Knowledge regarding periodontal disease and related systemic diseases among university students: A cross-sectional study
How to cite this article: Al Malak A, El Masri Y, Haidar C, Salameh P. Knowledge regarding periodontal disease and related systemic diseases among university students: A cross-sectional study. J Global Oral Health 2023;6:8-14.
Periodontal disease attained global concern especially after several studies linked periodontal disease with systemic diseases such as cardiovascular disease, diabetes mellitus, and cancer. Moreover, the prevalence of these systemic diseases among Lebanese population is considerably high. However, the knowledge regarding the periodontal health and related systemic diseases is unknown. The purpose of this questionnaire-based cross-sectional study was to examine Lebanese University students’ knowledge concerning periodontal health and related systemic diseases.
Materials and Methods:
In total, 461 students out of 520 took part between November 22, 2022, and December 1, 2022, with a 88.6% response rate and were asked to complete an online survey that included questions concerning healthy periodontium and its relation with systemic diseases.
The data revealed a poor knowledge regarding the relationship between periodontal disease and systemic diseases such as diabetes (27.5%), cardiovascular complications (28.9%), adverse pregnancy outcomes (27.5%), cancer (39.5%), respiratory problems (30.2%), and arthritis (22.1%). However, participants were aware of the healthy color and consistency of the periodontium (83.5%), (66.2%), and the need for dental check-ups (68.1%); moreover, public university and senior health-related students appeared with higher knowledge, compared with private and junior university students (P = 0.035, P = 0.048, and P < 0.001, respectively).
Knowledge regarding oral health in general and periodontal health specifically must be improved among university students. Therefore, awareness campaigns must be held to increase knowledge among them and consequently among their families regarding periodontal health.
The oral cavity is composed of mucosal and dental surfaces, which are inhabited by certain bacterial colonies. Imbalance of the bacterial flora in the oral cavity creates a disequilibrium that leads to certain infections such as caries and periodontitis. Studies showed that a high prevalence of the dentate adults over 30 years old in the USA suffer from periodontitis.
Just like any other body organ, the periodontium can be affected by diseases and gets infected and inflamed. The most common periodontal diseases are gingivitis and periodontitis. Gingivitis, the less severe form of periodontal disease, is the inflammation of the gingiva without causing any damage to the tooth’s underlying attachment apparatus, so no attachment loss will occur; thus, periodontal pockets will not be present. If left untreated, gingivitis can lead to an advanced form of periodontal disease called periodontitis, which is characterized by the loss of the tooth’s underlying supporting structures (bone, cementum, and periodontal ligament); therefore, it can eventually lead to tooth loss. The main etiological factor of periodontal disease is dental plaque. Some risk factors such as age, gender, and poor oral hygiene can attribute to its formation as well, or it can be a manifestation of certain systemic diseases such as diabetes and Crohn’s disease.[8,9] Different studies have shown a link between periodontal diseases and systemic conditions. It has been shown that periodontal pathogens could directly or indirectly be linked to systemic diseases such as cardiovascular disease, type 2 diabetes, rheumatoid arthritis, cancer, respiratory tract infection, and adverse pregnancy outcomes. Philstrom et al. found that periodontal disease is strongly associated with cardiovascular diseases such as ischemic heart disease and heart failure. The prevalence of these systemic diseases among the Lebanese population is considerably high. According to Jelwan et al., cardiovascular diseases have attributed to around 47% of all mortalities in Lebanon.
Due to the relations previously mentioned, precaution regarding periodontal diseases is essential to prevent systemic and dental outcomes. Periodontal diseases avoidance is realized by individual performance of important plaque control methods. The most efficacious method is the mechanical and chemical elimination of dental plaque. Inadequate oral hygiene and bad habits (such as smoking, drinking alcohol, and aggressive teeth brushing) are factors that can aggravate periodontal diseases and speed up their progression.
