Keywords
periodontal disease - obesity - gram-negative bacteria - dental students - knowledge
- attitude
Introduction
Periodontal disease (PD) and obesity are highly prevalent conditions in both industrialized
and developing countries. The World Health Organization (WHO) global oral health status
reported that oral diseases affect 3.5 billion people, with three quarters of those
affected living in low- and middle-income countries. However, the worldwide prevalence
of PD is around 19% among individuals aged 15 years and above, amounting to over 1
billion cases.[1] The disease is initiated by microbial plaque and uncontrolled immune responses.
It results in the deterioration of the tissues supporting the teeth, such as the periodontal
ligament and alveolar bone. If left untreated, it can lead to tooth loss.[2] PD has been associated with various systemic disorders, including diabetes, cardiovascular
disease, obesity, gastrointestinal and colorectal cancer, Alzheimer's disease, respiratory
tract infections, and unfavorable pregnancy outcomes.[3]
Obesity is a complex multifactorial disorder characterized by the abnormal accumulation
of fat, resulting in adiposity that can negatively impact health and quality of life.
It is associated with an increase in inflammatory biomarkers, resulting in chronic
low-grade inflammation. WHO has stated that obesity has reached epidemic proportions
and is projected to impact more than 1 billion adults worldwide by 2030. Obesity is
widespread in both high-income and low- to middle-income countries, as well as among
poorer socioeconomic groups.[4]
Research conducted at our dental college in the Kingdom of Saudi Arabia (KSA) revealed
that dental students experience oral health issues as a result of their dietary habits,
obesity, and sedentary lifestyle. The study revealed a strong correlation between
body mass index (BMI), diet, physical activity, and oral hygiene practices with decayed,
missing, and filled teeth (DMFT) in male dental students and interns. The study also
discovered a correlation between parents' higher levels of education and income and
increased BMI. The majority of dietary variables, particularly sugar items and a lack
of physical exercise, were found to be correlated with higher BMI.[5] Additionally, a recent review article estimated that the prevalence of people who
were overweight or obese in KSA is more than 60% in adults and 20 to 60% in adolescents
and children.[6]
Several clinical studies have suggested the association between PD and metabolic disorders
such as obesity and diabetes mellitus through shared genetic, etiological, and environmental
factors.[7]
[8]
[9] The 2017 PD classification reported that studies in animal models, case-controlled
studies, systematic reviews, and surveys showed a significant association between
PD and obesity. Similarly, several studies have shown that PD and obesity are risk
factors for one another.[10]
[11] Obesity was considered the second risk factor for PD because of shared inflammatory
mediators.[12] Epidemiological, clinical, and intervention studies demonstrated that antimicrobial
treatment of periodontal bacteria lowered the risk of obesity by attenuating systemic
inflammatory markers.[13] Furthermore, periodontal treatment improved the serum levels of inflammatory mediators
in overweight and obese patients.[14] Recent studies suggest that three mechanisms link oral bacteria to inflammatory
and metabolic disorders, such as obesity. The first mechanism involves the translocation
of oral bacteria into the gastrointestinal tract through saliva, detached portions
of oral biofilms, and regular activities such as brushing and flossing (the oral–gut
axis).[15]
[16] A recent study demonstrated that oral bacteria, namely periodontal pathogen Porphyromonas gingivalis, play a role in disrupting the balance of the gut microbiota in a mouse model of
obesity.[17] A second study established a connection between microbial pathogenesis and immunological
dysregulation in periodontitis and inflammatory bowel disease (IBD) through the oral–gut
axis. Periodontal bacteria P. gingivalis, Fusobacterium nucleatum, and Klebsiella, are believed to serve as the microbiological connection between PD and IBD.[18] The second mechanism involves the translocation of oral microbes from disrupted
periodontal plaque or harmful dental operations into the bloodstream, known as the
oral–blood axis.[15]
[19] Dissemination of bacteria and/or bacterial products (endotoxin) from inflamed periodontal
tissues into the blood circulation is believed to be one mechanism of the oral manifestation
of metabolic disorders such as obesity.[20] The third mechanism is known as the immune cell migration pathway in which T cells
(Th17) that arise during periodontal inflammation migrate and exacerbate gut inflammation
suggesting that oral and gut mucosae are immunologically connected.[21] Furthermore, a transcriptomic analysis identified five common genes shared by PD
and obesity that are involved in macrophage activity, B-cell receptor signaling, leukocyte
migration, and cellular immune responses.[22]
