Periodontal awareness, related knowledge, and analysis of clinical counselor in Galicia

! TESE DE DOUTORAMENTO PERIODONTAL AWARENESS, RELATED KNOWLEDGE, AND ANALYSIS OF CLINICAL COUNSELORS IN GALICIA Pedro Diz Iglesias ESCOLA DE DOUTORAMENTO INTERNACIONAL PROGRAMA DE DOUTORAMENTO EN CIENCIAS ODONTOLÓXICAS SANTIAGO DE COMPOSTELA ANO 2020 ! DECLARACIÓN DEL AUTOR DE LA TESIS “ Periodontal awareness, related knowledge, and analysis of clinical counselors in Galicia” D. Pedro Diz Iglesias Presento mi tesis, siguiendo el procedimiento adecuado al Reglamento, y declaro que: 1) La tesis abarca los resultados de la elaboración de mi trabajo. 2) En su caso, en la tesis se hace referencia a las colaboraciones que tuvo este trabajo. 3) La tesis es la versión definitiva presentada para su defensa y coincide con la versión enviada en formato electrónico. 4) Confirmo que la tesis no incurre en ningún tipo de plagio de otros autores ni de trabajos presentados por mí para la obtención de otros títulos. En Santiago, 12 de Junio de 2020 Fdo. AUTORIZACIÓN DEL DIRECTOR / TUTOR DE LA TESIS “Periodontal awareness, related knowledge, and analysis of clinical counselors in Galicia” Dña. Ana Estany Gestal D. Juan Manuel Seoane Romero D. Pablo Ignacio Varela Centelles INFORMA/N: Que la presente tesis, corresponde con el trabajo realizado por D/Dña. Pedro Diz Iglesias, bajo nuestra dirección, y a utorizamos su presentación, considerando que reúne l os r equisitos exigidos en el R eglamento de Estudios de Doctorado de la USC, y que como director de ésta no incurre en las causas de abstención establecidas en Ley 40/2015. En Lugo, a, 3 de Junio de 2020 Fdo. Ana Estany Gestal Fdo. Juan Manuel Seoane Romero Fdo. Pablo Ignacio Varela Centelles RESUMEN La enfermedad periodontal o periodontitis se define como una infección crónica multifactorial de etiología bacteriana asociada a la disbiosis de el biofilm bacteriano y caracterizada por la progresiva destrucción de los tejidos de soporte del diente (encía, hueso y ligamento periodontal). Mientras que la formación del biofilm bacteriano origina la inflamación gingival, conocida como gingivitis, la progresión a una peridontitis establecida se produce cuando el tejido de soporte (hueso y ligamento periodontal) se ve afectado. En la mayoría de los casos cursa de forma crónica mientras que en un pequeño porcentaje poblacional la progresión puede ser más rápida. La periodontitis comienza con la colonización microbiana del periodonto, generalmente en personas con mala higiene oral y mediante una serie de procesos bioquímicos y la consiguiente disbiosis bacteriana, (con aumento de los periodontopatógenos) se forman las bolsas periodontales donde las bacterias activan el sistema de defensa produciéndose la pérdida de inserción. En función del grado de pérdida se establece un diagnóstico y pronóstico de la enfermedad. En sus fases avanzadas, los signos y síntomas son evidentes con inflamación y sangrado generalizado de las encías, movilidad y/o migración patológica dentaria y como consecuencia final se produce la pérdida de los mismos. Los efectos de la periodontitis pueden ir más allá de la cavidad oral. Tras la diseminación bacteriana a través de los vasos sanguíneos y sus productos originados en el biofilm bacteriano se produce también un aumento de los mediadores inflamatorios producidos en la bolsa periodontal. Mediante esos mecanismos, la periodontitis se asocia a varias enfermedades sistémicas, especialmente la diabetes, y otras como la ateroesclerosis, la obesidad y el estrés. La relación con la diabetes ha sido muy investigada y se ha demostrado que no solo la diabetes exacerba los signos y síntomas de la periodontitis sino que también se ha visto una respuesta positiva en los niveles de glucemia sanguínea tras el tratamiento periodontal. Es por ello que las clínicas dentales deben promover el diagnostico precoz de este tipo de patologías muy asociadas con la salud periodontal. El tabaco se considera un factor de riesgo de periodontitis agravando la pérdida ósea y enmascarando alguno de los signos patognomónicos de la periodontitis como son la inflamación y el sangrado gingival. En pacientes fumadores la respuesta al tratamiento periodontal es menos predecible y por lo tanto el riesgo de progresión de la enfermedad es mayor. Antecedentes La prevención es el pilar más importante en todo paciente de riesgo y es por ello que una visita anual facilitaría un diagnóstico precoz de la enfermedad periodontal, lo cual evitaría una progresión a estadíos mas avanzados con peor pronóstico. En España se estima que tan solo un 15% de entre 35-44 años presenta unas encías sanas, mientras que el resto tiene algún tipo de patología periodontal. En personas mayores de 65 años únicamente el 10% tiene las encías sanas. Una condición necesaria para el diagnóstico de cualquier enfermedad es que el paciente acuda a una revisión, y para ello, el paciente ha de reconocer los signos y ! síntomas como una alteración de la salud. En el caso particular de la periodontitis, el sangrado gingival es normalmente el único signo evidente, hasta que en los estadíos más avanzados los signos son mas evidentes con movilidad dentaria y migración patológica. El principal inconveniente de la periodontitis es el diagnóstico tardío, lo cual requiere tratamientos más complejos y empeora el pronóstico de los dientes. El diagnóstico precoz es la manera más eficaz de reducir la pérdida dentaria evitando alteraciones masticatorias y estéticas así como reduciendo los costes económicos. Esta falta de alerta de los principales signos de la periodontitis y el hecho de que estos son comunes a gran parte de la población, e indoloros, dificulta un diagnóstico en sus fases iniciales. Se han realizado estudios analizando los efectos de intervenciones poblacionales para aumentar la alerta periodontal con resultados positivos, que sin embargo no se mantienen a lo largo del tiempo. Las actitudes positivas con los hábitos de higiene oral parecen estar directamente influidas por el conocimiento previo de la enfermedad. Por lo tanto, una condición previa debe ser la difusión del conocimiento por los distintos transmisores de salud (médicos, enfermeras y odontólogos) con el objetivo de mejorar la salud periodontal de la población y reducir su alta prevalencia. Un nivel bajo en el conocimiento de la enfermedad periodontal parece tener un efecto directo en la higiene oral y en la identificación de los síntomas como patológicos, junto con la falsa creencia de que la pérdida de dientes es una consecuencia directa del envejecimiento. El nivel socioeconómico de la población y el acceso a servicios sanitarios también se ha visto que afecta a la prevalencia de la periodontitis. Con la información obtenida de estudios previos se observó la necesidad de examinar si los déficits en el conocimiento de la enfermedad periodontal son o no comunes a toda la población, así como de definir los principales déficits en el conocimiento de la misma. Ante la ausencia de información en nuestro