Guo et al. showed that there is a link between bad oral health and bad health literacy. Therefore, in addition to plaque control, knowledge about periodontal health and its diseases as well as the systemic consequences triggered by periodontal diseases is essential, and patients must be educated and motivated to maintain regular oral hygiene to subsequently avoid the development of periodontal diseases and its systemic outcomes. At the American University of Beirut, Kassak et al. conducted a study that showed poor oral hygiene and dietary habits among students and found a correlation between them and different lifestyle behaviors. Therefore, they focused on the significant need to educate students on the importance of improving those habits. Therefore, knowledge and awareness are essential factors for good oral health. So far, knowledge regarding oral health remains vague among university students from developing countries such as Lebanon in comparison to those from developed countries. After an in-depth search, we noticed a lack of studies concerning the level of knowledge regarding periodontal health and periodontal diseases in our region, mainly in Lebanon where zero studies were conducted on the periodontal health and diseases students.[23-27] To learn more about this issue, we have decided to conduct a study among university students in Lebanon, which are considered a representative sample of the Lebanese population since they have different socioeconomic conditions, and levels of education, and they come from all Lebanese districts.
MATERIALS AND METHODS
Setting and study design
This is a cross-sectional study conducted on university students in Lebanon, between November 22, 2022, and December 1, 2022 with ethical clearance obtained from Institutional Review Board and Research Committees at Sahel General Hospital (Ref.num:23/2021). In Lebanon, there are around 180,000 university students distributed among nine relatively large universities, each one of them including more than 5000 students. The Lebanese University being the only public university out of them includes more than 40% of the total number of the enrolled students. An online questionnaire was generated using Google Forms and spread through social media platforms, applying the snowball method, to obtain a larger sample.
This study included 461 participants that met the following inclusion criteria and were eligible for the study: University students and are residing in Lebanon. All participants were provided with full explanation of the study and the questionnaire.
Data source measures
The questionnaire was composed of several multiple-choice questions along with a few open-ended ones related to the students’ demographical data such as age, gender, residence area, name of the university that the applicant attends, academic year, as well as the applicant’s major. Thirteen questions were divided into four subgroups related to the description of a healthy-looking periodontium, the initiating factor and signs of periodontal diseases, and the best method to prevent periodontal diseases were also proposed, similar to a study conducted by Alzammam and Almalki among university students, in addition, the relationship between periodontal diseases and systemic diseases such as cardiovascular disease, type 2 diabetes, rheumatoid arthritis, cancer, respiratory tract infection, and adverse pregnancy outcomes. Pihlstrom et al. found that periodontal disease is strongly associated with cardiovascular diseases such as ischemic heart disease and heart failure.
The Statistical Package for the Social Sciences (SPSS) software version 11.0 (SPSS®: Inc., Chicago, IL, USA) was used to enter and analyze the data. Percentages and means and standard deviations (SDs) were calculated. In addition to that, Chi-square test was used to do a comparison between subgroups.
A multiple linear regression was conducted using the knowledge scale as dependent variable. The ENTER method was used and adjusted beta coefficients were calculated based on the model. P < 0.05 was considered significant.
[Table 1] shows that the mean SD age of participants was 20.37 years (±2.03). Female participants occupied more than 85% of all participants. North Lebanon district and urban area accounted for more than half (57.2% and 70.1%, respectively) of the study sample. Approximately 72.9% of respondents were students enrolled in non-health-related majors, and more than half of participants were between 1st and 3rd year students (1st year 21.9%, 2nd year 17.6%, and 26.5% 3rd year students). Moreover, 65.9% of students were enrolled in the public university.
|Age (Mean±Standard deviation)||20.37±2.03|
|Lebanese district residency||Akkar||31||6.7|
|Post or undergraduate||Undergraduate||391||84.4|
|Academic year||First year||101||21.9|
[Table 2] shows that a high number of students could identify the correct color of a healthy gingiva (83.5%). Likewise, most of them were able to determine that the normal gingival consistency was firm (66.2%). However, the case was not the same regarding the gingival texture, where only 15.8% of the students believed it to have an orange peel appearance, while the majority of them (65.7%) thought that it was smooth. More than half of the students (54.7%) were aware that dental plaque is the initiating factor of periodontal disease, while the rest thought that the main factor was a systemic cause or did not know. About 60% of the students failed to recognize all the indicated signs of periodontal disease, and only 39.3% of them were able to identify all three signs. When it came to the questions related to the relationship between periodontal and systemic diseases, almost all questions had similar results where around half knew while the other half failed to answer correctly. An average of around one-third of the students recognized a relationship between periodontal disease and diabetes (27.5%), cardiovascular complications (28.9%), adverse pregnancy outcomes (27.5%), cancer (39.5%), respiratory problems (30.2%), and arthritis (22.1%). The majority of students are knowledgeable about the best method to prevent periodontal disease since 70.9% of them chose proper brushing and flossing as the correct answer. A great number of students (68.1%) claim to go to the dentist for a check-up whenever they experience periodic gingival bleeding.
