|Year : 2021 | Volume
| Issue : 1 | Page : 36-41
Change in periodontal status, oral health knowledge, attitude, and practices following video-based counseling: A cross-sectional study
K Shivaranjani, B Pratebha, Jananni Muthu, R Saravanakumar, I Karthikeyan
Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India
|Date of Submission||25-Apr-2020|
|Date of Acceptance||14-May-2021|
|Date of Web Publication||29-Jun-2021|
Dr. Jananni Muthu
Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry
Source of Support: None, Conflict of Interest: None
Background: Periodontal disease is one among the most common oral health problems which are prevalent among the adult population throughout the world. There is a notable lack of awareness related to oral hygiene-related practice among transgenders, a vulnerable group of population who face social stigma. Materials and Methods: 156 participants comprising 52 each of transgenders (Group T), males (Group M,) and females (Group F) were recruited. The oral health-related knowledge, attitude, and practices were estimated by means of a prevalidated questionnaire. The periodontal status, in terms of modified gingival index (MGI) and modified Community Periodontal Index (M-CPI), probing pocket depth (PPD), and clinical attachment loss (CAL), was estimated pre- and post-video counseling. Wilcoxon signed-rank test and Kruskal–Wallis test were used to compare scores. Results: The MGI scores were comparatively higher among Group T when compared to groups M and F before (1.72 ± 0.8) and after (0.93 ± 0.9) the video intervention (P < 0.005). The bleeding component of M-CPI, was highest in group F (23.35), followed by group T (21.8) and group M (19.71). The CAL comparisons were in the order of M > T > F while PPD followed F > T > M. Conclusion: The periodontal disease was marginally high among females, while the oral hygiene-related knowledge, attitude, and practices were observed to be poor among them. Video-based education improved the periodontal status, oral hygiene related knowledge, attitude, and practices of all male, female, and transgender populations.
Keywords: Health education, modified community periodontal index, modified gingival index, oral hygiene, periodontal status, transgender, video counseling
|How to cite this article:|
Shivaranjani K, Pratebha B, Muthu J, Saravanakumar R, Karthikeyan I. Change in periodontal status, oral health knowledge, attitude, and practices following video-based counseling: A cross-sectional study. J Mahatma Gandhi Inst Med Sci 2021;26:36-41
|How to cite this URL:|
Shivaranjani K, Pratebha B, Muthu J, Saravanakumar R, Karthikeyan I. Change in periodontal status, oral health knowledge, attitude, and practices following video-based counseling: A cross-sectional study. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2021 Nov 28];26:36-41. Available from: https://www.jmgims.co.in/text.asp?2021/26/1/36/319835
| Introduction|| |
Periodontal disease is a common oral health problem which is prevalent among the adult population throughout the world. The global data reveal that periodontal disease is a major burden on oral disease., Two national surveys were carried out in India to assess the oral health status in different states of India among the male and female populations. The National Oral Health Survey and Fluoride Mapping, 2002–2003, Dental Council of India, reported that severe periodontal disease was present in 7.8% in 35–44 years and 18.1% in 65–74 years, A report of the multicentric study, conducted under the Ministry of Health and Family Welfare, Government of India, and Collaborative Program of the World Health Organization reported the prevalence of periodontitis in terms of attachment loss ranged between 46% and 78% with 55% in Pondicherry.,
Apart from the male and female population, transgenders, now termed as “the third gender,” represent a special neglected vulnerable population group or community. Due to associated social discrimination, stigma, and job insecurities, they indulge in deleterious habits such as alcoholism, gutkha-pan chewing which contribute to periodontal problems. Available studies on the transgender population in India show periodontitis prevalence between 83% and 92.8%.,, The social discrimination in the transgender community causes gratuitous stress which is a contributing factor to the periodontal problems. Although transgenders constitute only a fraction of the total population, it is necessary to extend our knowledge and facilities in order to improve their overall health status.
Oral health problems affect the quality of life of a community., This is predominantly due to lack of knowledge and the proper attitude toward the importance of oral hygiene. Understanding existing oral hygiene practices and oral health knowledge of the community is necessary to organize oral health-care systems to prevent morbidity of periodontal disease. Oral health education, an important component of oral health promotion, aims at improving awareness, positive attitudes, and good oral health behavior.