entorno (sur de Europa), se diseñó un estudio transversal para evaluar el grado de conocimiento en la población gallega y si afecta por igual a toda la población, o si es posible identificar grupos poblacionales considerados de “riesgo”. Teniendo en cuenta que el primer contacto con el sistema sanitario público en Galicia es habitualmente el médico de familia y las enfermeras (el 84,4% visitó a su medico en 2018 frente al 40,5% visitó a su dentista), consideramos de vital importancia evaluar el grado de conocimiento de los principales transmisores de información en salud en el sistema sanitario gallego. Por otra parte, se presupone que las clínicas dentales son el mejor lugar para la educación en salud periodontal. Sin embargo, no hay información en nuestro entorno de cómo afectan las visitas al dentista en el nivel de conocimiento de la enfermedad periodontal en los pacientes. Metodología La revisión sistemática se diseñó siguiendo los requisitos recogidos en la guía PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) y fue registrada en PROSPERO (International Prospective Register of Systematic Reviews). Se evaluaron únicamente estudios transversales, dirigidos a la población general y adulta (>18 años), publicados en los siguientes idiomas: ingles, francés, alemán, italiano, portugués y español, excluyéndose estudios con muestras de conveniencia o dirigidos a sectores de la población con un conocimiento de la salud presumiblemente mayor. La búsqueda se realizó utilizando las bases de datos PubMed, EMBASE, y SciELo, seleccionando artículos publicados en el período 1998-2014, combinada con una búsqueda manual en la red de bibliotecas de las universidades gallegas. La estrategia de búsqueda fue la siguiente: “periodontitis OR periodontal disease” and “knowledge OR awareness”. Dos revisores independientes llevaron a cabo la búsqueda avanzada (PDI y PVC), y pusieron en común la búsqueda obtenida. Se eligieron los artículos por consenso y un tercer revisor participó cuando no había acuerdo. Tras evaluar el riesgo de sesgo (alto/bajo) de los artículos, se llevó a cabo un análisis crítico. La variable principal (conocimiento de la enfermedad periodontal) fue evaluada mediante la relación de respuestas correctas/incorrectas para cada cuestión en cada estudio. Las variables secundarias (dimensiones de la periodontitis) fueron definidas mediante la combinación de respuestas incorrectas para cada ítem relacionado con cada una de las siguientes dimensiones: alerta, etiología, riesgos asociados, signos y síntomas, factores de riesgo, tratamiento, conocimiento general, prevención y actitudes. Tras evaluar las lagunas de conocimiento de la enfermedad periodontal a nivel global y ver la ausencia de información en nuestro entorno, se diseñaron tres estudios transversales con un instrumento común (cuestionario) y con una metodología similar entre ambos. Los tres estudios se realizaron en Galicia, y el trabajo de campo tuvo lugar en distintas fases: de Marzo 2015-Junio 2016 y de Octubre 2016Diciembre 2016. El estudio fue aprobado por el Comité de Ética Santiago-Lugo dependiente de la Xunta de Galicia y registrado con el código #2014/600. El cuestionario fue desarrollado por un grupo de expertos con los ítems más relevantes obtenidos de la revisión sistemática, y el cuestionario fue pilotado en un grupo de 10 alumnos de Odontología y en 97 personas adultas (la mayoría >65 años) con el objetivo de evaluar la comprensión y utilidad del mismo. En total, 12 personas llevaron a cabo las entrevistas, 4 de ellos eran estudiantes de Odontología en su último año mientras que el resto ya habían completado sus estudios universitarios. En el desarrollo del cuestionario, los participantes debían enumerar las enfermedades orales que conocían. Si mencionaban el término enfermedad periodontal/periodontitis/piorrea se les consideraba en el grupo “muy conscientes (very aware)”. Si no lo mencionaban, se les preguntaba si habían oído hablar acerca de la periodontitis/piorrea. Si la respuesta era afirmativa se les consideraba en el grupo “consciente (aware)”, y si no conocían la patología se les daba una definición general de la misma y se les agradecía su participación (“no conscientes” (not aware)). Los participantes de los grupos “muy conscientes” y “conscientes” se desarrollaba el cuestionario al completo. ! Resultados Con respecto a la revisión sistemática, participaron un total de 7945 participantes en los distintos estudios y la distribución geográfica fue la siguiente: Europa, Asia y Oceanía. Todos mostraron un bajo riesgo de sesgo excepto en el estudio de Nueva Zelanda, con un riesgo de sesgo elevado. Se obtuvieron datos crudos de las preguntas realizadas, y fueron incluidas en cada una de las nueve dimensiones del conocimiento. El mayor déficit de conocimiento obtenido fue en el ítem de la “alerta” (80%), seguido por la “etiología” (75%) y los “riesgos relacionados” en tercer lugar (71,43%). La importancia relativa de las lagunas de conocimiento volvió a demostrar que la “alerta” y la “etiología” eran los campos donde se requieren intervenciones educativas, y también demostró un pobre conocimiento de la relación enfermedad periodontal-enfermedades sistémicas. En cuanto al primer estudio transversal, un total de 8206 personas fueron invitadas a participar y 3553 aceptaron la invitación (43,3%). La mayoría de los participantes fueron considerados “muy conscientes” (62,1%), mientras que más de un tercio no conocían la existencia de la enfermedad periodontal (37,9%); el 19,4% fue considerado “muy consciente” al enumerar entre las principales enfermedades de la cavidad oral la periodontitis y/o piorrea. En el grupo “muy consciente” hubo un mayor porcentaje de mujeres y universitarios (18-34 años). Se observaron lagunas en el conocimiento en el grupo considerado de mayor alerta. Estos “gaps” fueron encontrados en todos los ámbitos de la enfermedad periodontal excepto en la prevención y el tratamiento, para este grupo en concreto. Con el objetivo de conocer el grado de conocimiento en aquellos participantes que podrían padecer la enfermedad se les pregunto: “¿Le sangran las encías?” y “¿Se le mueve algún diente?”