Abstract

Introduction

Many forms of periodontal diseases affect children and adolescents. The simplified basic periodontal examination (BPE) is a screening tool for children aged seven to 17, which enables early recognition of such diseases. This study aims to investigate and compare methods of periodontal health assessments in the 'under-18s' across dental schools in the UK.

Materials and method

A web-based questionnaire was issued via email to teaching members of staff in each of the 16 undergraduate dental universities across the UK.

Results

Out of the 16 correspondents, ten universities completed the questionnaire, giving a response rate of 63%. All respondents were aware of methods of periodontal screening for children and adolescents such as the simplified BPE. All universities taught and used the 'simplified BPE'. The majority of universities started paediatric clinics in year three and carried out practical periodontal assessments in children aged seven and above, at first visit and at recall.

Discussion and conclusion

All UK dental schools were aware of, taught and used the simplified BPE as a method of periodontal assessment. Most universities seemed to comply with the guidelines being implemented.

Introduction

The prevalence, severity and extent of periodontal conditions is rising and becoming increasingly established in the primary dental care setting as a notable oral health problem in the younger age group.1 According to the Child Dental Health Survey 2013, 46% of eight-year-old children suffer from gingival inflammation. This increases to 60% in 12-year-olds.2

Gingival inflammation, described as gingivitis, can either be plaque induced or non-plaque induced and can arise from a very young age. Its prevalence rises throughout adolescence and has a particular circumpubertal onset, possibly due to changes in the oral commensal flora as a result of an increase in hormonal changes.3 Typical features of gingivitis include gingival redness, swelling and bleeding but no signs of alveolar bone loss.

Gingivitis can then progress to chronic periodontitis, which is characterised by irreversible loss of periodontal connective tissue attachment to the cementum, apical migration of the junctional epithelium beyond the cemento-enamel junction and alveolar bone loss.4 Periodontal diseases have been shown to increase the level of inflammatory markers in the body and thus may have greater systemic implications.7

Another form of periodontitis known as aggressive periodontitis can also manifest itself in adolescence. Although this form is much less common than chronic periodontitis, its effects can be very destructive and have an important impact on the affected patient's dentition.5

All children and adolescents should, provided they are cooperative, have extra-oral and intra-oral assessments carried out on them to exclude any potential pathology. An assessment of patients' periodontal condition should also be evaluated. More specifically, any abnormality in the gingival colour, contour and shape should be noted, as well as if there is any presence of inflammation, recession or suppuration.8

Implementing measures to ensure that periodontal diseases are detected as early as possible is of paramount importance for accurately diagnosing periodontal conditions, and consequently managing them appropriately in order to provide the greatest chance for successful treatment for affected patients.8 Early detection may also result in better control of systemic conditions related to periodontal diseases.

In light of this, in 2012 the British Society of Periodontology and the British Society of Paediatric Dentistry produced new guidelines for children and adolescents under the age of 18. They created a new screening method known as the 'simplified basic periodontal examination' (BPE).8

The aim of the simplified BPE was to create a quick, well-tolerated and effective screening tool available to all dental health practitioners whether they are based in dental practice, a hospital or a community setting, as part of their routine dental clinical examination. This screening tool could enable early recognition of any periodontal pathology, in order to provide the best possible outcome for the affected patients.8

The simplified BPE consists of carrying out a 'BPE assessment' on six index teeth rather than on the entire dentition (as done in adults) in order to reduce the risk of false pocketing. The simplified BPE method should be started in seven-year-old children and not before because periodontal problems in children below that age are rare and the index teeth to be 'probed' are often still unerupted. In children aged seven to 11, BPE codes 0 to 2 only are recorded whereas in children aged twelve to seventeen, the full range of BPE codes can be used. Finding 'true pockets' in children within the seven to 11 age range would be seen as uncommon and in these cases, referral to a periodontal specialist would be recommended.8 Carrying out a periodontal assessment on those index teeth could enable the detection of aggressive periodontitis in affected patients.9

In 2013, the Child Dental Health Survey reported that, since their last survey in 2003, the modified BPE was used as a method for monitoring periodontal health in 15-year-old children and over. The 2013 survey showed little difference over the past ten years in the prevalence of gingivitis in children aged 15.2 This may be related to the fact that until 2012 there were no established guidelines or standards providing advice related to periodontal screening in children.

The aim of the study is to firstly determine who delivers periodontal health teaching to undergraduate students across dental schools in the UK. The study also aims to investigate and compare methods of periodontal health assessments in the 'under-18s' in each respective dental school.

Materials and methodology

The pilot was conducted over a period of six weeks where one member of staff from each UK undergraduate university was contacted.

The research project was granted ethical approval by the University of Leeds Dental Student Research Ethics Committee.

The staff members were identified through the contact list of the Leeds Dental School's paediatric department. The members of staff contacted were involved in the delivery of periodontal teaching in paediatric patients. They were asked whether they were willing to complete a five to ten minute web-based questionnaire (supplementary online only information).

