Periodontists' Knowledge, Perception, and Professional Behaviour Regarding Patients' Psychosocial Factors and Treatment Outcomes in Nepal

Introduction: Psychosocial factors when present in patients affect their treatment decision making and prevent them from seeking dental care. It also plays an important role in predicting the severity of pain, periodontal disease, and wound healing. Periodontists can provide the best treatment plan but may fail to obtain expected outcomes as patients may not follow the recommendation made by them. Objective: To assess knowledge, perception and professional behaviour of Periodontists’ regarding patients’ psychosocial factors and responses to periodontal treatment in Nepal. Methods: A descriptive, online cross-sectional survey using Google Forms was conducted among the Periodontists practicing in Nepal from June 2021 to August 2021. A questionnaire developed by Kloostra et al. was modified according to our practice setup and used for the survey. A total of 48 periodontists practicing in the country responded to the questionnaire. Results were analysed using SPSS v.11.5. A p value <0.05 was considered statistically significant at 95% confidence interval. Results: A significant difference in response for relation with perceived pain, perception of pain, wound healing and wound integrity between stress and depression was observed in this study. There was a significant difference (P=0.001) in preparedness for communicating with patients after postgraduate training and after undergraduate training. Conclusions: Periodontists agreed that there is role of stress, anxiety and depression in their patients’ responses to treatment. The lack of preparation at dental school to consider impact of psychosocial factors when treating patients is highlighted.


INTRODUCTION
Periodontal disease is a multifactorial disease where many underlying factors affect treatment.Psychosocial factors can influence periodontal conditions possibly by modification of patients' behaviour (negligent oral hygiene, smoking or eating habits) with negative reflexes to immune functions which are harmful to periodontal health. 1 Stress also plays role in predicting pain severity, periodontal disease 2 and wound healing. 3,4Thus patients with anxiety often experience greater post-operative pain. 5The association of psychosocial factors and periodontal diseases and its effect on treatment outcome has been studied 6 where it Dr.Khushbu Adhikari, 1 Dr. Sajeev Shrestha, 1 Mr. Dharanidhar Baral 2 was found that patient with depression had a negative effect on treatment outcome after one year of periodontal treatment. 7though periodontists can provide the best treatment, they may fail to obtain expected outcomes, as patients with psychosocial factors may not follow their recommendation.
Research has also shown relationship between the quality of dental education and future professional attitudes and behaviours of practitioners. 8 A sample size of 71 was calculated using the formula, n=z 2 pq/d 2 ; where Z=1.96 at 95% confidence interval, p=85.4 % (periodontists think of using pharmacological agents for managing anxious patients) with reference to the study done by Kloostra et al., 9 q=1-p and d= margin of error=8.5 (10%).At the time of sample size calculation, a total of 54 periodontists were registered in the Nepal Medical Council.
Therefore, the sample size had to be adjusted for finite population and 15% of non-response was added and adjusted sample size became 48.Convenience sampling method was used for sampling.
Questionnaire by Kloostra et al. 9 was modified according to the study site practice setup.Face and content validity were done by experts.Internal consistency was determined by using Cronbach's alpha for reliability.Periodontists with a registered Nepal Medical Council number were included in the study.Periodontists not willing to participate in the study and who did not fill the questionnaire completely were excluded.A consent form was attached as a first page along with the information sheet and the participants who agreed to be a part of this study responded to the questionnaire.
A link to the questionnaire was generated through Google Forms (Alphabet Inc., USA) and shared via various social media platforms like Viber and Facebook Messenger to all the participants.A reminder message was again sent to all the participants through the same medium.

RESULTS
Forty-eight periodontists responded to the questionnaire.
The professional behaviour of the periodontists when dealing with patients with psychosocial factors.They rely more on special instructions before treatment (28, 58.3%) and less on use of pharmacological behaviour management, such as nitrous oxide inhalation (3, 6.3%) when dealing with such patients (Table 5).

DISCUSSION
All 48 periodontists responded to the questionnaire.The response rate was 100% which is very high when compared to with that of a similar study by Kloostra et al. 9 Participation of the periodontists shows their keen interest in the topic.
1][12] Periodontists in Nepal strongly agreed that there is a relation with perceived pain and wound healing when their patients are stressed, anxious and depressed.They also believed that presence of stress, anxiety and depression in patients affect perception of pain and better wound integrity occurs in the absence of these factors.They were not confident in their ability to perceive stress, anxiety and depression in their patients and did not believe that use of pain medication by their patients is influenced by the presence of psychosocial factors.A significant difference in response was evident for stress than anxiety and depression in relation with perceived pain, perception of pain, wound healing and wound integrity.In contrast, depression was found to have the most significant impact, when the relationships among anxiety, stress, and depression was investigated with pain perceptions; the use of pain medication; and wound healing following periodontal surgery. 13Therefore, it seems mandatory to educate periodontists about the significance of these psychosocial factors on patients' response to treatment.
In a study with dental students and general dentists, a positive relationship was seen between their self-perceived quality of education regarding treating patients from all segments of society. 14A significant difference was found when the level of education of periodontists and their preparedness for communicating with patients was compared in this study.Their preparedness increased after their post graduate training.It also highlights the need of inclusion of these topics in dental school curricula at the undergraduate level itself.However, practitioners need to update their information about these topics from time to time.Therefore, it seems important to develop continuing education programs and educational materials about this topic proper that can be availed easily by busy practitioners at any given time.
A study had reported a lack of knowledge and clinical experiences in dentists concerning providing care and treatment for patients with special needs during dental school. 15In regard to their professional behaviour in this study, periodontists relied more on special instructions before treatment (58.3%) when they recognised the underlying psychosocial factors in patients.At the very beginning of the treatment, ways to reduce anxiety, stress, and depression in patients should be considered and various pharmacological and non-pharmacological techniques could be used to reach this objective.But it was observed