Dentists are uniquely positioned in primary health care settings to offer millions
of children and adults health and behavioral interventions, such as stopping smoking,
consuming less sugar, and drinking less sweetened beverages, all of which are major
contributors to obesity. A scoping review examining weight stigma among dental professionals
in the health care sector suggested that stigma can influence the attitudes of dental
professionals toward patients who are obese. Stigma encompasses discriminatory behaviors
and beliefs directed toward persons due to their weight or body size. Weight stigma
in health care settings can result in health inequalities and the avoidance of medical
care. The lack of confidence and hesitation or discomfort in engaging in weight-loss
discussions were prominent barriers.[23] Furthermore, weight stigma can contribute to inaccurate clinical judgments and inefficient
allocation of limited research resources.[24] Other studies concluded that a lack of education in dental colleges about obesity
and its association with oral diseases might have been a contributing factor.[23]
[25]
[26]
Hence, this study aims to evaluate knowledge about the association and mechanisms
linking both conditions. Furthermore, this study also explores the attitudes of dental
students and interns in treating obese periodontal (OPD) patients. These aims can
be achieved using multiple predictors, including training needs, subjective norms,
and perceived behavioral control (PBC).
Materials and Methods
This was a cross-sectional study that applied an anonymous, online survey to dental
students in their third, fourth, fifth, and sixth year, as well as interns at the
College of Dentistry, King Faisal University (KFU), KSA, over the period from June
to July 2021.
Questionnaire
An electronic survey was conducted among dental students and interns at the KFU campus
after approval by KFU Research Ethics Committee (approval number: KFU-REC/2021-01).
Students in the foundation year (year 1) and the first year of dentistry (year 2)
were excluded because of their limited knowledge of the study subject. The sample
consisted of students in years 3, 4, 5, and 6, and interns were also included (n =156). The interns who graduated from the same college were participating in a 12-month
internship training program at the Dental Clinics Complex, KFU campus. The survey
was created using https://docs.google.com/forms. The survey questions were adapted from Awan et al[23] and Magliocca et al.[26] The questionnaire was sent to participants by e-mail and social media applications
(WhatsApp) prior to the end of the academic year in July 2021. Regular reminders were
sent out to all participants every 2 weeks through social media in order to increase
the participation rate. The survey included an introductory section that outlined
the significance of the aims of the study, a consent statement, and the e-mail address
of the principal investigator for contact purposes.
Variables and Measurements
The survey consisted of 25 items divided into 5 sections: (1) knowledge, (2) training
needs, (3) attitudes, (4) subjective norms, and (5) PBC. Participant responses were
scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly
agree) for all variables except for PBC. For PBC, participants were asked to rate
how easy or difficult, and their responses were scored as very difficult, difficult,
neutral, easy, or very easy, using a similar score as the Likert scale.
Knowledge of the association between obesity and PD was assessed by nine questions,
four of which focused on obesity and five on PD. The obesity questions assessed the
participant's ability to define, diagnose, and provide advice on diet and counseling.
The questions regarding PD were based on the participant's knowledge that (1) PD is
associated with metabolic disorders and obesity and (2) gram-negative periodontal
bacteria can be translocated from the oral cavity to the gut and other organs. Furthermore,
the questions considered the role of bacterial surface molecules lipopolysaccharide
(LPS) causing gingival inflammation, which can sustain chronic inflammation. The assessment
of the training needs was conducted through three questions, which aimed to enable
students to self-evaluate the knowledge they acquired during their university education
regarding dietary analysis and the provision of advice on weight loss to OPD patients.
Attitudes were assessed using six items, consisting of three items with positive wording
and three items with negative wording. They included the need to modify the furniture
and equipment to cater to obese patients and whether obese people lack the willpower
and motivation of normal-weight people. The negatively worded questions included difficulty
in feeling empathy and uncomfortableness to examine, asking about dietary habits,
or anti-obesity medications. Subjective norms were assessed using four items that
measured peer-assisted learning (PAL) through the support provided by colleagues and
seniors, as well as patient's willingness to accept advice on dietary habits and weight
loss.