The current study was planned with the primary objective of assessing the change in oral health-related knowledge, attitude, and practices (by a prevalidated questionnaire) and the changes in clinical parameters of oral health pre- and post-video intervention. The video-based counseling is an effective method of health education and was used as an intervention in our study.
| Materials and Methods|| |
The present study was a cross-sectional survey approved by the Institutional Review Board and the Institutional Ethics Committee (IEC No: IGIDSIEC2016NDP29PGSKPAI), Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry. It was conducted over a period of 3 months from January to March 2018.
Sample size determination
The sample size was calculated using standardized statistical software G Power 3.0 (Universität Düsseldorf, Germany). Considering 0.095 ± 0.16 as mean and standard deviation from the previous study, with the alpha value of 0.05 and beta value of 0.2. The sample size was calculated as 47 participants. Considering the 10% dropout, the final sample size was calculated as 52 in each group. The consecutive systematic sampling was employed for the recruitment of subjects into the study.
Male, female, and self-identified transgender individuals, systemically healthy, and 18–65 years of age were willing to participate in the study.
Mentally challenged participants, participants under hormonal therapy, who had already been exposed to any forms of oral health counseling or video demonstration, who underwent periodontal therapy within 6 months, participants diagnosed with HIV/hepatitis were excluded from the study.
Hundred and fifty-six participants from Pondicherry and Cuddalore comprising 52 transgenders, males, and females in each group were enrolled for the study. The age of the participants was in the range of 18–65 years. Participants belonged to Class I, II, and III of Prasad social classification among all three genders. Periodontal status was estimated in terms of Modified Community Periodontal Index (M-CPI) and Modified Gingival Index (MGI). The MGI is performed by scoring the buccal, distobuccal, mesiobuccal, and lingual gingival regions of all teeth are examined under visual examination and scored form 0–4. The score 0 corresponds to no inflammation; 1 to mild inflammation (slight color change, slight change in texture but not in all papillary or marginal gingivae); the score 2 indicating mild inflammation (same criterion as in score 1 but involving all papillary unit or marginal gingiva); the score 3 corresponding to moderate inflammation (glazing, redness, swelling, and/or hypertrophy of the papilla or marginal gingiva); the score 4 implies to severe inflammation (marked redness, swelling and/or hypertrophy of the papilla or marginal gingiva, spontaneous bleeding, or ulceration). The change in oral health-related knowledge, attitude, and practices were estimated by means of a questionnaire in all the three genders, before and after video oral health intervention. Changes in oral health knowledge, attitude, and practices, as well as the change in periodontal parameters, were evaluated at baseline and after 1 first month in all the three genders. Complete medical and dental histories were obtained. Habits, socioeconomic status, and periodontal parameters were recorded in a pro forma. Clinical parameters were recorded in terms of MGI and M-CPI before and after 1 month of video intervention. The changes in terms of oral health-related knowledge, attitude, and practices were assessed by means of a prevalidated 16-item, a close-ended questionnaire which was translated to local language and the reliability was checked before administering it to the study participants (kappa score – 0.78).
The video oral health intervention comprised information on the importance of sugar intake, brushing, techniques of brushing, harmful effects of tobacco, dental caries, and periodontal disease – cause, prevention, and its impact on systemic health. The intervention was given only once during the study after recording the baseline values. The changes in knowledge, attitude, and oral hygiene practices were assessed at baseline (preintervention) and immediate postintervention, 1st month. Clinical parameters were assessed at baseline 1st month. In our study, oral health knowledge was assessed among all three groups, for issues such as the impact of oral health on systemic health, cause, treatment, and identification of dental decay, cause of mouth cancer, and the awareness of dental facilities in their vicinity. All these were observed immediately after intervention and knowledge were assessed after a month's duration.
The stated objectives – clinical status by MGI, M-CPI, Oral-health related knowledge, attitudes, and practices by questionnaire were evaluated and compared after video-based counseling.
