Knowledge About The Interrelationship of Oral and Systemic Health Among Postgraduate Dental Students and General Dental Practitioners of West Tamil Nadu – A Questionnaire Study

INTRODUCTION

Oral health status is an integral element of general health. On examination, the oral cavity could exhibit manifestations of underlying general systemic disease and acts as an indicator of overall health.^[1] A variety of epidemiological studies have recommended that oral infection could be a risk factor for systemic diseases. Oral lesions are caused by systemic diseases such as diabetes mellitus, rheumatoid arthritis (RA), respiratory disease or chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), renal diseases, hematological diseases, and certain medications.^[2]

A myriad of oral mucosal lesions, including lichen planus and recurrent aphthous stomatitis, as well as gingivitis, periodontitis, dental caries, salivary dysfunction and oral infections such as candidiasis have been reported in people with diabetes mellitus. Previous studies have shown that DNA analysis of synovial joint fluid in RA patients exhibits oral pathogens suggesting their role in the etiology of RA.^[1] Oral and nasal bacterium have been identified in the COPD lung tissue microbiota suggesting aspiration of oral secretions as a major source of the COPD lung microbiota. Periodontitis results in the entry of bacteria into the circulatory system which in turn activates a host inflammatory response leading to exacerbation and thereby increasing the risk of CVD.^[3] Uremic stomatitis, mucositis, glossitis, dysgeusia, and candidiasis infections can develop due to the underlying renal disease.^[4] Patients with hematologic illnesses may present with gingival bleeding or glossitis depending on the etiology.^[4] So, it is necessary for dental professionals to update their knowledge about the management protocols of oral diseases of medically complex patients, and dentists have a pivotal role in educating patients regarding the link between oral foci of infection and systemic diseases, oral manifestations of systemic diseases and also the impact of oral health on the quality of life of individuals. Therefore, the objective of this study was to assess the knowledge about the interrelationship of oral and systemic health among postgraduate dental students and general dental practitioners of West Tamil Nadu.

MATERIAL AND METHODS

This online-based questionnaire survey was conducted with an estimated sample of 200 participants, and dentists who were inquisitive in the study were selected. The participants in this study were postgraduate students of various dental colleges and private and government dental practitioners of West Tamil Nadu, who were identified through Indian Dental Association (IDA) registered list. This study was approved by the Institutional Ethical Committee (VDCW/IEC/252/2021).

Postgraduate dental students from all specialties and general dental practitioners from private and government sectors, who were willing to take part in this study, were included in the study. Incomplete forms and subjects who refused to participate were excluded.

A self-administered close-ended questionnaire was developed from the literature research. The questionnaires were sent to faculty members of the Department of Oral Medicine for evaluation. Thirty dentists were chosen conveniently for the pilot test of the questionnaire.

Pilot test was conducted to ensure the content and face validity. The reliability was assessed, and Cronbach’s Alpha was found to be 0.82. After assessing validity and reliability, the questionnaire for this study was created using a Google platform that included a demographic data section with details including type of job, basic dental qualification, work experience, and questionnaire section for the evaluation of knowledge on oral health and systemic health link. Pilot-tested samples were not included in the main study. A consent statement was enclosed at the start of the questionnaire, and agreement was made prior to participation in the study. The study participants were postgraduate students of various dental colleges and private and government dental practitioners of West Tamil Nadu who were identified through Indian Dental Association’s registered list. Surveys were distributed through email to them. The questionnaire was scored by YES or NO responses. Responses of the participants were categorized into three: poor knowledge (yes to <50%), fair knowledge (yes to 51–75%) and good knowledge (yes to >75%).

Data obtained from the study were entered into Microsoft Excel Software, which was exported to Statistical Package for Social Sciences (SPSS) Version 25, IBM Statistics, the USA. Descriptive Statistics (frequency and percentage) were obtained and presented in tables and graphs. Comparison between the variables was performed using chi-squared test. Level of significance was set at 5% (P < 0.05  Statistically significant).

RESULTS

A total of 200 dentists participated in the study, among whom 100 were postgraduates and 100 were general practitioners [Table 1]. The age of the participants ranged from 21 to 60 years, and females (139) were more when compared to males (61).

Table 2 represents the association between knowledge about the systemic link and oral diseases based on occupational status, and had an insignificant P-value of 0.705.

Figure 1 data showed that the general practitioners and postgraduates had almost equal knowledge in the study.

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Figure 1:

Knowledge of general practitioners and postgraduates.

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The data in Table 3 revealed that the participants of our study had good knowledge about oral diseases in cardiovascular and respiratory systems and fair knowledge in diabetes mellitus, gastrointestinal, endocrine, and renal diseases and poor knowledge in liver, connective tissue disorders, and also about pregnancy.

Table 4 data shows that participants had comparatively good knowledge about the interrelationship between oral and systemic diseases regarding questions related to modern pacemakers, elective dental treatment in renal transplantation, and rheumatoid arthritis.

DISCUSSION

The oral cavity is considered as the “window to overall health.” It is known that neglect of dental problems can lead to serious oral complications and can affect patients’ quality of life.^[1] However, the understanding of the link between oral and systemic conditions is still emerging.^[2] In 1965, an article was published in the American Journal of Cardiology titled as “The necessity for effective dental health service in cardiology” that opened with the following statement: “In almost all ailments of the heart caused by microorganism, the source of the infection is known to be the pathologic and infected environment of the teeth.”^[5] Physicians have an elementary role in oral health and need to possess a basic dental knowledge. The examination of oral cavity frequently for identification of oral diseases at initial stages is necessary and must be referred to the oral physician for treatment.^[6] Local inflammatory diseases, such as periodontal diseases, induce systemic inflammation which can aggravate systemic diseases such as cardiovascular and respiratory diseases, diabetes mellitus, adverse pregnancy outcome, and many more.^[7]

In our study, 90% of the participants stated that a possible relationship between oral and systemic health exists. The overall knowledge of oral and systemic diseases among postgraduate and general practitioners was not statistically significant, and generated a P-value of 0.705. A significantly higher number of general practitioners with a working experience of 6–10 years had good knowledge about the link between oral and systemic diseases [Table 2].

