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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 200-206

Patient-reported oral health status and perceptions on oral hygiene before and after oral prophylaxis: A pre-experimental clinical study in Lagos, Nigeria


1 Department of Preventive Dentistry, Faculty of Dentistry, Lagos State University College of Medicine, Lagos, Nigeria
2 Department of Preventive Dentistry, Lagos State University Teaching Hospital, Lagos, Nigeria
3 Department of Pathology and Oral Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria

Date of Submission15-May-2019
Date of Decision23-Aug-2019
Date of Acceptance30-Aug-2019
Date of Web Publication1-Oct-2019

Correspondence Address:
Afolabi Oyapero
Department of Preventive Dentistry, Lagos State University College of Medicine, Ikeja, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_52_19

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  Abstract 


Background: Constant elimination of bacterial plaque from all nonshedding oral surfaces prevents the progression of periodontal diseases while oral prophylaxis supplements the patient's homecare plaque control. This study compared patient-reported outcomes of oral prophylaxis before and after the procedure and examined the relationship between self-rated and normatively assessed oral health at Lagos State University Teaching Hospital. Methodology: A pre-experimental design was employed while data were obtained using an interviewer-administered questionnaire. Oral cleanliness was documented using a five-point scale while participants' subjective assessment of their oral health status was done on Likert scale. The normative assessment was made with the oral hygiene index-simplified (OHI-S) and the gingival index (GI). Data entry and analysis were performed using the SPSS software version 20, whereas bivariate comparisons were made using the Chi-square and ANOVA tests. A 5% level of statistical significance was adopted. Results: Ninety-two respondents were enlisted. Sixty-seven (72.8%) respondents who rated their oral health as good had better oral hygiene with mean GI of 0.87 and OHI-S of 1.76 compared to the respondents with a poor self-rated oral health who had mean scores of 0.90 and 2.01, respectively. Females 39 (81.2%) had significantly better self-rated oral health (P = 0.048). Poor self-rated oral health was higher among participants with xerostomia and those that infrequently visited the dental clinic; and significantly higher among respondents with difficulty in mastication due to toothache within the past 6 months (6 [75.0%];P= 0.026). Conclusion: There was a positive association between self-rated oral health and normatively assessed oral health status. There was also a significant improvement in the subjects' perception on the benefit of scaling and polishing. The findings highlight the potential role of patients' beliefs and perceptions as potential impetus for treatment provision.

Keywords: Oral hygiene, oral prophylaxis, self-rated oral health


How to cite this article:
Oyapero A, Adeniyi AA, Fasoyiro O, Akinleye AI. Patient-reported oral health status and perceptions on oral hygiene before and after oral prophylaxis: A pre-experimental clinical study in Lagos, Nigeria. Indian J Dent Sci 2019;11:200-6

How to cite this URL:
Oyapero A, Adeniyi AA, Fasoyiro O, Akinleye AI. Patient-reported oral health status and perceptions on oral hygiene before and after oral prophylaxis: A pre-experimental clinical study in Lagos, Nigeria. Indian J Dent Sci [serial online] 2019 [cited 2019 Nov 15];11:200-6. Available from: http://www.ijds.in/text.asp?2019/11/4/200/268417




  Introduction Top


Oral diseases are extremely prevalent, and their impact on society and individuals are substantial.[1] Despite significant improvement in the oral health of people globally, challenges still exist, predominantly among disadvantaged groups, in all countries.[2] Poor oral health has a profound effect on general health, and several oral diseases are related to chronic diseases.[3] The most prevalent oral diseases are dental caries and periodontal diseases which have dental plaque as a principal etiologic factor. The role of plaque as the primary etiological factor in the development of periodontal diseases has been unequivocally established. Oral hygiene reflects the amount of plaque on teeth, and the level of oral hygiene in a population is positively correlated with the prevalence and severity of periodontal diseases.[4] Gingivitis is a reversible plaque-induced disease, resulting in gingival inflammation without the loss of connective tissue attachment, and it is a precursor to periodontitis in some individuals.[4]

Dental professionals largely agree that tooth brushing, which is a mechanical procedure for eliminating dental plaque, is the most appropriate and effective oral hygiene routine.[5] Oral prophylaxis or scaling and polishing of the teeth by a dentist or dental therapist is a nonsurgical intervention that is intended to supplement the patient's homecare plaque control. Scaling is the removal of plaque, mineralized plaque deposits, debris, and stains from the crown and root surfaces of the teeth. Polishing, however, is the mechanical removal of any residual extrinsic stains and deposits, generally undertaken by using a rubber cup or bristle brush loaded with a prophylaxis paste. This is commonly provided as part of the dental recall appointment,[6] and it is consequently partly dependent on patient's compliance.