Data were pooled and coded in the Microsoft Excel spreadsheet. R statistical software (version 3.6.1) was used to analyze the data. Continuous data were represented in the form of mean ± standard deviation, and the mean difference between groups was compared using the Wilcoxon signed-rank test and Kruskal–Wallis test as needed. A P < 0.05 was considered statistically significant.
| Results|| |
The mean age of participants enrolled in the study was 31.21 ± 8.4 years for transgender participants (Group T), 36.81 ± 9 years for male participants (Group M), and 34.62 ± 8.87 years for female participants (Group F). As per Prasad's social classification, most of the T and M groups were underclass I social class comparing to that of females. Female participants had a higher illiteracy rate compared to that of males and transgenders [Table 1]. The use of smoking forms of tobacco was highest among males with a prevalence of 30.8%. The use of smokeless forms of tobacco was highest among transgenders with a prevalence of 30.8%, followed by 7.7% of males and 3.8% of females [Table 1]. A higher rate of alcohol habit was seen among males (19.2%), followed by the transgender participants (9.3%).
|Table 1: Social demographic data, education and habit history of participants|
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Comparisons of oral health knowledge, attitude, and practice before and after video intervention
All questionnaire responses were compared by Wilcoxon signed-rank test.
Oral health knowledge (questions 1–7)
Assessing the response to knowledge-based questions, females had the least knowledge as compared to that of males and transgenders [Table 2]. Significant results were obtained after intervention for question 1 (group T), question 2, 5 (M and F groups), questions 3, 4, and 7 (all groups), and question 6 (group F).
|Table 2: Oral health awareness, knowledge, and practices questionnaire - pre- and post-intervention (in terms of percentages)|
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Oral health attitude (questions 8–10)
The response of participants for questions regarding oral health attitude, was assessed by 3 questions regarding awareness of bad breath, whether they visited a dentist or not; and the number of times they visited a dentist [Table 2]. Significant results were obtained after intervention for question 8 (group M) and question 9 (all groups).
Oral health practices (questions 11–16)
The response of participants for questions regarding oral health practices was assessed by six questions regarding the use of brushing habits and using other oral hygiene aids [Table 2]. Significant results were obtained after intervention for question 11 (Group F), questions 12, 13, and 15 (M and F groups), question 14 (group F), and question 16 (M and T groups).
Comparisons of the periodontal status before and after video intervention
Modified Gingival Index
The mean MGI score, at baseline, was high among transgenders (1.72 ± 0.80) followed by females (1.61 ± 0.85) and males (1.45 ± 0.81). All the three genders had moderate gingival inflammation at baseline which reduced to mild gingival inflammation at 1-month follow-up. The intragroup difference was statistically significant (P < 0.0005) in all three groups [Table 3].
|Table 3: Comparison of clinical parameters before and after video intervention|
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Modified Community Periodontal Index-bleeding sites
Before intervention, the number of bleeding sites was highest in females with the mean sites of 23.35, followed by transgenders (21.8) and males (19.71), whereas after oral prophylaxis and video oral health intervention the bleeding sites reduced to 9.85 in males, 11.27 in females, and 14.70 in males, at review. The intragroup difference was statistically significant (P < 0.005) in all three groups [Table 3].
Modified Community Periodontal Index-probing pocket depth
A Wilcoxon signed-rank test showed that there is a statistically significant (P < 0.05) difference between pre- and post-values among all three scores. Intergroup comparison of 1, 2, and 3 groups for scores 0, 1, and 2 was performed using the Kruskal–Wallis test. The average number of teeth with M-CPI score 0 (probing pocket depth [PPD]: 1–3 mm) for pocket depth was higher among males (17) before intervention followed by transgenders (13) and males (12). After the intervention, the average number of teeth with M-CPI score 0 (1–3 mm) for pocket depth was increased among males (23) followed by transgenders and males (21). The PPD for each score for various groups is shown in [Table 3].
Modified Community Periodontal Index-clinical attachment loss
Before the intervention, the percentage of teeth with Score 0 (loss of attachment 0–3 mm) was highest among males (47.75%) followed by transgenders (31.16%) and female (26.3%). The scores for all three groups are shown in [Table 3].
| Discussion|| |
Periodontal disease is a common oral health concern with a prevalence of 30%–40% which has been linked to risk factors of poor awareness and hygiene practices. The disease has not only been reported in males and females but also in transgenders with a very high prevalence in India. The transgenders (third gender) are neglected vulnerable populations of the Indian community, have a poor socioeconomic background, lead a stressful life, and have an addiction to oral deleterious habits. All these reasons contribute to periodontal problems.,
Transgenders face social isolation which can increase the periodontal disease as reported. Most of the male participants in our study worked as security personnel at the university. Apart from that, few of them were employed as drivers, carpenters, masons, and tailors. Apart from employed participants, women dependent on their spouse's income were classified based on the BG Prasad scale as per their family income. The habit of using smokeless tobacco was high among females (5.7%) and least among transgenders. Females were not reportedly exposed to any tobacco and alcohol-related habits. Another study reported the higher use of smokeless tobacco as compared to smoking forms among transgenders, which is in accordance with our study observations.