In our questionnaire study, knowledge-based questions about interrelationships of oral and cardiovascular diseases, respiratory diseases, gastrointestinal diseases, renal diseases, endocrine disorders, pregnancy, and autoimmune diseases were included [Figure 2].

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Figure 2:

Association of knowledge about various systems among participants; CVS: Cardiovascular system, GIT: Gastro intestinal system

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The rate of knowledge about the association between oral and cardiovascular system in our study was 84.1%, which was in accordance with the study conducted by Rasouli-Ghahroudi et al. on oral health status, knowledge, attitude, and practice of patients with heart diseases. The study reported that 75.0% had moderate and good knowledge about oral health, 24.3% agreed that cardiovascular diseases cause oral diseases and 55% agreed that oral diseases cause cardiovascular diseases.^[8]

In our study, 60% of the participants had knowledge about the role of bacteria in the initiation of atherosclerosis. However, there was a lack of knowledge about antibiotic prophylaxis for infective endocarditis in patients with rheumatic heart diseases and prosthetic heart valves, and generated an insignificant P-value of 1 (<0.05) [Table 4].

In this study, 83% participants had good knowledge about oral and systemic link in respiratory diseases compared to endocrine and gastrointestinal diseases. There was only a limited knowledge about the complications of aspiration of salivary secretions with an insignificant P-value of 0.402 (< 0.05) [Table 4].

About 65% of participants in our study had good knowledge about the link between the oral and gastrointestinal system, but minimum knowledge regarding the oral manifestations of gastrointestinal diseases. So, oral physicians must be knowledgeable on the oral manifestations and its impact on the gastrointestinal system.

Al-Khabbaz et al. conducted a comparative study on knowledge about the association between periodontal diseases and diabetes mellitus. Fifty percent of all study participants believed that patients with diabetes were more susceptible to tooth loss because of periodontal diseases, which was in association with our study.^[9] Parakh et al. conducted a study on comparing the knowledge between oral and systemic health and reported that there was an average knowledge (only 41% of participants) about the oral manifestations of diabetes.^[10]

Regarding the rate of knowledge in patients with renal problems in population of Davanagere, the study revealed a fair knowledge in dental interns regarding oral health problems among patients with renal problems.^[11] There was a good knowledge among participants regarding the elective treatment in renal transplantation with a P-value of 0.038 (<0.05) that was statistically significant [Table 4]. However, there was lack of knowledge among postgraduates regarding the link between uremic stomatitis and ammoniacal odor in renal failure.

Deficient knowledge was observed among participants in our study regarding pregnancy and oral health. There was a lack of awareness about the link of oral and renal disorders in our study, which was only 60% and was in accordance with a cross-sectional study conducted by Yavagal et al. on knowledge and attitude of dental interns about oral health considerations and periodontal diseases as a risk factor for preterm or low birth weight babies among dentists. Knowledge about oral diseases during pregnancy can enable the dentist in educating and motivating pregnant patients for dental treatment and thus prevent pregnancy-associated complications. The results of our study regarding pregnancy were not in accordance with the Questionnaire survey conducted by James et al. among dental students of Mangalore city on knowledge, attitude, and practice in treating pregnant women that reported that only 39.3% of students had sufficient knowledge regarding management of pregnant women in a dental chair.^[12]

Alowaini et al. reported that half of the dentists in earlier studies mentioned that Cardiovascular Diseases and periodontal diseases are firmly linked, and around 20% of the participants established the same concept. Lack of knowledge has been observed among the respondents regarding the substantial risk factors for periodontal diseases further leading to obesity, osteoporosis, and respiratory diseases.^[13]

AlJohani et al. and Al Sharrad et al. conducted a study with physicians and dentists. Both reported that lack of communication between physicians and dentists, insufficient knowledge or training in medical and dental schools or the lack of continuing education programmes resulted in improper management of serious chronic diseases in dental clinics as well as the neglect of oral health by physicians. Majority of the participants were aware about the relationship between periodontal and systemic conditions. Diabetes mellitus was the most frequent systemic disease (66.8%) that was known to be related to periodontal disease by the sample of medical doctors.^[14,15]

Both general practitioners and postgraduate students had insufficient knowledge and awareness about the interrelationship between lupus erythematosus and periodontal diseases, with a P-value of 1 (<0.005) [Table 4].

Some of the limitations of our study included a chance of bias because the questionnaire survey was sent via email. Moreover, for optimal results, the study must be carried out with medical students and doctors of all medical specialties and with equal participation of all specialties of dentistry on a large sample.

CONCLUSION

To provide optimum oral healthcare to medically complex patients, it is necessary to enhance the knowledge of oral and systemic health interrelationship among dentists. Greater emphasis must be placed on this association by inter-field (medical and dental) training programmes from the undergraduate level itself or by modifying the academic regulations. The lack of time and knowledge were the most common barriers in educating patients on the oral systemic connection. In addition, it is also advisable to develop a strong speciality in oral medicine, which would upskill a dental professional caliber to serve as a capable partner to general physicians. Moreover, continuing education programmes should be frequently conducted on educating dental, medical and other healthcare professionals on the flavorsome and latest evidence of the oral–systemic link. Oral physicians should continually update themselves about the changing protocols in the management of medically complex patients. They should establish strong collaborations with medical professionals for an efficient referral system and thus provide a comprehensive dental care for the patient.