Martins et al.[7] observed an association between self-perceived need and the utilization and purpose for dental visits. Oral health problems are influenced by demographic/socioeconomic factors and the use of health-care services can also be affected by the opinion an individual has about his/her health. Measurements of self-rated oral health may be used in population studies or act as a supplement to customarily used clinical measurements. They may also assist in the selection of treatment modalities, in monitoring patients, and in the identification of health determinants and risk factors. They could further aid in the selection of specific services for the population, the establishment of health services and priorities, and in allocating financial and supplementary resources.[8] Self-assessment can similarly serve as a motivational tool for good oral hygiene.[9]

Studies examining the relationship between self-rated oral health and patients' perceived benefit of oral prophylaxis in Nigeria are virtually nonexistent. The purpose of this research was thus to examine the relationship between self-rated and normatively assessed oral health and to compare patient-reported outcomes of receiving oral prophylaxis before and after the procedure at Lagos State University Teaching Hospital, Ikeja (LASUTH).


  Methodology Top


Study design

A pre-experimental design was employed to determine the self-reported and normatively assessed oral health and to evaluate the benefit of oral prophylaxis in a group of patients in the Preventive Dentistry Department at LASUTH.

Study setting

The setting of this study was Ikeja in Lagos State. Lagos State is located in the Southwestern geopolitical area of Nigeria and is bounded on the North and East by Ogun State; by the Republic of Benin on the West and by the Atlantic Ocean in the South. Although the smallest state with respect to the geographical area, Lagos is the largest city in Nigeria and it is one of the fastest-growing cities in the world, accounting for over 60% of the industrial and commercial activities in Nigeria. The dental center in LASUTH is the clinical unit of the Faculty of Dentistry of the Lagos State University College of Medicine and it is a referral center that meets the health needs of most residents within Lagos and its environs. The preventive dentistry unit has four operatories, each equipped with fully functional dental chair and its accessories. There is a central room that has three autoclaves for sterilizing instruments, two rooms where radiographs are taken and processed and patients' waiting area and restrooms. There are four dental nurses, on hand to assist the dentists and five dental therapists. The dental center is connected to the main hospital stand –by generator.

Sample size determination

The estimated sample size was computed using an equation for longitudinal intervention studies.[10]

This was determined using the formulae:

n = (u + v)2 (s1+ s2)2/(m1− m2)2

Using the mean and standard deviation values from a reference study,[11] and with an additional 20% of calculated sample size to make provision for design error, a total sample size of 90 was calculated.

Inclusion criteria

  • Participants aged 18 years and above with no history of periodontal therapy
  • Good general health and with no systemic risk factors for periodontal disease
  • No clinical evidence of significant periodontal disease (basic periodontal examination [BPE] sextant codes being <3) and
  • Those with 20+ permanent teeth.


Exclusion criteria

  • Participants with BPE code of 3 or more in one or more sextants with the requirement for extensive periodontal therapy
  • The requirement for prophylactic prescaling antibiotic prophylaxis
  • Use of removable prosthesis or orthodontic appliance
  • Systemic conditions (e.g., diabetes mellitus), medication use (e.g. phenytoin, cyclosporin, Ca channel blockers), and immunosuppressive states (e.g., HIV/AIDS) that pose a risk factor for periodontal health
  • Pregnancy.


Pretesting of the study instrument

A pretesting of the study instrument was done among 10 patients recruited from the LASUTH oral diagnosis clinic. The instrument for data collection (questionnaire) was administered and checked for clarity and ease of administration. Modifications were made based on the results of the pretest.

