Impact of periodontal knowledge and attitude on the status of the periodontium: A profile on West Godavari district, Andhra Pradesh, India

Abstract

Background:

Although regular patient education regarding the periodontal health/disease is advocated as a means of improving oral health, impregnable associations of periodontal knowledge and attitude with periodontal status have not been demonstrated.

Materials and Methods:

In a cross-sectional study conducted, 2400 participants were surveyed using a specially designed pretested pro forma to evaluate the knowledge and attitude concerning periodontal health and disease. The oral exanimation included recording of oral hygiene index, gingival index (GI), community periodontal index (CPI), and loss of attachment. Ethical clearance was obtained from the institutional review board. The data were analyzed using IBM SPSS version 21.0.

Results:

The mean age of the study population was 41.6 ± 9.5 years. The greater portion of individuals had high knowledge score (55.9%) and negative attitude (68.4%) toward periodontal health/disease. The mean oral hygiene index scores and GI scores were higher among individuals with high knowledge score and with negative attitude, and the differences were statistically significant among the groups. There was no difference in the mean plaque scores among individuals with different knowledge scores, but a higher score for individuals with negative attitude (1.24 ± 0.87) was evident. The proportion of individuals with healthy periodontium (score 0 for CPI and loss of attachment) had low knowledge score (54.3%); however, a positive attitude was elicited in 51.9% of the population.

Conclusion:

High knowledge score and negative attitude were related to periodontal status in West Godavari. Therefore, it can be emphasized that the presence of a positive attitude plays a key role in achieving better periodontal status.

INTRODUCTION

A vital aspect of the overall health status of an individual owes to the oral cavity which is regarded as a mirror and a gateway to oral health. Periodontal disease and tooth decay are the biggest threats to oral health among the various diseases affecting the oral cavity.[1] In spite of the great achievements in oral health, the load of periodontal diseases remains high in India and throughout the world.[2] In maintaining optimum levels of oral health, individuals need to be provided with the information regarding oral health as well as the determinants contributing to the same as they have proved to be a vital element in maintaining oral health. Individuals who have assimilated knowledge regarding oral health have shown to be the ones likely to have adopted self-care behavior.[2] In contemplation of planning successful public health, awareness campaigns are crucial to figure out three domains related to oral health at the population level, namely knowledge, attitudes, and behavior.[3]

Several studies admit the oral health knowledge, attitude, and behavior of young adults and their association with oral status.[4,5] Oliveira et al. reported that children without adequate oral health knowledge are twofold more likely to acquire caries than those with adequate knowledge.[6] The lack of authentic evidence regarding a strong association between the knowledge about oral health and its behavior has led to the controversy that the effects of oral health knowledge may be, perhaps, expressed through improved levels of oral health resulting from frequent utilization, only in the longer term.[7]

However, there are no recent reports examining the relationship between periodontal knowledge, attitude, and long-term periodontal outcomes such as loss of tooth or loss of attachment. From an epidemiological perspective, the existence of an association between inadequate knowledge about dental diseases as a risk factor has not been investigated.[7] However, the published data about the knowledge of periodontal diseases are not much from the southern states of India. Even though the National Oral Health Survey and Fluoride Mapping was done in 2002–2003, unfortunately, West Godavari district was not included as a sampling unit; hence, no reliable information was available regarding periodontal disease in the West Godavari population.[8] This study examined the association of knowledge levels and attitude regarding periodontal disease with the clinical periodontal status of the adult population living in West Godavari district, Andhra Pradesh, India.

MATERIALS AND METHODS

A descriptive survey was conducted among individuals from 18 to 65 years in West Godavari district, Andhra Pradesh. Individuals willing to participate and agreed to give informed consent were included in the study. To select a representative sample, stratified multistage random sampling was advocated. For sample selection, West Godavari district was divided into four zones. From each zone two mandals and from each mandal two villages were randomly selected. A sample size of 2400 was estimated by employing the sample size calculation for estimating a single proportion considering 95% confidence level, 2% margin of error, and population size of 3,900,000.

A specially designed pretested pro forma was employed for the collection of data (Questionnaire 1). It consists of 14 items to assess the knowledge level of participants regarding periodontal health and disease. Few items in the knowledge section focused on gingival health, few items addressed toward the causes and outcomes of periodontal disease, and few items focused on the impact of systemic diseases on the progression of periodontal conditions and prevention. The section on attitude comprised nine statements related to periodontal health and disease. Cronbach's alpha was calculated to assess the internal consistency and found to be 0.77. The external reliability reported was 0.85 for all questions by test–retest method. One correct statement was given for each question along with three wrong statements and wherein the participant responded to the statement by selecting one of the statements which were of yes, no, and do not know. The responses to the questions regarding periodontal knowledge were given score 1 (true) and score 0 (false). A sum score derived from 14 questions (range: 0–14) was calculated for each participant. Based on their total knowledge score, the participants were divided into three categories (score 0–4: low knowledge, score 5–9: medium knowledge, and score 10–14: high knowledge). Five-response categories were assigned to the statements associated with the periodontal attitude, namely strongly agree, agree, no opinion, disagree, and strongly disagree. The categories strongly agree and agree were combined to yield the measure of agreement, whereas the categories no opinion, disagree, and strongly disagree were combined to yield the measure of disagreement. Considering positive attitude (score 1) and negative attitude (score 0) for each statement, a sum score of periodontal attitude was calculated for each participant. Higher scores were indicative of a more positive attitude. For comparison with periodontal clinical parameters, all the participants were classified into two categories depending on their total attitude score (score 0–4: negative attitude and score 5–9: positive attitude).

