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INTRODUCTION
The American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) have recently classified periodontal diseases and conditions in three main groups: periodontal health, gingival diseases and conditions; periodontitis; and other conditions affecting the periodontium1,2. Periodontitis is characterized by microbially-associated, host-mediated inflammation resulting in loss of periodontal attachment. This is detected as clinical attachment loss (CAL) by circumferential assessment of erupted teeth using a standardized periodontal probe with reference to the cement-enamel junction (CEJ)3.Periodontal diseases are common and their prevalence varies in different populations4. An epidemiological study in Chile reported periodontitis in 93.45% of adults aged between 35 and 44 years and 97.58% of adults between 65 and 77 years of age5.
The long-term success of periodontal therapy has been studied widely and research fundamentally alludes to measurable clinical parameters such as probing depth, CAL, periodontal furcation involvement, bleeding on probing, tooth mobility and tooth migration. However, most of these parameters do not have a real impact on patient expectation, nor biopsychosocial implications6-8.
There has been a greater interest recently within the scientific community to involve patients in their own healthcare and treatment decisions. Several studies have focused on patient perception and various instruments have been developed to assess whether oral diseases and conditions influence quality of life. Despite an increase in dental practitioners’ interest, this scenario has also challenged the interpretation and communication of results9.
Quantitative tools for measuring satisfaction parameters include surveys such as the Oral Health Impact Profile (OHIP-49), which are widely used in these types of study. OHIP-49 is one of the most realistic and comprehensive instruments to evaluate oral health. It is based on a “disease/condition-deterioration-disability” model, comprising seven domains: functional limitation; pain; discomfort; physical incapacity; psychological incapacity; social incapacity; and other disadvantages. Its 49 questions measure the frequency and severity of oral problems concerning physical, social, and psychological wellness9,10.
In addition, qualitative research contributes to several disciplines by describing, interpreting, and theorizing about social interactions and experiences occurring both under natural and experimental conditions. This area of knowledge aims to understand perspectives and experiences, either individually or for groups of people and their local contexts, helping to grasp problems and their meaning from people’s different points of view. Open interviews and discussion groups are used to allow participants to express their own opinions until a saturation point is reached and all the information is collected11.
There is limited information concerning dental patients’ perceptions of their periodontal status, treatment outcomes, and impact on their quality of life. Further, most research in this field is related to diagnosis and disease impact, but not the actual treatment itself. The aim of this study is to explore patient experience for non-surgical periodontal therapy using a phenomenological approach.
STUDY POPULATION AND METHODOLOGY
Design and Ethical approval
A descriptive qualitative study using a phenomenography was carried out by the postgraduate periodontics specialist training program at the Faculty of Dentistry, Universidad de los Andes, Santiago, Chile. This project was approved by the University’s Scientific Ethics Committee (no. CEC201805).
Context of the study
Postgraduate students enrolled in the Periodontics Specialist Training Program at Universidad de los Andes have been treating patients since 2009. The program comprises 5 part-time semesters and focuses on the prevention, diagnosis and treatment of periodontal and peri-implant diseases, such as periodontitis.
Participants
A printed list was requested from the clinical records office of all patients treated for non-surgical periodontal therapy from 2017 till 2018 at our Faculty of Dentistry. All patients treated were invited to participate in this study and were contacted by telephone call. Participants who agreed to take part in our study signed a consent form before their interviews.
In-depth interviews
In-depth interviews were used and flexible guides developed to investigate all emerging themes and enquire in greater depth to clarify any answers. A homogeneous sample was used and estimated at 20 participants. All the interviews were performed by two researchers: one interviewed all participants (PV) while the other (MO) recorded the interview using two digital audio recording devices, in a quiet private room fit for purpose. Interviews took place between August and September 2018. Interviews ranged from 20 to 30 minutes and feedback was given to participants when necessary by the interviewer. Field notes were taken during the interviews as a means of backup. None of the participants knew neither of the interviewers and vice versa. Audio recordings were transcribed immediately after each session of interviews by one researcher (MO). The interviewer (PV) was not a specialist in periodontics with no specialist knowledge, no assumptions, reasons, nor interests in the research topic.
Transcription and data analysis
As data were collected, information was analyzed simultaneously until a saturation point was reached. Redundancy was established after the fifteenth interview. Through repeated reading of transcripts, frequently emerging themes were identified, and potential interview problems were detected and corrected. Data were analyzed by two researchers (DP and FC) through the following stages:
I. Detection of emerging themes through repeated reading of transcripts and elaboration of typologies to find first and second-order constructions guiding the development of concepts and prepositions.
II. Data coding consisting of a systematic method to develop and refine the interpretation of information obtained in the previous step.
III. Interpretation of data in the context they were obtained, considering if they were requested, or not; whether or not the interviewer had any influence on participants’ answers; and the effect of our own assumptions.
Researcher triangulation was used to avoid a risk of bias. Validation of information by two researchers (DP and FC) was further validated by a third researcher (CM). For situations where any themes were unclear, a new interview would have been considered. This, however, was not necessary in our study. The sampling and analysis flowchart are illustrated in figure 1.