PBC was assessed using three items to evaluate the ease or difficulty for the students
to apply special treatment, assess dietary habits, and advise weight loss. The study
assessed intentions by three items that reflected the future willingness to receive,
assess dietary habits, and provide advice on weight loss to OPD patients.
Data Analysis
The data were analyzed using the Statistical Package for Social Science (SPSS), IBM
SPSS Statistics v26. A descriptive analysis was used to provide a comprehensive summary
of the results. This included frequencies for the categorical variables, and mean
(±standard deviation). Pearson's chi-squared test was used to analyze the differences
between variables, while correlation was used to analyze the responses between the
participants. Regression analysis was used to investigate and predict the relationship
between the independent and dependent variables of the study. A p-value of 0.05 and 95% confidence interval (CI) were considered the significance level.
Results
The survey was sent to a total of 156 students and interns, with 110 (70.5%) successfully
completing and submitting the questionnaire ([Table 1]).
Table 1
Sociodemographic characteristics of participants
|
Characteristics
|
n = 110
|
%
|
|
Age range: 20–29 y
|
22 ± 1.65 SD
|
100
|
|
Year of study
|
|
3rd
|
34
|
30.9
|
|
4th
|
18
|
16.4
|
|
5th
|
24
|
21.8
|
|
6th
|
8
|
7.3
|
|
Intern
|
26
|
23.6
|
Abbreviation: SD, standard deviation.
Survey Instrument
All participants answered all questions as each question was marked as mandatory for
submission. Information on nonrespondents was not obtainable due to the nature of
the survey, which was anonymous and voluntary and did not collect any data on those
who did not participate. Nevertheless, the level of participation of year 6 dental
students was significantly lower in comparison to students in other years of the study.
Variables and Measurements
The survey questions underwent a peer-reviewed process conducted by two faculty members.
Additionally, the questions were pilot studied with a sample of 10 students to ensure
their comprehensiveness. The Cronbach's alpha values for the variable items are presented
in [Table 2].
Table 2
Reliability of the data (Cronbach's alpha)
|
Items
|
No. of items
|
Cronbach's alpha
|
|
Knowledge
|
9
|
0.582
|
|
Training needs
|
3
|
0.731
|
|
Attitudes
|
6
|
0.50
|
|
Perceived behavioral control
|
3
|
0.696
|
|
Subjective norms
|
4
|
0.632
|
Knowledge
Knowledge about Obesity Education
In this section, the students provided answers to the initial four questions. Most
participants (84.6%) were able to accurately identify the WHO's definition of obesity.
Additionally, a significant majority (78.1%) agreed that obesity is associated with
serious medical disorders. Furthermore, a considerate proportion (62.7%) demonstrated
the ability to analyze patient's dietary habits. Nevertheless, 41.9% responded negatively,
and 43.7% were neutral about skills gained at the university to provide weight-loss
counseling to patients ([Table 3]).
Table 3
Knowledge, training needs, attitude, and subjective norms, questions
|
Items
|
Strongly agree, n (%)
|
Agree, n (%)
|
Neutral, n (%)
|
Disagree, n (%)
|
Strongly disagreed, n (%)
|
|
Knowledge
|
|
Obesity is a chronic medical disease associated with serious medical conditions
|
43 (39.1)
|
50 (45.5)
|
4 (3.6)
|
4 (3.6)
|
9 (8.2)
|
|
I can correctly identify the WHO definitions of overweight, obese, and morbidly obese
patients
|
15 (13.6)
|
71 (64.5)
|
13 (11.8)
|
11 (10)
|
0
|
|
My knowledge allows me to analyze patient's dietary habits
|
13 (11.8)
|
56 (50.9)
|
28 (25.5)
|
9 (8.2)
|
4 (3.6)
|
|
At university, I gained the skills to provide weight-loss counseling to my patients
|
6 (5.5)
|
40 (36.4)
|
20 (18.2)
|
28 (25.5)
|
16 (14.5)
|
|
Periodontal disease is associated with metabolic disorders such as obesity
|
14 (12.7)
|
65 (59.1)
|
19 (17.3)
|
10 (9.1)
|
2 (1.8)
|
|