|Knowledge regarding periodontal health||What is the color of a healthy gingiva?||Pink||385||83.5|
|I do not know||48||10.4|
|What is the texture of a
|Orange peel appearance||73||15.8|
|I do not know||85||18.4|
|What is the consistency of a
|I do not know||118||25.4|
|Knowledge regarding periodontal disease||What is the initiating factor of periodontal disease?||Dental plaque||252||54.7|
|I do not know||110||23.9|
|What are the indicating
signs of periodontal disease? (Multiple answers)
|Gingival bleeding+Gingival swelling+Gingival redness||181||39.3|
|I do not know||65||14.1|
|Knowledge regarding relationship between periodontal disease and systemic diseases||Can periodontal disease lead to diabetes?||Yes||127||27.5|
|I do not know||232||50.3|
|Can periodontal disease lead
to heart complications?
|I do not know||230||49.9|
|Can periodontal diseases lead to adverse pregnancy
|I do not know||240||52.1|
|Can periodontal disease lead
|I do not know||193||41.9|
|Can periodontal disease
cause respiratory problems?
|I do not know||213||46.2|
|Can periodontal disease
|I do not know||237||51.4|
|Knowledge regarding prevention of periodontal disease||What is the best method to prevent periodontal disease?||Proper brushing and flossing||327||70.9|
|Consuming soft foods||77||16.7|
|Intake of vitamin C|
|I do not know||57||12.4|
|After experiencing regular gingival bleeding, do you go to the dentist for a check-up?||Yes||314||68.1|
Knowledge was frequently associated with health-related majors (mean = 7.704 ± 2.865) compared to non-health-related majors (mean = 5.012 ± 2.505) (P < 0.001); moreover, the past third years of college students appeared with the highest knowledge score, respectively, (>5th year) (mean = 6.739 ± 2.947), fourth year (mean = 6.227 ± 3.296), fifth year (mean = 6.135 ± 2.879) compared with the 1st year (mean = 5.66 ± 2.188), 2nd year (mean = 5.086 ± 2.637), and 3rd year (mean = 5.549 ± 3.045) (P = 0.048). Furthermore, public university students expressed high knowledge scores (mean = 5.944 ± 2.597) compared with private university students (mean = 5.350 ± 3.301) (P = 0.035); in addition, North Lebanon residents appeared with the lower knowledge result (mean = 5.244 ± 2.736) and Beqaa presented the higher knowledge scores (mean = 7.500 ± 2.431) (P = 0.001) [Table 3].
|Lebanese district residency||Akkar||5.871±2.405||0.001|
|Post or undergraduate||Undergraduate||5.747±2.895||0.93|
|Academic year||First year||5.663±2.188||0.048|
In [Table 4], the multivariable analysis of the knowledge-related scale is presented; a significantly lower knowledge scale is shown in second (beta = −0.999) and third (beta = −0.709) years at the university (compared to first years), particularly in private universities (beta = −0.54) and in non-health-related majors (beta = −2.543). There was a trend toward a better knowledge among students from Mount Lebanon and Beirut, compared to the North (P < 0.1). Other variables did not significantly affect the knowledge score.
|Parameter||B||Standard error||95% Wald
|Gender=Female vs. Male||0.054||0.3503||−0.632||0.741||0.876|
|Lebanese district=Nabatiye vs. North||1.444||0.8921||−0.304||3.193||0.105|
|Lebanese district=South Lebanon vs. North||0.035||0.8315||−1.595||1.664||0.967|
|Lebanese district=Beqaa vs. North||1.000||0.7839||−0.536||2.537||0.202|
|Lebanese district=Baalbek vs. North||0.299||0.6182||−0.913||1.511||0.629|
|Lebanese district=Mount Lebanon vs. North||0.686||0.3666||−0.032||1.405||0.061|
|Lebanese district=Beirut vs. North||0.730||0.4090||−0.071||1.532||0.074|
|Lebanese district=Akkar vs. North||0.528||0.5429||−0.536||1.592||0.330|
|Residence area=Rural vs. Urban||−0.237||0.2954||−0.816||0.341||0.421|
|Are you a UG or PG student?=PG vs. UG||−0.045||0.4002||−0.829||0.739||0.911|
|What year are you in?= >5 vs. 1st year||−0.797||0.7703||−2.308||0.713||0.301|
|What year are you in?=Fifth vs. 1st year||−0.699||0.5964||−1.868||0.470||0.241|
|What year are you in?=Fourth vs. 1st year||−0.636||0.4550||−1.528||0.256||0.162|
|What year are you in?=Third vs. 1st year||−0.709||0.3882||−1.470||0.051||0.068|
|What year are you in?=Second vs. 1st year||−0.999||0.4129||−1.808||−1.89||0.016|
|Which university do you attend?=Private vs. Public||−0.540||0.2664||−1.062||−0.18||0.043|
|What is your major?=Non-health-related vs. health-related||−2.543||0.3025||−3.136||−1.950||0.000|
Our study aimed to inform us about the level of knowledge regarding periodontal health and diseases in hopes of raising awareness and showing the importance of maintaining healthy periodontal conditions throughout one’s life.