. El 8,2% de los participantes respondieron afirmativamente a ambas preguntas. Se observó que este grupo de participantes eran de edad avanzada (>65 años), con menos estudios y con historial de fumar o haber fumado significativamente mayor que los correspondientes participantes “periodontalmente sanos” y “muy conscientes”. El segundo estudio de esta Tesis, enfocado en dilucidar el grado de conocimiento en profesionales sanitarios consistió en un total de 2375 invitados y un total de 1461 participantes con un porcentaje de respuesta del 61,5%. De los participantes, el 4% del subgrupo de población general conocía la etiología bacteriana, frente al 16% de enfermeras y el 34% de los médicos. El 44% de la población cree que el sangrado durante el cepillado es normal y solo es compartido por algunos médicos y enfermeros. En cuanto a la relación de la enfermedad periodontal con otras enfermedades sistémicas cabe resaltar que alrededor de un tercio de la población y la mitad de los sanitarios respondieron afirmativamente. La relación periodontitis-diabetes fue reconocida por el 76% de médicos y 66% de enfermeros mientras que la relación periodontitis-enfermedad cardiovascular fue correctamente contestada por el 52% de los médicos y el 65% de los enfermeros. Finalmente, en el tercer y último estudio transversal se analizó la asociación del conocimiento de la enfermedad periodontal y la asistencia habitual a clínicas dentales (al menos una vez por año). Un total de 3553 aceptaron la invitación y contestaron a las preguntas. La frecuencia de visitas al dentista disminuía con la edad y incrementaba con la familiaridad con el término periodontitis. Las mujeres predominan en el uso habitual, y estos son generalmente más jóvenes, con niveles educativos más altos y la probabilidad de padecer periodontitis es estadísticamente inferior que los que no acuden regularmente al dentista. Conclusiones - El numero de investigaciones acerca del conocimiento de la enfermedad periodontal es escaso y restringido a áreas geográficas con un nivel de desarrollo humano elevado. Esos estudios identifican lagunas en el conocimiento, siendo las más relevantes el bajo nivel de alerta, desconocimiento de la etiología y de la relación de la periodontitis con enfermedades sistémicas. - Los considerados “muy conscientes acerca de la enfermedad periodontal” y por lo tanto un nivel más alto de conocimiento estaban entre los 40-60 años, llevan adecuados habitos de higiene oral y niveles educativos más elevados pero demuestran un conocimiento insuficiente de la etiología, signos y síntomas, riesgos asociados o factores de riesgo de la enfermedad periodontal. - Hay un bajo nivel de conocimiento entre la población general y los principales referentes en salud, como son los médicos y enfermeros, desvelando alarmantes necesidades de intervención educativa para favorecer un diagnóstico y tratamiento temprano de la enfermedad periodontal. - El uso habitual de los servicios dentales se relaciona con el conocimiento de la periodontitis. Las intervenciones especificas con el objetivo de educar a la gente en el problema periodontal durante la visita rutinaria al dentista pueden tener efectos positivos en el conocimiento de la enfermedad periodontal. PEDRO DIZ IGLESIAS ! 4! this disease phenotype to environmental factors such as oral hygiene habits and smoking. Periodontitis is a chronic, non-communicable disease that shares risk factors with other inflammatory diseases such as diabetes, heart disease and chronic respiratory disease. Increased inflammatory markers in the bloodstream are associated with greater susceptibility for periodontal diseases and a worse response of the immune system against bacterial infection. Tobacco smoking, obesity, and poor nutrition have all been associated with greater risk of periodontitis (Chapple et al. 2017). Thus, longer life expectancy is related to a greater prevalence of periodontitis because most of the risk factors are acquired. Periodontal diagnosis must include an overall assessment of the risk factors such as various systemic diseases that may interact with the disease or its treatment. An accurate periodontal diagnosis consists on a full mouth comprehensive evaluation: periodontal probing of the teeth at six surfaces per teeth (mesiobuccal, midbuccal, distobuccal, mesiolingual, midlingual and distolingual) and periapical X-rays, followed by an appropriate treatment and secondary prevention. Once a periodontitis case is diagnosed, it may be useful to stage the extent and severity and the presence of masticatory disfunctions of the individual based on the current measurable extent of destroyed tissue attributable to periodontitis, and assess the overall complexity, which are specific factors determining the difficulties in the management and control of the disease (Tonetti et al. 2017). Professional dental cleaning and oral hygiene instructions can be enough for the management of gingivitis but, if not treated, it can further progress to periodontitis (Lang, Schätzle & Löe, 2009; Sälzer, Slot, Van der Weijden & Dörfer, 2015). This treatment initially consists on a non-surgical therapy: scaling and root planning, antiseptic and/or antibiotic prescription, but in some cases further surgical therapy may be required (Tomasi, Leyland & Wennström, 2007; Aljateeli et al. 2014). Long-term studies reported that after a complete periodontal therapy the rate of tooth loss dropped to 0.1/tooth/year, which is compatible with the preservation of the dentition for a lifetime (Matuliene et al. 2010; Chambrone, Introduction ! 5! Chambrone, Lima & Chambrone, 2010; Trombelli, Franceschetti & Farina, 2015). However, poor oral hygiene and non-compliance with periodontal therapy go along with progression of periodontitis and tooth loss (Hirschfeld & Wasserman, 1978; McFall, 1982; König, Plagmann, Rühling & Kocher, 2002). Dental care is important for prevention of early signs of inflammation and progression of the disease. Periodontitis can be prevented through effective management of gingivitis and promotion of a healthy lifestyle (Chapple et al. 2015; Jepsen et al. 2017). A pre-condition for treating any disease is the patient seeking consultation about signs or symptoms recognized as abnormal. Selfawareness of those signs and symptoms takes time and depends on the person´s background and health-related knowledge (Noonan, 2014). In the specific case of PDD, occasional gingival bleeding is often the only symptom noticed by patients until the advanced stages of the disease, when mobile teeth and periodontal abscesses frequently occur (Jin et al. 2011). Late presentation is an important issue in PDD as advanced disease requires more complex treatments and is associated with a worse prognosis (Salvi et al. 2014; Graetz et al. 2015). Early diagnosis of PDD is the most effective way to reduce tooth loss avoiding masticatory disfunction, along with cost reductions. However, poor PDD awareness and their consequences have been reported as the most important factor for treatment failure on a community basis (Jin et al. 2011). This lack of awareness implies a delay in the diagnosis, and this is because early signs and symptoms are quite common among adult populations and those are painless (Dye, 2012). Various interventions have been undertaken to increase public periodontal awareness (Martensson, Söderfeldt, Halling & Renvert, 2004; Gholami, Pakdaman & Montazeri 2017) with positive results that could not be maintained over time (Gholami et al. 2017). Positive attitudes towards oral health practices seem to be influenced by previous periodontal disease knowledge. Thus, it can be considered a pre-condition in order to take any additional approaches to improve oral health behaviour (Deinzer, Micheelis, Granrath & Hoffmann, 2009). Low periodontal knowledge may have a direct PEDRO DIZ IGLESIAS ! 