Periodontal disease and obesity are risk factors to one another
|
21 (19.1)
|
53 (48.2)
|
16 (14.5)
|
14 (12.7)
|
6 (5.5)
|
|
Gram-negative bacteria associated with periodontal disease can be transferred from
periodontal pockets to the gut through swallowing
|
17 (15.5)
|
55 (50)
|
19 (17.3)
|
12 (10.9)
|
7 (6.4)
|
|
Gram-negative bacteria associated with periodontal disease can be transferred from
periodontal pockets to the blood through injury
|
21 (19.1)
|
62 (56.4)
|
17 (15.5)
|
6 (5.5)
|
4 (3.6)
|
|
Endotoxins (LPS) produced by bacteria associated with periodontal disease and cause
gingival inflammation can also increase inflammation in obese patients
|
13 (11.8)
|
70 (63.6)
|
21 (19.1)
|
5 (4.5)
|
1 (0.9)
|
|
Training needs
|
|
I have received enough information about periodontal obese patients at my university
education
|
5 (4.5)
|
33 (30)
|
25 (22.7)
|
35 (31.8)
|
12 (10.9)
|
|
I have received enough information about dietary analyses at my university education
|
7 (6.4)
|
44 (40)
|
30 (27.3)
|
16 (14.5)
|
13 (11.8)
|
|
I have received enough information about advising periodontal obese patients to lose
weight at my university education
|
4 (3.6)
|
33 (30)
|
28 (25.5)
|
30 (27.3)
|
15 (13.6
|
|
Attitude
|
|
Treating obese patients in dentistry means I will need to make accommodations in equipment
and office furniture
|
23 (20.9)
|
46 (41.8)
|
28 (25.5)
|
11 (10)
|
2 (1.8)
|
|
It is difficult for me to feel empathy for an obese patient
|
3 (2.7)
|
20 (18.2)
|
22 (20)
|
45 (40.9)
|
20 (18.2)
|
|
Overweight people lack willpower and motivation in comparison to normal-weight people
|
13 (11.8)
|
50 (45.5)
|
20 (18.2)
|
19 (17.3)
|
8 (7.3)
|
|
I feel uncomfortable when examining an obese patient
|
9 (8.2)
|
27 (24.5)
|
16 (14.5)
|
28 (25.5)
|
30 (27.3)
|
|
I would feel uncomfortable asking an obese patient about dietary habits
|
12 (10.9)
|
34 (30.9)
|
18 (16.4)
|
32 (29.1)
|
14 (12.7)
|
|
I would feel uncomfortable asking an obese patient about the use of anti-obesity medications
|
15 (13.6)
|
32 (29.1)
|
19 (17.3)
|
29 (26.4)
|
15 (13.6)
|
|
Subjective norms
|
|
My seniors support me to receive periodontal obese patients and advise them to lose
weight
|
8 (7.3)
|
26 (23.6)
|
35 (31.8)
|
23 (20.9)
|
18 (16.4)
|
|
My colleagues support me in treating periodontal obese patients and advising them
to lose weight
|
6 (5.5)
|
37 (33.6)
|
28 (34.5)
|
20 (18.2)
|
9 (8.20
|
|
My periodontal obese patients accept assessing their dietary habits
|
3 (2.7)
|
51 (46.4)
|
45 (40.9)
|
6 (5.5)
|
5 (4.5)
|
|
My periodontal obese patients are willing to receive advice to lose weight
|
4 (3.6)
|
52 (47.3)
|
42 (38.2)
|
8 (7.3)
|
4 (3.6)
|
Knowledge about the Association between Periodontal Disease and Obesity
Most participants (71.8%) agreed that PD is associated with obesity. Additionally,
a considerable majority (67.3%) understand that PD and obesity are risk factors for
one another ([Table 3]).
Knowledge about the Role of Gram-Negative Bacteria in Obesity
When asked about the involvement of periodontal bacteria, most participants (65.5%)
agreed that gram-negative bacteria found in subgingival plaque could be transferred
to the gut by swallowing. Additionally, a significant proportion of participants (75.5%)
understand that periodontal bacteria released by injury or dental procedures can also
be transferred by blood to other body systems. Furthermore, a significant number of
participants (75.4%) successfully recognized endotoxin (LPS) as the mechanistic link
of chronic inflammation in both PD and obese patients ([Table 3]). Pearson's correlation of knowledge and training needs was found to be very low
positive and statistically significant (r = 0.295, p < 0.01). Furthermore, the correlation of knowledge and attitude and subjective norms
was markedly low positive with no statistical significance (r = +0.0 to 0.10). In contrast, knowledge and behavioral control showed negligible
negative correlation ([Table 4]).