Study protocol

Individuals who were presenting in the dental clinic for the first time were recruited into the study using the attendance register as the sampling, and enlisted participants were screened by the researchers to ensure that they fulfilled the eligibility criteria. The participants were informed about the study, and their consent to take part in the study was obtained in a prescribed form and carried out in accordance with the ethical standards of the Health Research and Ethical Committee. Research participants were scheduled for a routine scale and polish during the specified trial recruitment session.

Oral health interviews were conducted by the trained, calibrated dental researchers (kappa statistics of >0.8.) at baseline and after the scale and polish procedure using structured questionnaires. The oral health interviews provided data on sociodemographic characteristics, preventive dental behaviors, use of oral health services, history of oral pain and discomfort, subjective oral symptoms, and self-perceived oral health. The level of dental plaque and calculus was assessed using the oral hygiene index-simplified [12] The index has two components as follows: debris index-simplified and calculus index-simplified. The degree of debris and calculus deposition was graded on a numeric scale from 0 to 3, divided by the number of sites recorded. The areas examined were buccal of the upper first molar, upper right incisor, and left incisor, and the lingual of the lower first molar. The gingival index [13] was determined with sufficient lighting, a mouth mirror, and a dental probe. The teeth and gingiva were dried lightly with a blast of air and/or cotton rolls. The buccal, lingual, mesial, and distal surface areas of six index teeth (the upper right first molar, the upper right lateral incisor, the upper left first bicuspid, the lower left first molar, the lower left lateral incisor and the lower right first bicuspid) were examined and scored according to set criteria ranging from 0 for the absence of inflammation; to 3 for severe inflammation-marked redness and hypertrophy, tendency to spontaneous bleeding or ulceration.

Global self-rating of oral health was determined with a single question, “How would you rate your dental health? Would you assess it as excellent, very good, good, average, poor, very poor?” Consistent with convention, self-ratings were dichotomized. The highest three groupings of excellent, very good, and good were merged as good; while average, poor, and very poor were rated as poor self-rated oral health. Subjectively assessed oral health was assessed using Likert scale questions on the perceived need for dental treatment, use of oral prosthesis, perception on dry mouth, difficulty eating due to teeth toothache in the past 6 months; bleeding gums, bad breath, tooth sensitivity, joint pain and ability to chew different categories of food ranging from carrots to vegetable salad. Some of the Likert type responses ranged from very poor to very good; mild to very severe; never to always; and poor to excellent. Participants were asked to rate the importance of scale and polish (using a 5-point scale) for oral cleanliness; the maintenance of gingival health; prevention of halitosis; prevention of dental decay; and “whiteness” of teeth. Scores ranged from “1” indicating “of no importance at all” to “5” indicating “extremely important.”

A face mirror was given to the patient to visualize his oral cavity. A certified hygienist then conducted scale and polish (oral prophylaxis) under the supervision of a trained dentist. The definition of single-visit oral prophylaxis by Lamont et al.[6] was used to ensure a standardized approach to treatment delivery. This involved full-mouth sub- and supra-gingival scaling, carried out with a Cavitron ® ultrasonic scaler, to remove calculus, debris, and stain from teeth. In cases where participants were unable to tolerate ultrasonic instrumentation, hand scaling instruments were used. After scaling, teeth were polished using an air motor-powered rotary rubber cup, pumice, and polishing paste. The second part of the questionnaire was subsequently administered the patient visualized the oral cavity with a face mirror.

Ethical aspects

The protocol for the study was submitted to the Health Research and Ethics Committee of LASUTH, and written approval was obtained. The protocol was implemented in accordance with the provisions of the Declaration of Helsinki. All study participants also completed a written informed consent. The informed consent form contained the names and affiliation of investigators, a plain language description of the study, the duration of the study, the right to refuse to participate, the ethics committee approval, and the privacy guarantee. The duration of the study was 3 months.