The correspondents were informed, via a participation information sheet that was attached to the email, of the nature of the study, the benefits in partaking in such a study as well as its potential implications. Correspondents were also clearly informed that despite the study not being blind, all disclosed information would be kept confidential at all times. Sufficient information was delivered to ensure correspondents could make an informed decision as to whether they wanted to partake in the study. Respondents opting to complete the web-based questionnaire implied that consent had been obtained.

Before enabling the 'live form' of the questionnaire, the questionnaire was meticulously reviewed by specialists in both the field of periodontology and paediatric dentistry, and piloted by a small group of final year dental students. This was done to ensure the questionnaire was as succinct, easy to understand and as useful as possible.

The questionnaire itself was split into two parts. The first part consisted of asking the participants about the delivery of teaching carried out in their respective dental school. The second part of the questionnaire focused on what clinical practice was carried out in their undergraduate paediatric clinics.

The web-based questionnaire was sent out via email three times every two weeks over a period of six weeks. This frequency was chosen to maximise the response rate while avoiding excessive emailing.

The data collected were analysed using simple descriptive statistics. The results were represented qualitatively and quantitatively. The final results were interpreted and conclusions from the study were made.

Results

Sixteen members of staff involved in the delivery of periodontal teaching in paediatric undergraduate clinics were approached. Out of these 16 correspondents, ten responded and completed the questionnaire, giving a response rate of 63%.

The list of the 16 universities that were contacted across the UK is provided in Box 1

The ten respondents were anonymised.

Part 1 – Delivery of teaching

Most of the respondents were involved in the delivery of teaching, with only one out of ten respondents not involved in teaching. Respondents had varying roles in the delivery of teaching, with some being in charge of the entire clinical teaching while others had a smaller role within the delivery of teaching (Box 2).

All universities were aware of methods of periodontal assessment for children and adolescents and they all taught their undergraduate students about this. More specifically, all universities were aware of the simplified BPE, and they all used it as a method of periodontal assessment. However, none of the universities used any other methods of periodontal assessment.

Most of the teaching (8/10) was either carried out by the paediatric department only (4/10 universities) or by both paediatric or periodontal departments (4/10 universities) (Fig. 1).

Figure 1
figure 1

Department(s) that deliver periodontal teaching across UK dental schools

Full size image

Most of the teaching was carried out using a combination of different learning tools such as live lectures, practical exercises and clinical seminars, with nine out of ten universities using at least two different learning strategies (Box 3 and Fig. 2).

Figure 2
figure 2

Number of teaching combinations across UK dental schools

Full size image

In most cases (6/10), teaching regarding periodontal assessments in the 'under-18s' was started in the third year of the five year undergraduate course. However, a minority of the universities carried out teaching in either the second, fourth or fifth year (Fig. 3).

Figure 3
figure 3

Start of periodontal teaching across UK dental schools

Full size image

The great majority of universities (9/10) felt satisfied with the current way of teaching regarding paediatric periodontal assessment and did not feel there were any improvements that could be made in their respective undergraduate course. However, one respondent disclosed that their current way of teaching could be improved by having live demonstrations of the simplified BPE.

Part 2 – Clinical practice

The majority of the universities (7/10) started paediatric clinics in the third year of the five-year undergraduate course. However, two universities started paediatric clinics in second year and one in fourth year (Fig. 4).

Figure 4
figure 4

Start of paediatric teaching across UK dental schools

Full size image

All universities conducted both a visual assessment of the gingivae as well as a practical periodontal examination in children and adolescents. Moreover, the majority of universities carried out a practical periodontal assessment in all new patients (10/10) and at recall (9/10).

The majority of universities (7/10) conducted a practical periodontal assessment on children aged seven and over. However, two universities disclosed that practical periodontal assessments were only carried out on children aged 12 and above, while another on all children depending on their clinical presentation, irrespective of their age (Fig. 5).

Figure 5
figure 5

Different age groups at which practical periodontal assessment is carried out across UK dental schools

Full size image

Discussion

The main finding of this study was that all universities were aware of, taught and used the simplified BPE as a screening method for periodontal assessment in children and adolescents. No other periodontal screening methods available in the young were taught or used in paediatric undergraduate clinics.

Several assumptions were made in the study. Firstly, an assumption was made that the respondents were a representative sample to the population being investigated. However, if the respondents' data did differ to the non-respondents, this could have resulted in non-response bias. Indeed, the lower the response rate, the higher the risk of non-response bias, and since this questionnaire only had a response rate of 63%, there is a possibility that non-response bias may have occurred in our study.10

Moreover, an assumption was made that the 'appropriate' participant had completed the questionnaire. In the participation sheet that was attached to the email, participants were advised that if they did not meet the criteria for the study, they should forward the email to a more appropriate member of staff. Due to this limited control over who had completed the questionnaire, this could have also led to bias. This might have been reflected in one of the results, when one participant stated that they had no involvement in the periodontal teaching in children and adolescents.