Table 4
Pearson's correlation analysis of the variables
|
Knowledge
|
Training needs
|
Attitude
|
Subjective norms
|
Behavioral control
|
|
Knowledge
|
1
|
|
|
|
|
|
Training needs
|
0.295[a]
|
1
|
|
|
|
|
Attitude
|
0.067
|
0.080
|
1
|
|
|
|
Subjective norms
|
0.106
|
0.523[a]
|
–0.062
|
1
|
|
|
Behavioral control
|
–0.016
|
0.021
|
0.120
|
0.104
|
1
|
a Correlation is significant at the 0.01 level (2-tailed).
Training Needs
The assessment of participants' needs for knowledge to evaluate their behavior toward
OPD patients was conducted using three questions. Most of the participants (65.5%)
expressed the opinion that the university lacks sufficient topics about OPD patients.
Additionally, 53.6% of participants agreed that they were not provided with enough
knowledge to assess diet as well as to provide advice on weight loss (66.4%) to OPD
patients ([Table 3]). Pearson's correlation of training needs and subjective norms showed moderate positive
and statistical significance (r = 0.523, p < 0.01). However, it showed negligible positive nonsignificant correlation with attitude
and behavioral control (r = +0.0–0.10; [Table 4]).
Attitude
When the participants were questioned about their attitude toward OPD patients, the
majority of them expressed empathy (59.1%), willingness to examine (52.8%), and readiness
to provide proper equipment and furniture for obese patients (62.7%). Similarly, a
large proportion of the participants felt comfortable asking about dietary habits
(58.2%) and anti-obesity medications (57.3%). In contrast, most of the participants
expressed the belief that obese individuals lack both the willpower and motivation
for health (57.3%; [Table 3]). Pearson's correlation of attitude and behavioral control was found to be very
low positive and statistically nonsignificant (r = 0.120). The correlation with knowledge and training needs was markedly low positive
with no statistical significance (r = +0.067 and +0.080, respectively). In contrast, the correlation of attitude and
subjective norm showed negligible negative with nonsignificance ([Table 4]).
Subjective Norms
Subjective norm questions were designed to evaluate the provision of PAL in our college.
The majority of the students (69.1%) agreed they did not receive PAL from their seniors,
while 39.1% did not receive PAL from their colleagues. In contrast, half of the respondents
(50.9%) thought positively that OPD patients would accept advice on weight loss and
assessing their dietary habits (49.1%; [Table 3]). Pearson's correlation of subjective norms and training needs showed moderate positive
and statistical significance (r = 0.523, p < 0.01).
Perceived Behavioral Control
PBC was used to evaluate stigma by asking about the level of difficulty or ease. Half
of the respondents (50%) expressed difficulty in providing advice on weight loss,
while 40.9% thought it would be difficult to assess OPD patient's dietary habits in
their future practice. Nevertheless, 38% agreed that it would be easy to treat future
OPD patients, while 31% maintained a neutral point of view ([Table 5]). Pearson's correlation of behavioral control was found to be very low positive
and statistically nonsignificant with attitude and subjective norms. However, the
correlation with knowledge was markedly low negative with no statistical significance
([Table 4]).
Table 5
Perceived behavioral control questions
|
Items
|
Very difficult, n (%)
|
Difficult, n (%)
|
Neutral, n (%)
|
Easy, n (%)
|
Very easy, n (%)
|
|
Perceived behavioral control
|
|
How easy or difficult do you think it will be for you to apply a special treatment
for periodontal obese patients in your future practice?
|
6 (5.5)
|
28 (25.5)
|
31 (28.1)
|
39 (35.5)
|
6 (5.5)
|
|
How easy or difficult do you think it will be for you to advise periodontal obese
patients to lose weight in your future practice?
|
7 (6.4)
|
48 (43.6)
|
18 (16.4)
|
31 (28.2)
|
6 (5.5)
|
|
How easy or difficult do you think it will be for you to assess the dietary habits
of periodontal obese patients in your future practice?
|
9 (8.2)
|
36 (32.7)
|
30 (27.3)
|
28 (25.5)
|
7 (6.4)
|
Abbreviations: n, the number of responses; %, n divided by the total number of responses.