RESULTS
All 15 interviewees (8 females and 7 males) were 32 to 78-year-old adults (mean 53.13 ± 13.22 years) with periodontitis. Four emerging themes were identified following repeated readings of transcripts: (i) lack of information about periodontal disease; (ii) patient experience during treatment; (iii) treatment implications; and (iv) clinician-patient relationship. All the emerging themes and subcategories are illustrated in table 1.
Table 1: Emerging themes and their subcategories with examples provided by participants
| Emerging themes | Subcategories | Examples |
|---|---|---|
| Lack of knowledge about periodontal diseases | Aesthetics, tooth loss and implants, comprehensive treatment need, amazement, bleeding, poor hygiene, gingival inflammation, tooth mobility | “I honestly didn’t have a clue what periodontitis was. The postgraduate dental student I was assigned to explained to me the problem I had and that I could lose all my teeth if I didn’t have treatment.” 51-year-old man |
| Perioperative experience | Nervousness, tolerable pain, resignation, fear and discomfort towards dental instruments, better than expected, exhausting and invasive, gradual improvement, comprehensive and fulfilling care, cannot remember | “At the beginning I was angry at myself. I wondered how could have things got to this, because of the state of my mouth. I was also quite surprised how invasive treatment was... How’s it possible for man to reach the moon and yet no other solution is available to clean one’s teeth! [laughing]¨ 51-year-old man |
| Treatment implications | Pain, discomfort, sensitivity, feel nothing concerning periodontics | “My gums felt frail at first. My teeth were sensitive for quite a long time... I was told to use a special toothpaste and now I brush my teeth and have no further problems.” 58-year-old woman |
| Clinician - patient relationship | Relief, trust, support, empathy, closeness | “The postgraduate students who treated me were so kind and lovely with me. They were welcoming and took their time to answer all my questions, explaining to me, step by step, everything I was supposed to do. They were also under the supervision of their clinical tutor all along.” 62-year-old woman |
Emerging themes were organized in order of appearance from participants’ reports while subcategories correspond to coding of the most repeated concepts reported by participants in the study.
(i) Lack of information about periodontal disease
Most of the interviewed patients reported their reason for attendance was not due to periodontal disease treatment. Interestingly, their reasons for attendance were mainly focused on aesthetics, pain, and discomfort. Periodontitis was diagnosed at the faculty’s Diagnostic Clinic before patient referral to postgraduate specialist training students for treatment. Patients were subsequently informed about the presence of their periodontal disease and the need for periodontal treatment. A patient said, “Well I knew that the specialists knew what they were doing, I just wanted to have my mouth in good condition.” (78-year-old man). Some patients were surprised because they did not know of the existence of periodontal disease. Others could relate periodontitis to some of their symptoms such as tooth mobility, bleeding during tooth brushing, tooth migration, and halitosis. Another patient reported, “At first I had a problem with my gums. When I cleaned my teeth, they bled a lot. It stopped for just a few days and then started all over again.” (67-year-old man).
(ii) Perioperative experience
Several patients associated periodontal treatment with feelings of anxiety, pain and discomfort, and resigned themselves before undergoing dental treatment. Another patient told us: “I was nervous before the procedure in my mouth, then I felt pain for some moments, but it was manageable…. I thought it was my fault for not taking good care of myself, so this is for my own good” (41-year-old man). Another patient said: “at the beginning, it was hard to understand why my gums were being scraped, but after while I got used to it and even asked for more local anesthesia when it hurt, without any fear” (51-year-old man). One patient pointed out the comprehensive approach to her treatment: “It is much better than I expected because when I went to the public healthcare system, they treated me for only 20 minutes, but here I had about five sessions as far as I remember, cleaning tooth by tooth with anesthetic, so she [the dentist] had a lot of work with me” (62-year-old woman). Another patient talked about her positive experience of treatment: “Actually the treatment was very rewarding. I used to have my teeth cleaned once a year, but never as deep as this.” (64-year-old woman).
(iii) Treatment implications
Almost all patients reported dental hypersensitivity after treatment sessions with different duration and stimuli: “Well, I had some dental sensitivity, but it didn’t last long… just for three to four days, because I can tolerate pain quite well” (62-year-old woman). Another participant added: “I don’t have much sensitivity, but I still have my tea not too hot and not too cold either. Until now I can tolerate hot things better, but I’m not having any treatment at the moment” (51-year-old woman). Someone else reported: “I had some sensitivity at first, but I had been told it was to be expected. Changes between hot and cold, like drinking water, felt painful” (51-year-old man). Only one patient did not refer to any postoperative pain at all: “I didn’t feel the difference. The only thing that I noticed was food retention between my teeth.” (78-year-old man).