Analysis

Data were analyzed using the SPSS (Statistical package for social sciences) for Windows (version 20, Chicago, IL, USA) statistical software package. Frequency distribution tables were generated for variables and measures of central tendency and dispersion were computed for numerical variables. Since the data were normally distributed-determined using the Shapiro–Wilk test, descriptive statistics, including means, standard deviations, and percentages were used to summarize the demographic variables and health-related behavior of the study sample. The Likert type responses were converted to scale and dichotomized with responses below the mean rated as poor and those ≥ to the mean score categorized as good. The Chi-square test was used to determine the level of association between categorical variables. The ANOVA tests were used to compare means and a 5% level of significance was adopted.


  Results Top


The participation rate was 100% and there were no incomplete responses. Ninety-two respondents were seen. The mean age in our sample was 40 ± 7.5 years; a higher proportion was females 48 (52.2%) and majority of participants (66.3%) had the tertiary level of education. Most had finished high school, with an average of 12.5 years of education. Sixty-seven (72.8%) participants rated their oral health good.

Aged participants above 60 years (P = 0.006), males and uneducated participants had worse oral hygiene and more gingival inflammation. Aged participants > 60 years and those uneducated also had worse self-rated oral health, while females had significantly better self-rated oral health (P = 0.048). Higher levels of gingival inflammation and worse oral hygiene was associated with poorer self-rated oral health across all sociodemographic variables explored [Table 1].
Table 1: Association between sociodemographic characteristics, oral hygiene, and self-rated oral health

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[Table 2] shows differences in selected variables according to self-rated oral health and clinical categories. Poor self-rated oral health was higher among respondents with an increased perceived need for treatment; that do not use dentures; those with xerostomia and those that infrequently visited the dental clinic. It was, however, significantly higher among respondents with difficulty in mastication due to toothache within the past 6 months (P = 0.026); and those with pain or discomfort in the past 4 weeks (P = 0.042).
Table 2: Association between dental health and self-rated oral health

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A higher percentage of the study participants that had poor self-rated oral health had difficulty with chewing fresh carrots, firm meat, fresh apples, and even salad even though the association was not statistically significant. Poor self-rated oral health was significantly higher among respondents with gingival bleeding (P = 0.017); and those with oral malodor (P = 0.005) [Table 3].
Table 3: Association between masticatory ability, oral health status, and self-rated oral health

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Oral prophylaxis was thought to be important by the majority of respondents for keeping mouths clean and gums healthy, whitening teeth, and preventing bad breath, and tooth decay. There were significant differences in patients' perception of the benefit of scale and polish after the procedure except in the domain of its ability to whiten teeth [Figure 1].
Figure 1: Comparison of patient perceptions of scale and polish before and after the procedure

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  Discussion Top


A person's oral health can be measured in two profoundly diverse methods, either by clinical examination by a dental professional or by the patient's self-assessment. This study aimed at determining the relationship between self-rated and normatively assessed oral health and to compare the patient's self-reported outcomes of receiving a scale and polish before and after the procedure at LASUTH. The participation rate was 100%, and there were no incomplete responses due to questionnaire data being collected via interview. The interpretation of the results is, however, with caution due to the pre-experimental nature of the study design and because all participants were recruited from LASUTH. A comparison of the findings of this study with those of others is also made carefully because these studies had used different approaches for allocating individuals into groupings of poor and good self-rated oral health. This may limit the ability to generalize these findings to the general population, but the results still provide the template for further exploratory study.

Ninety-two respondents were seen. Aged respondents (>60 years) had significantly worse oral hygiene, and they also had a higher proportion of participants with poor self-rated oral health. This was in agreement with studies Okunseri et al.[14] and Kim et al.[15] which showed that elderly people were more likely to rate their oral health worse than young adults. Kiyak [16] noted that the preservation of oral esthetics was the main criterion in successful aging. The loss of teeth which often accompanies aging can cause in a discrepancy in speech, esthetics, and self-esteem.[17] Conversely, Neumann et al.[18] found that older people are more satisfied with their dental appearance and evaluated their appearance more favorably.