Regression Analysis
Linear regression analysis was used to investigate if training needs (hereinafter
TN) have a significant impact on knowledge (hereinafter KN) and subjective norms (hereinafter
SN). The hypothesis tests if TN has a significant impact on KN and SN. In hypothesis
H1, TN significantly predicted KN (F (10.298), p < 0.002). Moreover, the R
2 = 0.087 depicts that the model explains 8.7% of the variable for KN. Similarly, the
dependent variable TN was regressed on predicting SN and to test hypothesis H2. TN
significantly predicted SN (F (40.635), p < 0.000), which indicates that TN can play a significant role in shaping SN. Moreover,
R
2 = 0.273 depicts that the model explains 27.3% of the variable for SN ([Table 6]).
Table 6
Linear regression analysis
|
Hypothesis
|
Regression weights
|
Beta coefficient
|
R
2
|
F
|
t-value
|
p-value
|
95% confidence interval
|
Hypothesis supported
|
|
Lower band
|
Upper band
|
|
H1
|
TN → KN
|
0.226
|
0.087
|
10.298
|
3.209
|
0.002
|
0.086
|
0.366
|
Yes
|
|
H2
|
TN → SN
|
0.523
|
0.273
|
40.635
|
6.375
|
0.000
|
0.406
|
0.772
|
Yes
|
Abbreviations: H1 and H2, hypothesis; TN, training needs; KN, knowledge; SN, subjective
norms.
Discussion
This cross-sectional study explored multiple factors that influence preventive behaviors
among dental students and interns. These factors included KN, TN, attitudes, SN, and
PBC to predict a range of preventive behaviors toward OPD patients. Acquiring KN through
dental education is vital for implementing preventive behavior toward OPD patients.
A recent meta-analysis reported a positive association between obesity and PD with
an odds ratio of 1.35 (95% CI: 1.05–1.75).[27] The bidirectional link between PD and obesity has been established through a common
inflammatory pathway.[28]
[29] Hence, KN questions were divided into two distinct sections: PD and obesity. The
majority of the participants on the obesity questions were able to define obesity,
diagnose it, and provide advice on diet.
Nevertheless, they did not possess the necessary skills to provide counseling for
weight loss ([Table 3]). Encouragingly, over 70% of the participants recognized that PD and obesity are
associated with each other and risk factors for one another. This result was supported
by studies that reported PD and obesity are associated with each other and are risk
factors for one another.[7]
[30]
The PD questions aimed to assess the respondent's KN about the link between gram-negative
periodontal bacteria and obesity. The majority of participants agreed that periodontal
bacteria transferred to the gut by swallowing through the oral–gut axis. Wu et al[31] reported that the salivary microbiome of obese individuals harbored significantly
more abundant bacteria of the genera Prevotella, Catonella, Granulicatella, Solobacterium, Peptostreptococcus and Mogibacterium compared to nonobese individuals. In a cross-sectional study by Pataro et al,[32] it was discovered that obese individuals had higher frequencies of periodontal bacteria
in their mouth and gut compared to normal-weight individuals. Seventy-six percent
of the participants agreed that periodontal bacteria translocate to other body systems
through the blood by the oral–blood axis. This result agreed with a study that demonstrated
that obese or cardiovascular disease patients with severe PD exhibited high numbers
of periodontal pathogens P. gingivalis, Aggregatibacter actinomycetemcomitans, and Prevotella intermedia in their subgingival plaques.[33] More than 75% of respondents agreed that inflammation is the mechanistic link between
the two conditions and is initiated by periodontal gram-negative bacteria and their
LPS (endotoxin). LPS is an essential surface molecule present on the outer membrane
of gram-negative bacteria. According to Rangarajan et al,[34] LPS is a potent inducer of innate and adaptive immunity. Translocation of LPS to
the bloodstream causes chronic endotoxemia that results in persistent inflammation
in a range of diseases such as obesity, diabetes, and atherosclerotic cardiovascular
and liver problems.[35] Furthermore, Hashim[36] presented evidence that demonstrates the association between PD and obesity. The
mechanistic link was initiated by the dysbiotic microbiome and inflammation resulting
from the activity of the proteolytic enzymes produced by gram-negative bacteria and
their endotoxin component of LPS.