6! influence in oral hygiene practices together with the existent belief that tooth loss is an unavoidable and direct consequence of ageing (Lin, Wong, Wang & Lo, 2001). Such attitudes and cultural beliefs can be detrimental to oral and periodontal health (Hosadurga, Boloor & Kashyap, 2015). The KAP (knowledge-attitudes-practices) education model assumes the only obstacle for making positive health choices is ignorance. Therefore, information alone can induce changes in behaviour. Unfortunately, knowledge is a necessary but not sufficient condition for behaviour changing, tough this model is still useful. PDD knowledge can be grouped in 9 determinants that may modulate self-perceived periodontal health. (1) awareness of periodontal disease, a necessary precondition for a patient seeking specialist consultation, (2) knowledge about bacterial etiology, (3) risk factors, (4) signs and symptoms, (5) prevention of the disease, (6) systemic conditions associated to periodontal disease, (7) related risks (8) treatment and (9) attitudes towards the disease. In this sense, the retrieval of information about potential gaps of knowledge in all of these topics would facilitate specific, community-based interventions. Once patients are aware that there is a problem with their gingivae, they would be expected to see their dentist. However, primary healthcare clinics seem to be the first place patients visit for consultation, as many patients with oral health concerns usually ask their physician rather than their dentist (Ahluwalia, Crossman & Smith 2016). In fact, 84.48% of the Spanish population had visited a physician, and just 40.5 % had visited a dentist in the same period (National Institute of Statistics, 2018). Some investigations have reported a lack of knowledge of primary care physicians about oral disorders (Mouradian et al. 2003; Rabiei, Mohebbi, Patja & Virtanen, 2012), and this may affect periodontal disease diagnosis. The role of primary care physicians and nurses in preserving their patients’ oral health is particularly relevant as the Fédération Dentaire Internationale's (FDI) new definition of oral health promotes incorporation of it into the mainstream of health to ensure optimal oral and general health (World Dental Federation, 2017). Introduction ! 7! On the other hand, dental clinics seem to be the best place to undertake periodontal health education. Much of the burden of patient education lies with the dental hygienist, because of their positive influence on patient´s knowledge, motivation and attitudes to oral care (Ultembroek, Schaub, Tromp, & Kant, 1989), and also because dentists find important barriers for educating their patients such as lack of time, patient compliance or remuneration. Actually, hygienists find themselves highly skilled and knowledgeable about patient education, although it is not always implemented to those high standards, frequently lacking adequate assessment of patients’ educational needs and showing poor patient empowerment (Rantanen et al. 2010). Unfortunately, no information on the performance of Galician dental clinics in periodontal health education could be retrieved. Taking into account the existing literature, lack of knowledge about PDD could be a global phenomenon that may well affect our community to some degree. This phenomenon implies the already described undesirable consequences for the general population, which could be magnified if their natural formal referents in healthcare (physicians or nurses) are not proficient enough in periodontal health topics and dental clinics provide insufficient or inadequate periodontal health education. ! Objectives ! 9! 2. OBJECTIVES - To identify the most relevant gaps of knowledge about PDD among the general public and to disclose whether they are culturally consistent. - To assess the level of periodontal awareness among laypersons in Galicia and to disclose whether very periodontally aware people have higher level of knowledge. - To assess periodontal knowledge among Galician primary healthcare physicians and nurses. - To explore dental clinics´ performance on periodontal education in Galicia by comparing periodontal health knowledge among regular and inconsistent dental attenders. ! Methodology ! 11! 3. METHODOLOGY 3.1 Systematic Review This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) (Annex 1) guidelines and was registered in the International Prospective Register of Systematic Reviews (PROSPERO) - number CRD42015015883 –. (Annex 2.) Papers were included if reporting on cross-sectional, communitybased, quantitative studies on adult individuals (or ≥6% minors), providing original data about knowledge on PDD, and were written in English, German, French, Italian, Portuguese or Spanish languages. Publications on risk groups or reporting either on convenience samples or on population subgroups where a given level of health literacy could be presumed were excluded. This includes studies on patients with medical conditions, as most require regular contact with a healthcare provider: these individuals may/should have received oral health counseling to increase their level of knowledge. The EMBASE, PubMed and SciELO databases were used for identifying relevant papers published from 1998 to 2014, together with a handsearch at the Galician network of university libraries. The search strategy was “periodontitis OR periodontal disease” and “knowledge OR awareness” as keywords and freetext and was undertaken in November 2014. Two reviewers (PD-I and PV-C) independently searched the databases and reviewed both titles and abstracts. The results were discussed and merged into a single list including potentially eligible articles and those whose abstract provided unclear information. These publications were retrieved for full-text assessment and individually evaluated by both reviewers. Differences concerning eligibility were solved by consensus: when it was not attained, a third reviewer (JS-R) was called. The quality assessment was performed according to the criteria by Bennet et al. (2011), using 38 specifically designed items. PEDRO DIZ IGLESIAS ! 