personal and professional dental care practices and ensure optimum adherence to these. According to a US report, daily hygiene routines and healthy lifestyle habits have been shown to provide a frontline defense in disease prevention and health promotion18. This includes twice daily tooth brushing using a systematic approach and daily interdental cleaning by flossing. In the present study, Table 3 shows that all the doctors (100%) utilized tooth brush with paste to clean their teeth, a finding comparable to the 99.4% reported among health care professionals in Riyadh19 and the 99.1% among internal medicine residents in Nigeria20. This is however not an unexpected practice for these highly skilled professionals.

Table 3 shows a low frequency of twice daily brushing pattern (43.2%, n=102) by the doctors which is however at variance with the recommended practice (morning and at bedtime)21. The reasons for this behavior may not be unconnected to the demand of work and late arrival at home which could make bed time brushing a hideous task for the doctors. We also observed as shown in Table 3, that most of the doctors in this study utilized vertical brushing technique while a low frequency adopted the roll technique. Although, the Bass and roll techniques are advised quite often by dental professionals, a recent study has emphasized the need for more evidence regarding the most effective tooth brushing method that should be recommended further suggesting that it should be tailored to the individual and a method that causes minimal damage to the hard and soft tissues22. Although, the use of dental floss is known to provide good access to interproximal areas of teeth23, its poor utilization in this study and its significant association with low knowledge and attitude scores (Table 3 and Table 4 respectively), underscores the importance of oral health education and promotion by dentists through the media. Its low use among Nigerians has been reported in some studies as well24,25. The poor distribution of dental floss at social events may adduce to this. It is also noteworthy to mention that few doctors had visited the dental clinic six-twelve monthly previously. This practice is below expectation. The main reason given for their visits was because of dental pain, and not for routine dental checkup, and appears to be a common practice among the general population, a factor corroborated by other Nigerian studies20,24.

There is need for a shift in orientation towards preventive dental visits among doctors in Nigeria. This is buttressed by the lack of perceived dental problem as their reason for not visiting. Most of the doctors did not assess their patients’ oral cavity regularly which may have been due to their inadequate knowledge of PD and possibly a lack of the required clinical skill needed to perform this. It has been proposed that failure of most physicians to conduct an oral examination as a part of general physical examination may be due to lack of confidence or training during their medical education26.

Conclusions

In conclusion, senior resident doctors in Nigeria have positive attitudes regarding periodontal health. However, poor knowledge of PD and PD as risk factor for some systemic illnesses, coupled with unsatisfactory oral hygiene and dental examination practices are evident among the doctors.