INTRODUCTION

Periodontal disease is a common inflammatory condition, which starts from gingivitis and progresses to periodontitis. Periodontal disease often occurs as the result of the activity of pathogenic microbiota and its effect on the innate and adaptive immune responses and subsequent development of inflammatory processes. Changes in the immune system negatively affect the tooth-supporting structures and can lead to attachment loss, bone loss, and eventual tooth loss [1-3]. Periodontal disease affects both males and females and its prevalence increases with age [4-6]. According to the World Health Organization statistics, about half the children and the majority of adults worldwide may experience variable levels of periodontal disease [4]. The incidence of periodontal disease is 96.30% in India [7], 62% in Georgia [8], less than 10% to 77% in Latin America [9], and 47% in the United States [10].

Screening for periodontal disease and proper and prompt treatment planning is highly important for several reasons. First, periodontal disease is among the main causes of tooth loss [11, 12]. Second, periodontal disease may be associated with some systemic disorders such as cardiovascular diseases, diabetes mellitus, osteoporosis, pulmonary diseases, systemic infections, premature birth, and cancers of the oral cavity, upper gastrointestinal tract, and the lungs [13-15]. Moreover, periodontal disease can negatively affect the quality of life [16, 17].

Several indexes are used in epidemiologic studies to assess the periodontal status of patients. The community periodontal index of treatment needs (CPITN) is among the most important indexes used to determine the periodontal treatment need of patients [18]. It was designed by Ainamo et al., in 1982 upon request by the World Health Organization [19]. Different health organizations worldwide use CPITN to assess the periodontal status and the treatment needs of their respective communities [20]. However, CPITN is an index of treatment needs and cannot replace clinical indices such as clinical attachment level, since it cannot differentiate between different periodontal conditions [21].

During the recent decades, the CPITN has been frequently used for the assessment of periodontal status and the need for periodontal treatment in different communities. According to the CPITN, periodontal treatment need was 61% in an Indian subpopulation ≥ 15 years of age [22]. Zovko et al., in Herzegovina evaluated the treatment needs of 20 to 49-year-olds and reported that 8% required oral hygiene instruction, 81.8% required prophylaxis and initial treatment, and 2.6% required professional treatment [23]. Hesari et al., in Iran reported that only 1% of 35 to 45-year-olds had CPITN=0 [24]. Sanei et al., evaluated 13 provinces of Iran and reported healthy periodontal status in only 14.5% of the population of adolescents. They showed that CPITN was significantly higher in boys, villagers, those with occasional tooth-brushing, and large families [25].

Considering the high prevalence of periodontal problems reported in previous studies, it is imperative for dental clinicians to thoroughly evaluate the periodontal status of patients during dental visits [26]. However, despite the high prevalence and significance of periodontal disease, periodontal therapy is sometimes overlooked in the treatment planning of patients [27]. Thus, this study aimed to assess the dental clinicians’ attention to periodontal therapy in the treatment planning of patients presenting to dental clinics of Isfahan city, Iran.

MATERIALS AND METHODS

This descriptive, cross-sectional study was carried out at the School of Dentistry, Isfahan University of Medical Sciences, in 2016. The target population comprised of patients presenting to dental clinics of Isfahan city in 2016.

The inclusion criteria were age ≥19 years, patients presenting to a general dentist, and both the patient and dental clinician’s consent for participation in the study. Not answering the questions in the questionnaire and dental clinicians not consenting to the study were the exclusion criteria.

Patients were selected by cluster sampling. First, the list of dental clinics (both private and public) in 14 districts of Isfahan city was obtained and from each district, proportionate to the population of the respective district, one to three clinics were randomly chosen. Uncooperative clinics were excluded and replaced. In each selected clinic, patients were selected using convenience sampling. A total of 251 patients were enrolled as such. After briefing the patients about the objectives and methodology of the study, written informed consent was obtained from them and a checklist was used to collect information regarding age, sex, level of education, frequency of daily toothbrushing, history of previous dental treatments, and cigarette smoking. After routine dental examination of patients by the attending dentist in the clinic, the treatment plan suggested by the dentist was recorded in a checklist.

Periodontal examination was performed using a periodontal probe (612 WHO) and a dental mirror on a dental chair under adequate lighting by an experienced dentist. The periodontal status of the patients and their periodontal treatment needs were determined using the CPITN according to Table 1 [28].

A complete oral examination was carried out. Each jaw was divided into six sextants (one in the front and two in the back of each arch). Accordingly, the number of teeth in these sextants included 14-17, 13-23, 24-27, 34-37, 33-43, and 44-47. In each sextant, a minimum of two teeth had to be present with no indication for extraction. In the case of the presence of fewer than two teeth, the single tooth was included in the next sextant. Bleeding on probing was evaluated using a periodontal probe by applying a load of less than 25 g. After 20 seconds, the presence/absence of bleeding was recorded. Pocket depth was measured in six points around each tooth including the mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual, and distolingual and the maximum value was recorded. As shown in Table 1, the maximum score of each sextant was recorded. Next, the patients’ checklists and the suggested treatment plans by dentists were evaluated and compared with the actual treatment needs to determine whether the treatment plan includes periodontal therapy or not. If periodontal therapy had been mentioned in the treatment plan, the agreement of the suggested treatment with the actual patient needs was evaluated. The collected data were analyzed using SPSS version 24 via the chi-square test, Kruskal-Wallis test, and kappa coefficient. The level of significance was set at P<0.05.