12! Each item was verified, and its presence recorded as “yes”, absence as “no”, and partially/unclearly present as “not clear”. Articles scoring >50% of “yes” items were allocated a low risk for bias, whereas those scoring >50% of “no” were classified “high risk for bias”. Any other circumstance was categorized as moderate risk.! Data extraction was independently undertaken by three reviewers (PD-I, AEG, PVC) using a purpose-made form. PDD were defined as “any inflammatory alteration of the gum (periodontium) in a dentate subject” in order to identify as many reports as possible. Gap of knowledge was defined as “the absence of answer, incorrect answer, or erroneous identification or definition given by 33% or more of the sample investigated in each study”. Awareness was defined as the act of "taking account" of a state of affairs (National Center for Biotechnology Information, 2015). The primary outcome of this study (PDD knowledge) was the percentage of right answers to each question/item in relation to wrong/don't answer/don't know responses for each question and study. A secondary outcome (dimensions of periodontal knowledge) was defined as the combined percentages of incorrect responses for each item related to the following dimensions: awareness, etiology, associated risks, signs and symptoms, risk factors, treatment, general knowledge, prevention, and attitudes. The prevalence of gaps of knowledge in each dimension was presented as a percentage of questions where a deficit was identified related to the total number of questions made to investigate a given dimension in all the reports included in this review. In order to determine the relative importance (RI) of the gaps in each dimension, a mathematical formula was developed using the number of papers investigating each dimension -research priority-, their methodological quality (Q) –headings: “methods”, “sample selection”, and “research tool” in table 2-, the depth in which each dimension is explored -number of questions made-, and the percentage of gaps of knowledge identified. (G): RId =∑Qn *Gn Methodology ! ! 13! This approach permits weighting the importance of each dimension in the whole periodontal knowledge (the more relevant, the more reports would have investigated it), the quality of each individual investigation, and the importance of the gaps of knowledge in each dimension in each study. 3.2 Cross-sectional studies 3.2.1 Sociodemographic framework After disclosing the most relevant gaps in the literature by means of the systematic review, we undertook three different cross-sectional studies in order to assess the consistency of our findings among the Galician general population and to evaluate the performance of their immediate health counselors (physicians, nurses, and dentists). These studies shared the same instrument but included minor variations in methods and samples studied.! The protocol of the investigations was approved by the SantiagoLugo Committee for Ethics in Research (number 2014/600), (Annex 5) and complied with the Spanish regulations and the Helsinki Declaration on ethical principles for medical research involving human subjects (World Medical Association, 2013). The results obtained from this research protocol are reported following the STROBE guidelines (Strengthening The Reporting of Observational studies in Epidemiology) (Vandenbroucke et al. 2014) (Annex 3).! The fiedlwork was carried out in Galicia (North-Western Spain), an autonomous region with 2,708,339 inhabitants unevenly distributed in 29,574.4 km2, whose gross domestic product per capita is 21,358 € and their life expectancy at birth of 82,78 years, reported by Instituto Galego de Estadística (IGE, 2018). The last study, about regular use of dental services and its relation to periodontal knowledge was done in the city of Ourense (Northwest Spain), with an income per capita of 21,155 € and 105,893 inhabitants (IGE, 2018) who are served by 80 physicians and 85 nurses working at the primary care level (IGE, 2018) through a free, universal, national healthcare system. Data from general population were obtained from 1 March 2015 to 30 June 2016 in the four Galician provinces (A Coruña, Lugo, PEDRO DIZ IGLESIAS ! 20! Table 1. Summary of the papers considered for review. Results ! ! 21! Most reports showed an adequate quality and a low risk of bias, whereas only one was found to be at high risk (Croxson, 1993) (table 2). Table 2. Quality assessment of the articles considered PEDRO DIZ IGLESIAS ! 22! Raw data from each study were used to identify gaps of knowledge about a question, and these questions were grouped into 9 “dimensions” of periodontal knowledge. The grouping process and the results obtained are depicted in table 3a & 3b in order to preserve the richness of the original data and to clarify the procedure. Unfortunately, one paper shows information about certain variables grouped under a common heading and it was impossible to calculate raw data (Airila-Mansson et al. 2004). Table 3a. Gaps of knowledge identified in the literature Results ! ! 23! Table 3b. Gaps of knowledge identified in the literatur PEDRO DIZ IGLESIAS ! 24! When all dimensions were considered, a higher percentage of knowledge deficits was identified in “periodontal awareness” (80%), followed by “PDD aetiology” (75%). Less frequent gaps were disclosed in issues related to attitudes towards the disease (36.36%) and prevention (36,84%) (table 4). Table 4. Summary of the distribution of the gaps of knowledge identified in this critical systematic review The methodological quality of the selected papers (presence of the items under the headings “methods”, “sample selection”, and “research tool” detailed in table 2) was expressed as a percentage divided by ten, and showed a wide variation among studies, ranging from 1.58 to 8.42. Martensson et al. (2004) and Airila-Mansson et al. (2004). scored both 3.68; and Lin et al. (2001). and Deinzer et al. (2009) reached 6.32 and 7.37 respectively. Results ! ! 25! Figure 2. Relative importance of gaps of knowledge The application of the formula for relative importance of the lack of knowledge in each dimension highlighted the need for educational interventions about disease awareness and etiology, and also revealed a weak knowledge about the relationship between PDD and systemic disorders (fig. 2). The size of each point in the figure is related to the relative importance of each dimension in the deficit in periodontal knowledge considered as a whole. 0 1 2 3 4 5 6 7 8 9 10 0 200 400 600 800 1000 1200 1400 1600 1800 2000 Awareness Aetiology Related Risks Signs & Symptons Risk factors Treatment General aspects Prevention Attitudes Relative importance Items PEDRO DIZ IGLESIAS ! 26! 4.2 Periodontal awareness and what it actually means: A crosssectional study A total of 8,206 subjects were invited to enter the study, and 3,553 of them accepted the invitation (43.3%). All completed questionnaires were useful for the aims of the investigation. The main socio-demographic features of the sample are summarized in table 5. Most participants were classified as “periodontally aware” (1,517; 42.7%), and only 19.4% (n=689) could be included in the “very aware” group according to the criteria set for the study. More than one third of the interviewees had not heard about periodontitis/pyorrhoea and were categorised as “not aware” (1,347; 37.9%). The “very aware” group included a higher percentage of women (373; 54.1%). Periodontal awareness seemed to increase with age and diminished among people elder than 64. The very aware group included a higher proportion of university graduates (table 5). Results ! ! 27! Table 5. Main features of the sample studied and distribution of the awareness level. PEDRO DIZ IGLESIAS ! 