According to our study, there has been no significant difference between males and females regarding the level of knowledge. Likewise, neither did the residency area, whether urban or rural, nor the level of education, whether undergraduate or postgraduate, have an effect on the level of knowledge among university students. However, certain other demographical factors had a major significance regarding the issue.
The first three years showed lower knowledge and attitude toward periodontal health, diseases, relation with general health, and prevention compared with higher education level students (4th, 5th, >5th). Higher education students might experience and receive more dental care and thus increase their knowledge of oral health and periodontal diseases. According to Márquez-Arrico et al., the knowledge regarding oral health increased for higher education students.
Our findings also revealed that public university students showed better knowledge than their counterparts in private universities (5.944 ± 2.597, 5.350 ± 3.301, respectively); in Lebanon, the majority of public university students are from a lower socioeconomic status compared to the private university students. According to several studies, oral health knowledge and attitude toward oral health are highly associated with the socioeconomic status.[30-32] However, the lack of awareness toward the low socioeconomic status students can be compromised by the easy access to the internet and obtaining more knowledge regarding oral health. A study conducted by Maharani et al. showed that the majority of their population used the internet as a source of oral health knowledge.
According to our findings, health-related majors students showed better knowledge concerning the periodontal health, initiating factor of periodontal diseases and the relationship between periodontal diseases and systemic diseases, in comparison to non-health-related majors (7.704 ± 2.865 and 5.012 ± 2.505, respectively); this variation might be explained by the curiosity of health-related students to increase their oral health knowledge and overall health. In addition non-health-related students receive no oral health education at all during their university study, and their curriculum contains no information regarding oral health education.
Regarding the causal agent of periodontal disease, 54.7% of the students were aware that plaque is the initiating factor of periodontal disease, this coincides with the finding of El-Qaderi among Jordanian university students 51%, and approximately three quarters (70.09%) acknowledge that the best preventing method of periodontal disease is proper brushing and flossing. However, on the other hand, this finding does not guarantee the validity of their claims nor does it prove that they use an adequate brushing technique or brush for a sufficient duration.
Concerning the relationship between periodontal disease and general health diseases, the majority of students scored very low in this section. Lebanese Universities and especially dental faculties in Lebanon are to blame for such results since it is their responsibility to ensure the spread of awareness and knowledge regarding periodontal and oral health in general among university students. This can be improved with the aid of multiple social media platforms, performing interactive lectures with non-dental students, and spreading brochures on campus. In addition, the lack of knowledge within the students’ households might have played a huge role in achieving such results as well. A great number of those students’ parents or the students themselves may suffer from diseases that may be correlated to periodontal disease, but their insufficient knowledge regarding this topic would not help them to recognize severity of the issue. Therefore, awareness campaigns must be held among university students to increase knowledge among them and consequently among their families regarding periodontal health, in hopes of decreasing the number of people in Lebanon suffering from periodontal diseases and their effect on the general health as well.
Our study possesses several strong points, mainly by being the first cross-sectional study regarding knowledge of periodontal disease and related systemic diseases among university students in Lebanon. Due to lockdown and online courses, online surveys were used in data collection. Hence, it was possible that responders could search for information before answering, this would lead to an information bias. Further studies are suggested to confirm our findings.
The study showed lack of knowledge and awareness concerning the texture of healthy gingiva and the initiating factor and signs of periodontal disease. Furthermore, there is a very poor knowledge regarding the presence of the relationship between periodontal disease and systemic diseases.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Conflicts of interest
There are no conflicts of interest.
Financial support and sponsorship
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