RESULTS AND DISCUSSION

This study evaluated 251 patients presenting to active dental clinics in 14 municipal districts in Isfahan city. Table 3 presents the demographic information of patients. According to the treatment plans suggested by the attending dentists of the clinics, 205 patients (81.7%) required restorative treatments, 16 (6.4%) required orthodontic treatment, 83 (33.1%) required prosthetic treatment, 132 (52.6%) required endodontic treatment, 71 (28.3%) required surgical treatment and 51 (20.3%) required periodontal therapy.

According to the CPITN, of 251 patients, 34 (13.5%) had healthy gingiva. Of the remaining patients, 56 (22.3%) had bleeding on probing, 89 (35.5%) had supra-gingival or subgingival calculus, 53 (21.1%) had 4-5 mm deep pockets and 19 (7.6%) had ≥6 mm pocket depth. According to the CPITN, of 251 patients, 34 did not require any special care, 56 required oral hygiene instruction, 142 required oral hygiene instruction, and scaling and root planing (SRP), and 19 required oral hygiene instruction, SRP, and periodontal surgery.

Concerning the treatment plans suggested by dentists, dental clinicians did not suggest any periodontal treatment for 200 patients while among these 200 patients, 56 (28%) required oral hygiene instruction, 103 (51.5%) required oral hygiene instruction and SRP, and 7 (3.5%) required oral hygiene instruction, SRP and periodontal surgery. Also, 49 patients underwent SRP; out of which, 39 required oral hygiene instruction in addition to SRP, and 10 required oral hygiene instruction, SRP, and periodontal surgery. Of a total of 251 patients, 2 underwent periodontal surgery, who also required SRP according to the CPITN (45 2).

The Chi-square test revealed that the suggested periodontal treatment plan had a significant difference with the actual treatment needs of patients (P<0.001). On the other hand, the kappa statistic revealed that the agreement between the suggested treatment plan and the need for periodontal treatment was not significant (kappa=0.024, P=0.18).

Table 3 presents the frequency distribution of gingival health status and the treatment needs of male and female patients. According to the chi-square test, the gingival health status and the treatment need were significantly different between males and females such that females had a more favorable gingival health status and fewer treatment needs. It should be noted that none of the female patients had ≥6 mm pocket depth and no female patient required periodontal surgery; whereas, 12.5% of males had ≥6 mm pocket depth, and 14% of males required periodontal surgery.

According to Table 3, patients with healthy gingiva had the lowest mean age (27.9±4.7 years) while those with ≥6 mm pocket depth had the highest mean age (46.5±8.9 years). One-way ANOVA revealed a significant association between the gingival health status and patients’ age (P<0.001). Patients with no periodontal treatment need had the lowest mean age (27.9±4.7 years) while those requiring SRP and periodontal surgery had the highest mean age (44.8±9.8 years). Accordingly, a significant association was noted between age and periodontal treatment needs of patients (P<0.001).

As shown in Table 3, gingival health status and the treatment need had a significant association with cigarette smoking such that smoker patients had a lower level of gingival health; 39.1% of smoker patients had 4-5 mm pocket depth and 18.8% had ≥6 mm pocket depth. The prevalence of 4-5 mm and ≥6 mm pocket depth in non-smokers was 15.9% and 2.2%, respectively (P<0.001). In terms of treatment needs, smoker patients had higher treatment needs such that 21.7% of them required periodontal surgery, while this rate was 2.2% in non-smokers (P<0.001).

According to Table 4, patients with an elementary level of education had the lowest level of gingival health; 14.3% had 4-5 mm pocket depth and 57.1% had ≥6 mm pocket depth. The prevalence of 4-5 mm and ≥6 mm pocket depth in patients with high-school education was 39.4% and 24.8%, respectively. These values were 33.3% and 18.5% in patients with a university education, respectively. The linear by linear test revealed a significant difference in gingival health status according to the level of education of patients (P<0.05). As shown in Table 4, the treatment need was significantly different according to the level of education of patients such that 38.5% of those with elementary education required oral hygiene instruction, SRP, and periodontal surgery while this rate was 7.2% among patients with a high-school level of education and 4.7% in those with university education (P<0.001).

As shown in Table 4, gingival health status and the treatment need were significantly different according to the frequency of toothbrushing by patients. Patients who did not brush their teeth had a lower level of gingival health such that 50% of patients who did not brush their teeth had ≥6 mm pocket depth. However, none of the patients who brushed their teeth twice daily had ≥6 mm pocket depth. In terms of treatment needs, those who did not brush their teeth had higher treatment needs such that 50% of them required periodontal surgery while this rate was 3% among those who brushed their teeth twice daily (P<0.001).