28! Our results permitted the identification of gaps of periodontal knowledge among the very aware group of laypersons in all aspects explored except for “prevention” and “treatment” (table 6a, table 6b). Table 6a. Gaps of periodontal knowledge among very aware laypersons (n=689) The presence of gaps of knowledge about aetiology, in the recognition of signs or symptoms, or about the relationship of periodontitis with other disorders were particularly interesting and showed that even this population subgroup was susceptible to a potential delay in diagnosis of periodontitis, which may be aggravated by the reported lack of adequate oral self-care routines and dental check-ups. Age, higher education, and adequate oral self-care practices were related to periodontal awareness. In fact, periodontally aware people were likely to be in their late forties-early sixties, follow sound oral Results ! ! 29! care routines, and hold a professional or university degree. Gender or tobacco habit did not seem to have a clear part in this issue. Table 6b. Gaps of periodontal knowledge among very aware laypersons (n=689) PEDRO DIZ IGLESIAS ! 36! An interesting finding is that related to the identification of PDDs (table 10): holding a healthcare degree does not seem to warrant a better knowledge of early (red and bleeding gums) and advanced (tooth mobility and tooth loss) symptoms and signs of periodontal diseases. In fact, laypersons seem to recognize tooth mobility and tooth loss as symptoms of PDDs more frequently than do physicians and nurses. Despite these findings, only 8.9% of physicians and 15.1% of nurses find normal some degree of gum bleeding when brushing their teeth, compared to 27.1% of other university graduates (p=0.018). Table 10. Signs and symptoms of PDDs Results ! ! 37! 4.4 Regular dental attendance and periodontal health knowledge. A cross-sectional survey. A total of 8,206 individuals were invited to enter the study, and 3,553 accepted the invitation (response rate: 43.3%). All questionnaires were included in the analysis. The first question in the survey was whether the participant had heard about periodontitis/pyorrhoea (yes: 62.1%; n=2,206; no: 37.9%; n=1,347). Volunteers were classified by the frequency of their dental visits as “regular users” (at least once a year) (59.3%; n=1,945) or “inconsistent users” (any other response) (40.7%; n=1,339). The frequency of regular dental visits diminished with age and increased both with periodontal disease familiarity and academic achievements (table 11). Females predominate among regular dental attenders (65%; p<0.001); regular users of dental services are also significantly younger, higher educated, and less likely to be experiencing periodontitis than their counterparts occasionally visiting their dentist (table 11). More than one third (37.9%; n=1,347) of the participants had never heard of periodontitis, and many (54.4%; n=589) fit within the regular dental attenders’ group. Those familiar with the disease were questioned about different aspects of periodontal health and about their preventive attitudes. In this subset of patients, regular users accounted for 61.5% of the sample (n=1,356). When asked about the aetiology of periodontitis, few participants (12.4%; n=272) answered correctly (bacteria), but significant differences could be observed between regular (15.4%; n=210) and inconsistent (7.3%; n=62) users of dental services (p<0.001). Regular dental attenders recognised health problems related to periodontitis better than the group of inconsistent users (table 12). When asked to mention at least two symptoms of periodontitis, regular attenders also performed better than their counterparts (42.4% vs 31.4%; p<0.001). The same occurred when asked whether they find normal to experience some bleeding when toothbrushing (31.6% vs 44.7%; p<0.001). PEDRO DIZ IGLESIAS ! 38! Table 11. Mean features of the whole sample by frequency of dental visits. Results ! ! 39! Regarding periodontal risk factors (table 12), both oral hygiene and smoking were well recognised by the sample. Other factors were better recognised by the group of regular users. It is worth mentioning participants attribute bacteria a relevant role in periodontitis, but only as a risk factor, not as an aetiological agent. When asked about preventive attitudes and beliefs, 90.8% (n=1,176) regular attenders said periodontitis can be prevented compared to 85.6% (n=658) of inconsistent users (p<0.001). These differences diminish when questioned about whether periodontitis can be treated (89.8% vs 85.9%; p=0.008). The same phenomenon occurred with the distribution of non-smoking volunteers in both groups (78.8% vs 72.9%; p=0.001). Participants were also classified by their reported oral self-care routines in two groups: adequate routines (toothbrush and interdental cleaning at least once a day) and inadequate practices (any other response). Although the number of interviewees reporting adequate routines was low, regular attenders consistently reported better habits (14.6% vs 5.9%; p<0.001). Table 12. Risk factors and relationship with other health problems. PEDRO DIZ IGLESIAS ! 40! Regular dental attenders also elicited better periodontal knowledge than their inconsistent counterparts (table 12). Logistic regression analysis (figure 4) showed the chances for having an above-median periodontal health knowledge are almost equally influenced by higher education (OR 1.64; 95%CI: 1.30-2.06) and regular use of dental services (OR 1.67; 95%CI: 1.40-2.00), and negatively conditioned by age (>64: OR 0.68; 95%CI: 0.51-0.90). Figure 4. Logistic regression analysis to disclose factors influencing periodontal knowled ! ! ! ! In an attempt to further disclose the part of educational achievements in periodontal health knowledge, the group of participants with compulsory education was explored in more detail (table 13), and inconsistent dental users showed significantly poorer results in all aspects but aetiology of periodontitis. Results ! ! 41! Table 13. Distribution of periodontal knowledge among the “compulsory education” subgroup As participants with higher chances of being experiencing periodontal problems could be more likely to require periodic dental care, volunteers reporting both bleeding gums and tooth mobility were identified. The distribution of these participants by their frequency of dental visits showed no significant differences (7.3% vs 7.7%; p=0.698). Not all regular dental attenders likely to be experiencing periodontitis were familiar with the disease (51.5%; n=73). ! Discusion ! 43! 