Taken together, the participants demonstrated KN that PD and obesity are associated
and serve as mutual risk factors. Furthermore, they understand the two conditions
are linked by inflammation that was initiated and driven by gram-negative subgingival
plaque bacteria and their LPS products. Despite their KN, only 42% of respondents
agreed that they gained the necessary skills to offer weight-loss counseling to OPD
patients. This outcome indicates a deficiency in confidence or competency, as evidenced
by the participants' answers to questions on PBC, TN, and lack of PAL. Nevertheless,
Pearson's correlation analysis revealed that KN was positively and significantly correlated
with TN questions that investigate self-assessment ([Table 3]). Similarly, regression analysis revealed that TN have a significant impact on KN.
Moreover, the model (H1) suggests that TN are likely to improve KN by 8.7% ([Table 6]). The results clearly direct the positive effect of TN. These results and the discrepancy
in skills offer a valuable understanding of our curriculum focus on obesity-related
oral diseases. Our results aligned with a study that explored the KN and beliefs of
dental students and interns at King Saud University, KSA, about overweight/obesity
(OW/OB) in children and adults. The study involved 260 respondents, mostly males,
and found that half had average KN of OW/OB, with pediatric KN being lower. Only 34%
chose BMI as the best method for identifying OW/OB. The study offered justification
for including OW/OB in dental education.[36]
In contrast, previous studies have indicated that dental students receive little formal
education, ranging from 0 to 1 hour, on the topic of obesity.[23]
[26] Given that both studies relied on self-reported surveys, it is possible to hypothesize
that the participants did not retain KN over time. In our study, the reason for participants'
inability to offer advice and counseling to OPD patients may be attributed to their
limited KN in providing guidance and support for weight loss to obese patients. Their
education primarily focused on advising and counseling on health behavioral changes
such as smoking cessation and limiting or reducing sugar intake rather than weight
loss for obese patients.
This study utilized SN questions to investigate the perceived social norms of the
students as they relate to their patients, colleagues, and seniors. Half of the students
believed that OPD patients would accept their dietary assessment and weight loss advice,
indicating a positive attitude toward OPD patients. In contrast, most students agreed
that they did not receive guidance from their colleagues and seniors, indicating a
deficiency in PAL. Insufficient PAL in our study aligns with the findings of a cluster
randomized controlled trial, which investigated the involvement of senior dental students
in teaching their junior counterparts. This trial indicated that PAL is not utilized
to its full potential in dental education.[37] Collectively, these findings indicate that PAL ought to be incorporated into dental
curriculum, ideally in a mixed clinical group practice setting. This study found that
SN have a positive but not statistically significant correlation with intentions.[38] However, there was no correlation between SN and attitude ([Table 3]). In regression analysis, TN significantly predicted SN. Our results clearly direct
the positive effect of TN as the model (H2) suggests that TN are likely to improve
SN by 27.3% ([Table 6]).
The purpose of the questions on PBC was to assess the level of difficulty in providing
special treatment, assess dietary habits, and advice on weight loss for future OPD
patients. The PBC questions yielded varied responses, with approximately one-third
of participants reporting difficulty, while another third reported ease in providing
treatment to OPD patients. Comparable findings were documented for assessing dietary
habits. These results contradict the participants' positive attitudes toward assessing
dietary habits and treating OPD patients. The Pearson correlation analysis revealed
a positive correlation between PBC and attitude; however, this correlation was not
statistically significant ([Table 3]). An investigation on predictive behavior of National Health Service (NHS) dentists
in North Central London reported that attitude is an important factor for dentists
to provide advice on diet, smoking, and alcohol. Nevertheless, PBC has a limited impact
as a predictor of changing dentists' preventive behavior.[39] The findings of our study support the implementation of evidence-based learning
methods in the dental curriculum to enhance preventive behavior toward OPD patients
in dental care.
The evaluation of participants' attitudes toward OPD patients yielded intriguing results.