Majority of the study participants rated their oral health as good (72.8%). This proportion was similar to that obtained in a South African study.[19] In agreement with previous studies,[20],[21] we found that females tended to rate their oral health better than males. Women tend to groom themselves better and are known to oral seek health care more than males. Contrariwise, some researchers observed problems related to oral health, such as difficulty chewing, talking or pain are more commonly reported by women,[22] with a prevalence of negatively self-rating their oral health 20.0% higher than among men. Gender differences are not easily explained, but females generally tend to disparage themselves more severely compared to males and women have conventionally been held to higher beauty standards by society. We also observed that those reporting higher education often reported better oral health which was linked to improved clinical oral health outcomes. This may be as a result of better comprehension of the importance of dental health and an improved effort to maintain proper oral health through improved health-seeking behaviors.

There was a positive association in this study between the self-rated oral health of the study participants with their normatively assessed oral health status with those who rated their oral health as good having better oral hygiene and gingival health. Furthermore, a higher percentage of the study participants that had poor self-rated oral health had difficulty with chewing fresh carrots, firm meat, fresh apples, and even salad even though the association was not statistically significant. Poor self-rated oral health was significantly higher among respondents with gingival bleeding and those with oral malodor. Studies have shown that when oral health is compromised, overall health, mental health, and quality of life may be diminished as well.[23] Consistent with previous studies,[14],[24] we observed that good self-rated oral health was strongly associated with regular dental attendance. Poor self-rated oral health was also higher among participants with an increased perceived need for treatment; that do not use dentures; those with xerostomia. This is consistent with a previous study's findings,[25] that those who reported oral health problems such as tooth sensitivity, bleeding gums, and bad breath were significantly less likely to rate their oral health as good. Other researchers also observed that people who have difficulty eating, untreated dental caries,[26],[27] and high scores for Decayed, Missing, and Filled Teeth [28] had poor self-rated oral health.

We similarly observed in this study that those that infrequently visited the dental clinic were marginally more likely to report poor self-rated oral health. Participants with a recent complaint of dental pain were, however, significantly observed to have poor self-ratings of oral health. There has been a controversy on whether regular dental attendance enhances oral health. It has been suggested that regular dental attendance is associated with improved oral health, resulting in less untreated disease, higher numbers of functioning teeth, lower rates of tooth loss, and less acute symptoms.[29] On the other hand, Baker [30] observed that not visiting the dentist in the past 12 months was linked to better self-reported oral health, opining that a recent visit may be due to the presence of symptoms. Conclusively, preventive dental visits seem to have been associated with a good self-rating of oral health, whereas restorative or symptomatic visits have been associated with poor self-ratings of oral health.[31],[32]

A novel aspect of our research was the incorporation of a single visit scale and polish or oral prophylaxis into the self-rating assessment protocol of our study. Since oral prophylaxis is the acceptable professionally administered plaque control regimen, incorporating patients' views in the delivery of this procedure may potentially motivate the patient on their home-based and self-administered plaque control procedures such as tooth brushing and flossing as well as facilitate dental recall appointments.

Scale and polish were thought to be important by the majority of participants for keeping mouths clean and gums healthy, whitening teeth, and preventing bad breath and tooth decay. After intervention, there were significant differences in patients' perception of the benefit of scale and polish except in the domain of its ability to whiten teeth. Gingivitis, resulting from poor oral hygiene can potentially lead to periodontitis which has possible associations with systemic diseases such as diabetes mellitus, cardiovascular disease, and adverse pregnancy outcomes.[33] A critical component in the prevention of periodontal disease is the control of dental plaque by the patient. Patients' perspectives on their health influence their disposition to receive professional counsel and treatment.[34],[35] Hence, patient education and training in personal oral hygiene which should form an integral part of any treatment plan may be facilitated by incorporating the patients' self-assessment at each visit for oral prophylaxis.


  Conclusion Top


There was a positive association between self-rated oral health and normatively assessed oral health status. Respondents that rated their oral health poorly had a higher need for dental treatment. There was also a significant difference in the subjects' perception of the benefit of scaling and polishing. The findings highlight the potential role of patients' beliefs and perceptions as a potential impetus for treatment provision. Valid self-reported measures of oral health thus offer a low-resource, and low-cost method of obtaining data [36] with potential policy, theoretical, and practical applications. Adding self-perception to clinical assessments could provide a comprehensive basis for the allocation of health resources, the monitoring of oral health thus enhancing clinical practice.[37]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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