5. DISCUSION The diagnosis of a disease is the result of a chain of events where patients and clinicians interact conditioned by the signs and symptoms of the disorder and the health system (Sogaard, 1988; Holtzman, Atchison, Macek, & Markovic, 2017). Assuming that certain awareness and knowledge are required for an early diagnosis, assessing it at a community level seems to be a logical precondition for an educational intervention. Although this assessment has necessarily to be undertaken on a local basis, published reports point at a deficit of periodontal knowledge worldwide, which seems to be independent from the geographical area and type of population studied (Martensson et al. 2004; Gholami et al. 2014b). Despite knowledge is just a single aspect among a series of factors affecting health attitudes, it can be considered a pre-condition of additional measures to improve oral health-related conducts. (Deinzer et al. 2009). ! The results obtained from our investigations have confirmed the initial hypothesis that there is a general problem in terms of awareness and knowledge about periodontal disease, which is a global phenomenon, even affecting countries and regions with a high human development index (Varela-Centelles et al. 2016). It has been suggested that the social determinants of health (i.e., educational background, economic status, living conditions lifestyles, and working environment) are largely responsible for oral health inequalities worldwide (Petersen & Ogawa, 2005; Petersen, Kandelman, Arpin, & Ogawa, 2010). Among the three most relevant oral diseases (caries, PDD and oral cancer), periodontal disease exhibits the strongest association with social, economic and behavioural risk variables (Hobdell et al. 2003), Therefore, interventions that modify socioeconomic environment and enhance control of risk factors are important strategies for promotion of oral health in the community. PEDRO DIZ IGLESIAS ! 44! Despite that no study included in the systematic review presented in this PhD dissertation assessed all aspects about periodontal knowledge, the employed methodology let to identify the level of awareness, aetiology and related risks as the most important deficits in knowledge among the population. These findings were also confirmed for the Galician population, even in the “very aware” subgroup of the population, with a higher level of education (Varela-Centelles et al, 2019). There are two main actors in the diagnosis of the disease: the patient and the healthcare professional. The time elapsed until an adequate treatment is started traditionally depends on the patient readiness to seek advice and on the knowledge of the clinician. The patient should be able to distinguish normalcy from disease and the clinician should be able to recognize early signs and symptoms to adequately address patient´s needs. Unfortunately, our results have unveiled a worrying lack of knowledge about aetiology and signs and symptoms of both primary care physicians and nurses. Chronic periodontal disease is also very common among the adult population frequently visiting their physician for systemic conditions. If the medical practitioner is unable to recognise early signs and symptoms of periodontal disease in a patient, this person would rarely be sent to an oral healthcare professional (Mouradian et al. 2003; Rabiei et al. 2012). The third mainstay that modulate an early diagnosis, the Health System, represents a very relevant factor in Galicia due to the reduced number of dental practitioners working in the national health service and the limited periodontal treatments offered on a free, universal basis (preventive actions for children and pregnant women) (https://www.sergas.es/Asistenciasanitaria/Documents/892/guiatecnica_saudebucodental.pdf).), which means that the burden of treatment of oral pathologies lies on the private sector. ! In this way, our research has demonstrated a positive effect of regular dental attendance in terms of periodontal knowledge. A recent systematic review found that educational interventions in health services offer significant improvements in periodontal outcomes, Discusion ! ! 45! concluding that educational interventions undertaken by health professionals in the context of their practice have the potential to promote oral health in the population (Menegaz, Silva & Cascaes, 2018). Psychological interventions have become a matter of interest because of their reported positive effects (Kakudate, Morita, Sugai & Kawanami, 2009), although the certainty of evidence in support of these approaches is low and therefore, they not should yet be routinely provided in dental care (Werner et al. 2016). The “Motivational Interview” is one of these promising psychological interventions with usually good acceptance by patients, although aspects such as the best number of sessions and their length, together with the level of training required to use it effectively and the optimal timing and targets have not been sufficiently investigated (Randall, 2018). Another issue with oral health promotion are the methods of evaluation, which are reported to be poor and in need of further development (Watt, Fuller, Harnett, Treasure & Stillman-Lowe, 2001), with the lowest performing measures in the categories of healthy lifestyle and health literacy (Watt et al, 2006). In this sense, our indirect approach to the issue of periodontal health promotion in dental clinics may offer an approximation to the problem and a starting point for further research and interventions on this topic. The results of our research show a worrying lack of knowledge and awareness of PDD, that tough common to other developed countries, is aggravated due to important gaps of knowledge amongst the professionals in our health system (Primary care physicians and nurses). All these factors combined describe a problematic situation in the normal diagnosis pathway for such a high prevalent disease (PDD). 5.1 Limitations There are some limitations that must be mentioned. In general, our investigations dealt with attitudes towards oral health problems. It is just about what people would do or even they report to do, but the actual behaviour cannot be objectively known. To be aware about PEDRO DIZ IGLESIAS ! 52! (Sippli, Rieger & Huettig, 2017). Medical and dental professionals should work together to raise public awareness and promote good oral health as part of the healthy lifestyles message (WHO, 2010; Ford et al. 2010). As a European directive establishes common requirements for basic medical and nursing training, this problem may well be found elsewhere in the European Union (European Union, Directive 2005/36/EC). Increasing awareness of common dental and periodontal pathologies among physicians and nurses would favour an early diagnosis. The size of the problem is obviously related to the prevalence of regular dental check-ups, as those areas whose population is more reluctant to visit the dentist regularly rely more on the physicians’ periodontal knowledge. Increasing public’s periodontal information is intuitively positive and strengthening oral health education will lead to improved attendance at scheduled dental check-ups (Sato & Oda, 2011), which in turn, increases the chances for opportunistic education in dental offices. Lack of knowledge may influence periodontal health inequalities (Jin et al. 2011), and PDD shares modifiable risk factors with a range of chronic systemic disorders (Jürgensen et al. 2012). This circumstance offers an opportunity for policy-makers and institutions to promote periodontal health knowledge among lay public, which may contribute to reduce the observed gap between regular and occasional dental attenders. 