The oral exanimations included determination of simplified oral hygiene index (OHI-S),[9] gingival index (GI),[10] plaque index (PI),[10] community periodontal index (CPI), and attachment loss.[11] Data collection was carried out by six trained examiners. Intra- and interexaminer reliability was calculated using kappa statistic (κ =0.80). Detailed information related to the process of interviewing was advocated in an attempt to ensure uniformity in data collection and avoidance of interviewer variability. On the other hand, interviewers received appropriate guidelines related to the ethical issues which were delivered by the main researcher.

The study was presented in the institutional review board and the ethical clearance was obtained (VDC/RP/2016/17). (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used to analyze the collected data. Frequency tables, percentages, and cross tables were generated. For comparison of knowledge and attitude with periodontal status, independent t-test, Chi-square test, and one-way analysis of variance were employed. Significance level was set at < 0.05.

RESULTS

A total of 2400 individuals participated in the study, with a mean age of 41.6 ± 9.5 years. The greater portion had high knowledge score (55.9%) and negative attitude (68.4%) toward periodontal health/disease (knowledge scores: high – 55.9%, medium – 24%, and low – 20.1%; attitude scores: positive – 31.6% and negative – 68.4%).

Table 1 shows the comparison of periodontal knowledge and attitude scores with different periodontal clinical parameters such as OHI-S, PI, and GI. The mean OHI-S and GI scores were higher among individuals with high knowledge score and with negative attitude, and the differences were statistically significant between the groups. There is no difference in the mean plaque scores among individuals with different knowledge scores, but the score was higher for individuals with negative attitude (1.24 ± 0.87).

Table 1.

Comparison of periodontal knowledge and attitude scores with different periodontal clinical parameters (plaque index, gingival index, and the simplified oral hygiene index)

	Mean±SD
	PI	GI	OHI-S
Knowledge score
Low knowledge (score 0-4)	0.84±0.04	0.74±0.05*	1.99±0.84*
Medium knowledge (score 5-9)	0.80±0.06	0.66±0.01	2.04±0.77
High knowledge (score 10-14)	0.78±0.02	1.11±0.06	2.07±0.74
Attitude score
Negative attitude (score 0-4)	1.24±0.87*	0.58±0.06	2.02±0.90*
Positive attitude (score 5-9)	0.63±0.33	0.60±0.33	1.86±0.78

*Statistically significant, P<0.05. PI – Plaque index; GI – Gingival index; SD – Standard deviation; OHI-S – Simplified oral hygiene index

Table 2 shows the comparison of periodontal knowledge and attitude scores with CPI. The proportion of individuals with healthy periodontium (score 0) was higher among individuals with low knowledge score (54.3%) and with positive attitude (51.9%). Bleeding on probing (score 1) was higher for individuals with high knowledge score and with negative attitude. Calculus deposit score (2) was the overwhelming problem among individuals with medium knowledge score (52.2%), whereas shallow and deep pockets representing score 3 and 4 were evidenced among people with high knowledge score and with negative attitude.

Table 2.

Comparison of periodontal knowledge and attitude scores with the community periodontal index

	Healthy score 0	Bleeding score 1	Calculus score 2	Shallow pockets score 3	Deep pockets score 4	Excluded
Knowledge score (%)
Low knowledge (score 0-4)	54.3	35.6	38.1	15.6	0.3	4.1
Medium knowledge (score 5-9)	30.6	22.7	52.2	21.0	1.2	1.6
High knowledge (score 10-14)	24.7	41.8	48	26.4	3.9	3.2
Attitude score (%)
Negative attitude (score 0-4)	31.4	42.9	37.5	22.5	2.6	2.1
Positive attitude (score 5-9)	51.9	39.4	23.6	21.8	1.9	2.4

A similar relationship was found on comparison of periodontal knowledge and attitude scores with Clinical loss of attachment (CAL). The proportions of individuals with 0–3 mm of loss of attachment were higher among individuals with low knowledge score (62.1%) and with positive attitude (61.3%). Scores 1, 2, 3, and 4 for loss of attachment were higher among individuals with negative attitude [Table 3].

Table 3.