(iv) Clinician-patient relationship
Generally, patients described good relationships with their dentists, and mentioned their empathy towards them. Clinicians were caring throughout periodontal treatment: “I felt that she was very concerned about me. I don’t know why she was so kind, considering I’m just a patient. I felt that my case was important to her.” (41-year-old woman). Another participant told us: “I had a great experience because my dentist was really good. They were always concerned about me checking that everything was OK. I really appreciate that, so my experience was wonderful…” (47-year-old woman). Patients also described the treatment environment as a trustworthy and supportive space: “…very good. They supported and helped me a lot. I was depressed at the time and [whimpers] … They helped me with my teeth.” (58-year-old woman). Someone said: “My dentist was never alone. She was always asking her clinical tutors about my treatment and how it was going. She always checked if in doubt.” (64-year-old woman).
DISCUSSION
The interviews conducted in this study allowed to determine the different visions that patients have about periodontitis, periodontal treatment, and the consequences entailed. Regardless of age or gender, many of the opinions and the experiences were similar between the different participants. Some authors suggest that the strategic selection of a specific group of individuals with periodontitis is useful for understanding psychosocial processes with periodontal conditions even when it is not always possible to extrapolate the results in all cases12.
It is important to bear in mind that qualitative studies do not aim to generalize results to the population at large. However, it is important to consider that different socio-economic and educational conditions do influence the prevalence, incidence, and progression of periodontal diseases, including the Chilean population5,13,14. Differences in social status may affect patients’ experience after periodontal treatment, as some authors have proposed8,15. Given the sample in this study was quite homogenous, it is hard to determine whether socio-economic status did influence patients’ periodontal treatment experience or not.
Regarding participants’ lack of knowledge of periodontal diseases -particularly with reference to its diagnosis- participants did not know of the existence of this pathology, they were surprised to learn that they had it, and had left the responsibility to specialists in the management of their oral healthcare. This suggests a somewhat limited access to information within the general population from healthcare professionals from the moment periodontal disease is diagnosed. Results from this study are in agreement with those reported by others in the literature12,16. However, these cannot be generalized given the participants in this study belonged to a postgraduate specialist training program in periodontics.
In terms of participant perioperative experiences, these were described as painful and exhausting, but patients resigned themselves to undergo periodontal treatment because they perceived that not doing so would eventually lead to tooth loss. Stenman et al. also documented feelings of patient anxiety and uncertainty, but these were directly related to future dental problems perceived by patients despite some of them feeling confident that their periodontal condition was under control to avoid a similar situation later on8. Fardal and Hansen reported that approximately 12% of patients referred for periodontal treatment were considered highly anxious. The main reason for their anxiety was fear of pain and previous bad experiences. Despite this, anxiety levels decreased as periodontal therapy progressed17. Recently, Horne et al. using a qualitative approach found that it was not unusual for participants to have had avoided dental care prior to seeking treatment. Reasons for this included high cost, fears related to previous negative experiences, embarrassment, or no perceived need15.
According to other previously published data7,12,16, this study concurs with the most frequent periodontal treatment implications: dental hypersensitivity, pain, and discomfort, especially in relation to temperature changes.
Clinician-patient relationship was reported to be good, and participants felt confident they were given the opportunity to ask questions and resolve any doubts regarding their periodontal status, or general health, which has already been reported in the literature8. However, another study highlights that patients feel that information about their health status is delivered late, suggesting patient motivation and support is the responsibility of clinicians16.
Another problem perceived in this study was the difficulty of patients in identifying and explaining exactly what and how they felt, describing their condition, and understanding the treatment, which may be influenced by educational level. In a previous epidemiological study, one of the risk indicators for CAL was educational level. A lower level of education might be related to poorer oral hygiene, lower frequency of dental check-ups and decreased dental health cover5.
There was a noticeable lack of participant knowledge regarding periodontitis as a chronic pathology and the need to establish long-term periodontal support therapy to educate patients and prevent disease progression. Some studies suggest that when individuals attend dental examinations on a regular basis, they need to receive dental education about periodontitis (e.g., periodontal pockets, bleeding gums, and tooth mobility)8,12. In doing so, some patients may show more interest in seeking information about their periodontal condition and getting to know their situation better16.
Despite the fact that the sample in this study is not sufficiently heterogenous, there are few studies available worldwide which address qualitatively the perception of patients’ experiences in periodontics. However, though ungenerizable, the opinions expressed by participants in this study may signal areas for further research in this field.
CONCLUSION
Patient quality of life can be affected by periodontal diseases and its treatment. Reasons for attendance mainly include bleeding gums, tooth mobility, and aesthetic problems. However, patients seem to have limited knowledge about periodontal diseases. Periodontal therapy can generate pain, fear, and is considered invasive, whereas dentine hypersensitivity may occur post-operatively. Despite this, patients treated at postgraduate specialist training level in this study would still be willing to undergo treatment again and were generally satisfied with the level of care and treatment received
The results from this qualitative study cannot be extrapolated to the population at large, but seem to suggest that there might be a need for dental schools to promote more education about periodontal diseases for the public and patients alike. Educating patients about consequences and treatment options for periodontal diseases is paramount to strengthen and foster good dentist-patient relationships, and help alleviate the burden and anxiety of clinical procedures and their postoperative effects.