1
Department of Periodontology and Oral Implantology, College of Dental Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal; 2 School of Public Health and Community Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal.
It seems crucial to explore role of dental education.Hence, aim of this study was to assess knowledge, perception, and professional behaviour of Periodontists' regarding patients' psychosocial factors and responses to periodontal treatment in Nepal and how well their education prepared them to consider these issues while treating their patients.perception, and professional behaviour regarding patients' psychosocial factors and treatment outcomes.Ethical clearance for the study was obtained before conducting the study from the Institutional Review Committee, B. P. Koirala Institute of Health Sciences, Dharan, Sunsari, Nepal (Ref.615/077/078-IRC).

First
part of the questionnaire was regarding sociodemographic and academic background of the periodontists.One main question with two sub questions regarding continuing dental education (CDE) on communication with patients was also included (Response: Yes /No).There were two questions on their preparedness during undergraduate and postgraduate training to communicate with special needs patients also added (Response: 5-point Likert scale ranging from 1= not at all to 5 = very well.Second part consisted of 18 statements based on knowledge specifically concerning the impact of anxiety, stress and depression on patients' responses to periodontal treatment (Response: 5-point Likert scale ranging from 1= disagree strongly to 5 = agree strongly).Third part consisted of five questions related to their professional behaviour when treating patients with psychosocial factors (Response: Yes /No).The form was closed for responses after the data collection period was over.Data collected was entered in Microsoft excel 2007 and exported into Statistical Package for Social Sciences (SPSS) for Windows, Version 11.5.Chicago, SPSS Inc. for statistical analysis.The descriptive statistics were calculated as percentage, mean, standard deviation(SD) along with tabular and graphical presentation.For the inferential statistics, one-way analysis of variance (ANOVA) was applied to find out significant differences between their knowledge and perception of psychosocial factors in their patients and outcomes of periodontal treatment.Paired t test was applied for their levels of knowledge in undergraduate and postgraduate education at 95% CI, where level of significance is considered as P <0.05.
in Province-1, and 2 (4.2%) in Province-4.They are equally distributed (4, 8.3%) in Province-2 and -5.While there are no periodontists in Province-6, only 1 (2.1%) is present in Province-7.Majority of the participants (26, 54.2%) had not attended a CDE program within the past two years on communicating with patients.Only 23 (47.9%) think it to be useful.While, most participants (30, 62.5%) believed that CDE has an impact on the management of patients.Difference in response for stress, anxiety, and depression across different domains along with pairwise comparison of the same was done (Table 2, 3).A statistically significant difference in response was found for relation with perceived pain (P=0.006) and perception of pain (P=0.035) for different psychosocial factors.Post hoc pairwise comparison showed statistically significant difference for relation with perceived pain and perception of pain between stress and depression P=0.005 and P=0.039 respectively.A statistically significant difference in response for stress, anxiety, and depression in correlation with wound healing (P=0.001) and wound integrity (P=0.022) was also found.Post hoc pairwise Adhikari et al: Periodontists' Knowledge, Perception, and Professional Behaviour Regarding Patients' Psychosocial Factors and Treatment Outcomes in Nepal factors when treating patients by Periodontists in Nepal.Their age ranged from 29 to 56 years, while most of them being in their thirties.More than 50% periodontists had less than 10 years of experience, which shows that Nepal is in the beginning phase of postgraduate course in periodontology.Most of them have completed both their undergraduate and postgraduate training in Nepal itself.There has been a remarkable increase in number of periodontists in Nepal in the last decade, as there was limited provision for postgraduate study then, in Nepal.Practicing in private hospitals is more prevalent among them, this may be due to lack of adequate positions for dental faculty in the government health plan of Nepal.Their distribution can also be seen in the developed areas of the country rather than the rural areas with a greater number of them practicing in province 3.The number was comparable among periodontists who did or did not attend continuing dental education program on communicating with patients within the past two years.They also believed that CDE had an impact on the management of patients.Therefore, the role of continuing dental education on patient communication, its impact and usefulness in daily practices of periodontists cannot be overlooked during their training and post training years as well.

Table 1 :
Demographic characteristics of Periodontists of Nepal.

Table 2 :
Comparison of response scores for different psychosocial factors across different domains.

Table 3 :
Pairwise comparison of response for different psychosocial factors across different domains.

Table 4 :
Level of education of periodontists and their preparedness for communication with patients.

Table 5 :
Professional behaviour of the periodontists when dealing with patients with psychosocial factors, n (%).