The majority agreed to provide appropriate equipment and furniture for OPD patients
([Table 3]). However, these results contradicted the findings of two studies[23]
[26] that reported 35 and 30% of dental students recognized the importance of making
accommodations for obese patients. Our results can be attributed to the presence of
adjustable armrest dental chairs, armless chairs in the waiting areas, and convenient
access to dental clinic buildings. Most respondents showed empathy for OPD patients
and were willing to assess their dietary habits and inquire about obesity medications.
Conversely, most participants believed that overweight and obese people lack willpower
and determination. Two studies[23]
[26] also found that dental students hold similar unfavorable attitudes and stereotypes
toward obese patients. In addition, a similar study[25] surveyed 2,965 American Dental Association members and found that a significant
number of general dentists believed that overweight individuals lack the willpower
to control their diet. Using Pearson's correlation analysis, this study found no significant
positive correlation between attitude and any other variables. This implies that our
students and interns may have been swayed by societal stigma and prejudice against
those who are overweight and obese. The international consensus on eradicating the
stigma around obesity asserts that weight stigma is deemed unacceptable in contemporary
society due to its detrimental impact on both the human rights and the well-being
of those affected. Rubino et al[24] proposed that academic institutions should actively promote education on weight
stigma to the development of a revised public perception of obesity that aligns with
current scientific understanding. Furthermore, dentists and allied staff should evaluate
their own attitudes and views about individuals with obesity and how this can impact
the dental services they provide. Dental colleges should encourage, facilitate, and
disseminate KN of stigma and its effects, along with stigma-free skills and practices.[23]
The results of this study indicate that the students and interns acquired KN regarding
the association between PD and obesity and that subgingival gram-negative bacteria
play a significant role in the mutual bidirectional link of inflammation. However,
the participants are deficient in the essential skills to assess diet and provide
advice on weight loss for obese patients. The lack of specific KN regarding obesity,
along with the absence of PAL and societal stereotyping of obese individuals, might
be identified as the cause for insufficient skills. Collectively, the participants
in this study showed a positive attitude toward the provision of appropriate equipment
and furniture, as well as empathy. A review examined the methods used to assess obesity
in 62 dentistry schools in the United States about the obesity subjects covered in
dental school curricula. The response from 35 surveys indicated that the subject of
obesity has been integrated into the predoctoral dentistry curriculum and is considered
significant for dentists and dental students by the majority of participants. Nevertheless,
most predoctoral dentistry clinics do not regularly assess weight and height or compute
BMI for comprehensive care patients. The review suggested that predoctoral dentistry
curricula should place greater emphasis on the problem of obesity and that predoctoral
dental clinics should incorporate examinations of obesity into their practice.[23] In light of the ubiquity of obesity and obesity-related oral health and diseases,
it is important to provide suitable facilities and services for individuals with obesity,
and this should become a mandatory criterion for accrediting medical institutions
and hospitals.
Limitations
There are some limitations in this study. Initially, this study was conducted at one
center exclusively for male students, which may limit its ability to accurately represent
the state of obesity education at dental colleges throughout KSA. Furthermore, it
is important to note that subjective comments from dental students and interns in
questionnaires may not provide an accurate representation of their current behavior.
Ultimately, students and interns who are overweight or obese or have affected family
members may exhibit a favorable bias in their attitudes due to their own firsthand
experiences.
Conclusion
Given the documented bidirectional link between PD and obesity, it is imperative to
integrate obesity education into the dental curriculum. The existing blueprints that
have been developed to improve oral health behavior through dietary modifications
and smoke cessation can be extended to incorporate plans for weight loss for overweight
and obese patients. Practical strategies for the mitigation of stereotyping and weight
stigma should be adopted. Guidelines should be developed for the entire dental team,
including PAL and interprofessional continuous education. It is necessary to create
and use competency-based recommendations for handling obese dental patients. Finally,
dental practices should consider BMI measurement as a standard of care procedure.
Implementing such strategies is necessary to achieve the goals of KSA Vision 2030,
which aims to reduce obesity rates by 3% from the baseline level. Furthermore, dental
colleges in KSA need to collaborate and align their curriculums to prevent and intervene
to achieve the objectives of the WHO acceleration plan to stop obesity.