In the present study, we used video oral health intervention to bring about changes in oral health knowledge, attitude, and practices. Video oral health intervention can be deemed successful if participants exposed to the intervention changed their existing oral practices and adopted the recommended practices. In our study, participants had adopted changes in their oral hygiene practices like brushing twice a day, using toothbrush and toothpaste, using other oral hygiene aids in a month period. Video oral health (audio-visual) intervention was reported to be better than other intervention methods such as pamphlets and lectures by a study done among schoolchildren and in a hospital setting-based study.,
Oral hygiene practices such as brushing twice a day and using other oral hygiene aids were adopted better by females followed by males and transgenders. Participants who were not using toothbrushes and toothpaste started using these aids for better oral hygiene. This change was observed more in females compared with males and transgenders. The practice of changing toothbrushes for every 3 months was better adopted by transgenders, followed by males and females. In our study, attitude toward oral hygiene appeared to be better among males followed by transgenders and females. A study on the comparison of these three groups from India showed that males, females, and transgenders all had similar hygiene practices, and the difference was insignificant.
In our study, the females were observed to have poor knowledge about oral health before the intervention and on postintervention. The improvement in knowledge was also found to be least among females. It was also observed that desirable oral hygiene practices were least among females as compared to males and transgenders even after intervention. The data from the current study contradict the previous study, where the transgenders had the least oral health practices and knowledge. In a study, done among patients in a hospital setup, the authors reported a significant improvement in knowledge after the audiovisual intervention. The results of this study were similar to our study where a significant improvement in knowledge was observed between baseline and immediately postintervention. To the best of our knowledge, there are few studies,, in male and female genders and no studies among transgender that measured the impact of an intervention. The reason that we attribute retention of the impact of an intervention is that audiovisual aids realistically emphasize oral hygiene knowledge and enhances understanding among those exposed to the intervention.
In our study, the indices used to record periodontal parameters were MGI and M-CPI. The average number of teeth with M-CPI score 2 for the pocket was higher among females (7 teeth) before intervention followed by transgenders (5 teeth) and males (4 teeth). After the intervention, the average number of teeth with M-CPI score 2 for the pocket was reduced among males (2 teeth) followed by transgenders (3 teeth) and females (4 teeth). In our study, the prevalence of deep pockets was high among females followed by transgenders and males. This observation is in contradiction with the previous studies,, where transgenders had a higher prevalence of deep pockets. The women represented the lower socioeconomic group, had low educational levels, and oral hygiene knowledge or practices in our study (as opposed to the other two groups), which could contribute to a higher incidence of periodontal disease.
Our results are similar to that of the prevalence of shallow pockets among transgenders in a study done among transgenders in Bhopal. In our study, transgenders had a higher loss of attachment of 6–8 mm which is in accordance with the previous study. The prevalence and severity of periodontal disease were reportedly higher among transgenders compared to the male and female population in literature. In our study, the parameters measured for the periodontal disease were high among the female population and not among transgenders. This observation is in contradiction to a previous study.
The overall oral health attitude, knowledge, and practices among females were marginally poor, as more females belonged to the lower class and were illiterate and unemployed compared to males and transgenders. Similar results were observed in a study were male and female genders were compared for the difference in oral health knowledge and practices., The strength of the study is the inclusion of transgender. The limitations include smaller sample size in groups and simple questionnaire-based assessments. Further longitudinal studies, with more innovative health education methods, are recommended.
| Conclusion|| |
A high severity of periodontal disease and poor oral hygiene knowledge, attitude, and practices were noticed among the female and transgender population compared to males. Video based oral health education may be a feasible tool in providing tele-counseling to such vulnerable groups.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]