Comparison of periodontal knowledge and attitude scores with loss of attachment

	0-3 mm	4-5 mm	6-8 mm	9-11 mm	12 mm or more	Excluded
Knowledge score (%)
Low knowledge (score 0-4)	62.1	24.8	1.4	0.6	0.0	1.1
Medium knowledge (score 5-9)	52.4	24.6	3.2	1.7	0.6	2.9
High knowledge (score 10-14)	41.7	39.3	4.2	2.3	0.4	3.7
Attitude score (%)
Negative attitude (score 0-4)	47.7	39.9	13.6	2.3	0.5	3.1
Positive attitude (score 5-9)	61.3	20.2	11.0	0.1	0.2	5.6

DISCUSSION

Periodontology which is one of the fast-growing dental specialties not only covers preventive and curative aspects of oral health but also ramifies a broad range of systemic conditions such as hypertension, atherosclerosis, diabetes, and preterm low-birth-weight babies to name a few. The importance of periodontal health is considered to be nascent and presumption of it is still variable. Although there have been impressive advances in both dental technology and in the scientific understanding of oral diseases, significant disparities remain in both the rates of periodontal diseases and access to dental care among subgroups of the population.

For prevention and promotion of periodontal health, both knowledge and attitude regarding the periodontal disease are essential.[12] The present epidemiological survey is pioneering in nature and provides a comprehensive overview in relating the level of knowledge and attitude about periodontal health/disease with periodontal status of an adult population residing in West Godavari district, Andhra Pradesh.

With regard to the etiology of periodontal disease and the role of dental plaque in its causation along with the importance of oral hygiene in preventing gingivitis, a high knowledge score was evidenced in majority of the participants. This observation is in contrast to earlier findings regarding the causation of periodontal disease among adults in Jordan and in the Iranian population.[13,14] However, a high percentage of Chinese adults were literally unaware regarding the etiology of oral diseases.[15] The high knowledge scores of periodontal diseases among the study population are attributed to adequate and regular health education programs, concerning these conditions in West Godavari district by the surrounding dental institutes.

Regarding the importance of oral diseases and their impact on occupational and social relationships, the attitude among our participants was largely negative. Negative views toward preventive practices, including oral hygiene and regular checkups, were expressed. In addition, the study found negative attitudes of the participants toward scaling. They considered that scaling is harmful for gingival health and is similar to studies conducted in Iran and Hong Kong.[14,16] This negative attitude of the study population toward scaling might be responsible for poor periodontal status.

In general, the study population with high knowledge scores and negative attitude had poor periodontal findings when compared to individuals with low knowledge and positive attitudes toward periodontal health/disease. The acceptance of the hypothesis that the knowledge score is not strongly related to periodontal health ignores several considerations that deserve exploration. It is entirely possible in this study population that negative attitude washes out the knowledge effects. The oral health behavior is strongly influenced by the attitudes which naturally reflect one's own experiences, family believes, cultural perceptions, and other life situations.[17,18] Dental neglect is also another factor responsible for poor periodontal health which is very prevalent in every segment of the study area and is witnessed in all social and economic strata. Less importance of the society in its attitude toward dental health as compared to general health has been observed.[19] Public health programs have failed to achieve the depth and penetration into the society necessary to bring about the difference in societal attitude. However, attitudes are associated beliefs of an individual which can vary from individual to individual. However, a positive attitude toward oral health can be emphasized from the school level as an early incorporation of a positive attitude toward the maintenance of good oral hygiene, thereby ensuring a disease-free mouth is warranted. The active participation of the society involving parents and teachers is of paramount importance as they play an important role in educating their children toward oral hygiene.

CONCLUSION

Our study evidenced that majority of the study population had high knowledge score and negative attitude toward periodontal health/disease and experienced poor periodontal status. It was also evident that negative attitude had a greater influence on periodontal status of adults in West Godavari. This requires oral health awareness and motivation programs that can be effective in improving knowledge, modifying attitudes, and thereby improving oral health practices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

QUESTIONNAIRE: Questionnaire 1

1. Knowledge questionnaire

   1. What is dental plaque? (soft colorless and sticky deposits containing microbe and food debris)
   2. What is the normal color of gums? (Pink and firm)
   3. What causes gum disease? (Dental plaque)
   4. Which one is an early sign of gum disease? (Red gingiva)
   5. Which one is the outcome of progressed gum disease? (tooth mobility)
   6. Is diabetes affects the progression of gum disease? (Yes)
   7. Mostly gum diseases are preventable (Yes)
   8. Twice a day toothbrushing can prevent gum diseases (Yes)
   9. Method of brushing is important for gum health (Yes)
   10. Brushing together with flossing is efficient in preventing gum disease (Yes)
   11. Regular dental visits can prevent gum disease (Yes)
   12. Periodic scaling can prevent gum disease (Yes)
   13. Avoiding smoking prevents gum disease (Yes)
   14. Alcohol has effect on gingival/periodontal health (Yes).

2. Attitude questionnaire

   1. Diseases of the oral cavity are less important than diseases affecting the general health
   2. A person's oral hygiene status would play a detrimental role on their social relations
   3. There is nothing to be worried about if the gums bleed during brushing
   4. Tooth brushing is very important in maintaining the oral hygiene
   5. One should visit a dentist only if they have problem with their teeth
   6. Using salt for brushing the teeth will prevent gum disease
   7. Treatment of the gums on a regular basis would be harmful to a person
   8. Regular periodic scaling would result in gaps between the teeth
   9. I won't mind if the teeth are affected as a result of gum disease.