Another assumption that was made was to assume that participants had disclosed an accurate description as to how teaching and paediatric clinics were being carried out. However, there was a possibility that participants had not in fact disclosed all the information, in order to prevent their university from being undermined, leading to report bias.11 For example, all respondents stated that they were aware of and used the simplified BPE as a screening method for periodontal assessment in the young. However, three out of the ten respondents also stated that they did not carry out a practical periodontal assessment on children between the ages of seven and 17, which is not in accord with the simplified BPE guidelines published in 2012. Therefore, this raises the question as to whether all universities, despite being aware of the simplified BPE, actually complied with its guidelines. Another example was that one university stated that they taught periodontal teaching in fifth year but then started paediatric clinics in fourth year. This raises the question as to whether the students carried out a proper simplified BPE or whether they did so without any prior teaching. This thus raises a further question as to how effective the periodontal assessment would be without any prior teaching.

Another possible explanation for the discrepancies between what was being taught and what was being carried out could be due to a lack in recall from the participants. This may have led to recall bias and can therefore have an impact on the validity of the results.12

The questionnaire itself had several flaws. Firstly there was no question asking which university each member of staff was affiliated to. This may not seem like a limitation, however, it exposed deviation from the information given to them in the participation information sheet. Had the correspondents known that they would not be identifiable by the researchers, a higher response could potentially have been achieved, reducing the non-response bias.10 This problem could have been avoided by piloting the questionnaire with a bigger group, in order to increase the chance of this being detected before the questionnaire was issued.

Another limitation to the questionnaire was that it contained 'closed' questions. This might have resulted in respondents misinterpreting the question.13 Furthermore, one could argue that communication also manifests itself in hand gestures and signs that cannot be translated in questionnaires, which potentially leads to further misinterpretation. This could have been avoided by carrying out either a telephone or face-to-face interview, which would have enabled researchers to clarify any uncertainties the participants may have had experienced. Organising an interview as such would have also provided more in-depth answers regarding specific areas and would have been a realistic suggestion in light of the small study sample. However, carrying out a web-based questionnaire has its advantages compared to telephone or face-to-face interviews. Web-based questionnaires provide a quick and easy way of collecting, analysing and exporting data. They are also more cost effective as they save the researchers valuable time, which would have been lost by travelling to different geographic areas in the UK to conduct face-to-face interviews. Web-based questionnaires are also more cost-effective than traditional printed questionnaires as paper and postage costs are eliminated.14

Furthermore, a limitation from the study was that no other methods of periodontal assessments were reported from the universities that participated. It is unclear as to whether this was because the simplified BPE was suggested to participants rather than because they actually only use this method. As a result of this, it was not possible to achieve one of the aims of the study, which was to compare the different methods of periodontal assessments carried out across universities in the UK. However, the second aim of the study, which was to determine who delivers periodontal health teaching to undergraduate students across dental schools in the UK, was achieved.

The findings were consistent with published literature. Indeed, this study found that the majority of universities used methods of periodontal screening, which was supported by Clerehugh (2008), who highlighted the importance of their use.5 Moreover, the majority of the universities reported carrying out a practical periodontal screening in children and adolescents between the ages of seven and 17, which was supported by the guidelines provided by the Scottish Dental Clinical Effectiveness Programme.15 Similarly, all universities reported to be using the simplified BPE, which was supported by Clerehugh and Kindelan (2012), who emphasised the importance of this quick and easy to use screening tool for prompt diagnosis and subsequent management of periodontal diseases.8 However, it seemed that no other studies investigated what UK dental schools implemented as part of their undergraduate course, making our study an isolated one.

The study had a small sample due to the restricted number of universities offering dentistry as a course at undergraduate level. In light of this limited sample size, no statistical tests were calculated and no percentages were used in the results section, in order to avoid misrepresenting the results. Due to our small sample size and the fact that it was an isolated study, the impact that this study might have on future studies is limited. However, our study could have the potential to be a pioneer study for future paediatric periodontal screening studies. Being aware of the universities' current attitudes towards the use of periodontal screening in children and adolescents has made it possible to help future studies identify specific aspects that could be ameliorated, whether it is in the delivery of teaching or in the implementation of screening.

Even though the majority of our respondents seemed to comply with the guidelines provided by the 2012 British Society of Paediatric Dentistry and British Society of Periodontology, stricter standardised implementation protocols across all universities would make reaching a 'gold standard' in this field more attainable.8

Conclusion

In conclusion, periodontal diseases do not just affect adults but are also widely prevalent among paediatric populations. Having measures put in place to enable early recognition of such diseases could mean better success rates and thus a better quality of life for those affected. One known method of periodontal assessment is the simplified BPE, which is a quick and easy screening tool widely accessible to dental healthcare practitioners. Out of the ten universities that responded to our questionnaire, all universities were aware of, taught and used the simplified BPE, demonstrating the effectiveness of the guidelines implemented by the BSPD and BSP in 2012.