5.4 Future research Future investigations should address educational interventions that must include general population and physicians and nurses, which are important figures in our Public Health System, to increase the level of awareness and the importance of an early diagnosis. Furthermore, those interventions must be monitored to see the medium and long-term effect on periodontal knowledge and attitudes towards PDD. Continuation of this line of research beyond the limitations of our studies and to promote educational programmes in public dental clinics to increase people awareness of PDD would provide interesting benefits to the community Discusion ! ! 53! Oral health literacy, conceived as knowledge on the causes of oral diseases, ability to apply this understanding and to incorporate selfcare behaviours, and also to navigate the healthcare system when needed, should be a research priority. Finally, an assessment of offclinic periodontal counsellors together with the evaluation of periodontal information available through mass media or from online sources seems to be a logical step to increase periodontal awareness and early diagnosis of periodontal diseases. ! ! Conclusions ! 55! 6. CONCLUSIONS - The number of available community-based investigations on periodontal knowledge is scarce and restricted to areas with a very high level of human development. These studies identify gaps of knowledge in every geographical area, being the more relevant a low awareness, poor knowledge about the etiology of PDD and their relationship with systemic disorders. -Very periodontally aware people were in their late 40–60 s, followed sound oral care routines and held a degree but elicited insufficient knowledge about aetiology, signs-symptoms, related risks or periodontal risk factors. -There is a low degree of periodontal knowledge both amongst the public and their primary care physicians and nurses and unveil unreliable targets (primary healthcare workers) for educational interventions to improve early diagnosis and treatment of periodontal disorders. -Reported regular dental attendance is related to periodontal health knowledge. Specific interventions for promoting tailored patient education on periodontal topics during routine dental visits may have a positive effect on laypersons’ knowledge about periodontal health. ! ! References ! 57! 7. 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Van der Velden U., Abbas F., Armand S., Loos B.G., Timmerman M.F., Van der Weijden G.A., Van Winkelhoff A.J., Winkel E.G. (2006). Java project on periodontal diseases. The natural development References ! ! 71! of periodontitis: risk factors, risk predictors and risk determinants. Journal of Clinical Periodontology, 33(8), 540–548. Varela-Centelles P., Diz-Iglesias P., Estany-Gestal A., SeoaneRomero J.M., Bugarín-González R., & Seoane J. (2016). Periodontitis awareness amongst the general public: a critical systematic review to identify gaps of knowledge. Journal Periodontology, 87(4), 403– 415. Varela-Centelles P., Diz-Iglesias P., Estany-Gestal A., Blanco-Hortas A., Bugarín-González R., Seoane-Romero J.M., & Blanco J. (2019). Periodontal awareness and what it actually means: A cross-sectional study. Oral Diseases, 25(3), 831-838. Watt R.G., Fuller S.S., Harnett R., Treasure E.T. & StillmanLowe C. (2001). Oral health promotion evaluation – time for development. Community Dentistry and Oral Epidemiology, 29(3), 161–166. Watt R.G., Harnett R., Daly B., Fuller S.S., Kay E., Morgan A. & Treasure E.T. (2006). Evaluating oral health promotion: need for quality outcome measures. Community Dentistry and Oral Epidemiology, 34(1), 11–17. Werner W., Hakeberg M., Dahlström L., Eriksson M., Sjögren P., Strandell A. & Wide Boman U. (2016). Psychological interventions for poor oral health: a systematic review. Journal of Dental Research, 95(5), 506-514. World Health Organization (WHO), Framework for Action on Interprofessional Education & Collaborative Practice, 2010. Reference number: WHO/HRH/HPN/10.3. Accessed 14 February 2020. World Dental Federation [Fédération Dentaire Intrnationale]. (2017). Definition of Oral Health. Retrieved from: http://www.fdiworlddental. org/oral-health/fdis-definition-of-oral-health. Accessed 23 September 2017. PEDRO DIZ IGLESIAS ! 72! World Medical Association, 2013.!World Medical Association Declaration of Helsinki; Ethical Principles for Medical Research Involving Human Subjects. Retrieved from: https://www.wma.net/wp-content/uploads/2016/11/DoHOct2013-JAMA.pdf.!Accessed!20!June!2017. Zhu L., Petersen P.E., Wang H.Y., Bian J.Y., Zhang B.X. (2005). Oral health knowledge, attitudes and behaviour of adults in China. International Dental Journal, 55(4), 231-241. ! ! ! ! PEDRO DIZ IGLESIAS ! 74! 8. ANNEXES Annex 1. PRISMA Statement http://www.prismastatement.org/documents/PRISMA%202009%20checklist.pdf! Annexes ! ! 75! PEDRO DIZ IGLESIAS ! 76! Annex 2. PROSPERO registration https://www.crd.york.ac.uk/PROSPERO/documents/Registering%20a %20review%20on%20PROSPERO.pdf $ Annexes ! ! 77!  35263(52,QWHUQDWLRQDOSURVSHFWLYHUHJLVWHURIV\VWHPDWLFUHYLHZV  $V\VWHPDWLFUHYLHZDQGPHWDVXPPDU\RISHULRGRQWDOGLVHDVHVDZDUHQHVV NQRZOHGJHDERXWDHWLRORJ\SUHYHQWLRQDQGULVNIDFWRUVDPRQJWKHJHQHUDOSXEOLF 3DEOR9DUHOD&HQWHOOHV-XDQ06HRDQH5RPHUR3HGUR'L],JOHVLDV   &LWDWLRQ 3DEOR9DUHOD&HQWHOOHV-XDQ06HRDQH5RPHUR3HGUR'L],JOHVLDV$V\VWHPDWLFUHYLHZDQGPHWDVXPPDU\RI SHULRGRQWDOGLVHDVHVDZDUHQHVVNQRZOHGJHDERXWDHWLRORJ\SUHYHQWLRQDQGULVNIDFWRUVDPRQJWKHJHQHUDOSXEOLF 35263(52&5'$YDLODEOHIURP KWWSZZZFUG\RUNDFXN35263(52B5(%5$1',1*GLVSOD\BUHFRUGDVS",' &5' 5HYLHZTXHVWLRQV :KDWDUHWKHPRVWUHOHYDQWJDSVRINQRZOHGJHDERXWSHULRGRQWDOGLVHDVHV" $UHWKHVHJDSVJHRJUDSKLFDOO\FRQVLVWHQW" 6HDUFKHV :HZLOOVHDUFKWKHIROORZLQJHOHFWURQLFELEOLRJUDSKLFGDWDEDVHV(0%$6(3XE0HGDQG6FL(/27KHVHDUFK VWUDWHJ\ZLOOLQFOXGHWKHWHUPVSHULRGRQWLWLVDQGNQRZOHGJHRUDZDUHQHVVDVNH\ZRUGVRUIUHHWH[W7KHVHDUFKHVZLOO EHOLPLWHGWRWKHODVW\HDUV2QO\SDSHUVLQ(QJOLVK*HUPDQ)UHQFK,WDOLDQ3RUWXJXHVHRU6SDQLVKZLOOEH FRQVLGHUHG 7LWOHVRIWKHSDSHUVLGHQWLILHGXVLQJWKHVHDUFKVWUDWHJ\ZLOOEHVFUHHQHGWRGHWHFWVWXGLHVWKDWSRWHQWLDOO\PHHWWKH LQFOXVLRQFULWHULDRXWOLQHGHOVHZKHUH$EVWUDFWVRIWKHVHOHFWHGVHWRISDSHUVZLOOEHUHYLHZHGDQGILOWHUHGDFFRUGLQJWR WKHREMHFWLYHVRIWKHVWXG\DQGWKRVHDUWLFOHVK\SRWKHWLFDOO\UHOHYDQWZLOOEHUHWULHYHGIRUDIXOOWH[WDVVHVVPHQW$ VHFRQGDXWKRUZLOOUHYLHZWKHVHSDSHUVDQGDQ\GLVDJUHHPHQWEHWZHHQDXWKRUVZLOOEHUHVROYHGWKURXJKGLVFXVVLRQ ZLWKDWKLUGDXWKRUXQWLODFRQVHQVXVLVUHDFKHG 7\SHVRIVWXG\WREHLQFOXGHG &URVVVHFWLRQDOFRPPXQLW\EDVHGTXDQWLWDWLYHVWXGLHV &RQGLWLRQRUGRPDLQEHLQJVWXGLHG .QRZOHGJHDERXWSHULRGRQWDOGLVHDVHV 3DUWLFLSDQWVSRSXODWLRQ $GXOWV ,QWHUYHQWLRQVH[SRVXUHV 3HULRGRQWDOGLVHDVHVDUHGHILQHGDVDQ\LQIODPPDWRU\GLVRUGHURIWKHSHULRGRQWLXPJXPVLQDGHQWDWHLQGLYLGXDO $JDSRINQRZOHGJHDERXWDQLWHPLVGHILQHGDVDQDEVHQFHRULQFRUUHFWLGHQWLILFDWLRQRUGHILQLWLRQRIWKDWSDUWLFXODU LWHPE\RUPRUHRIWKHVDPSOHVWXGLHG &RPSDUDWRUVFRQWURO 'LIIHUHQFHVEHWZHHQJHRJUDSKLFDODUHDVZLOOEHLQYHVWLJDWHG &RQWH[W 6WXGLHVLQYHVWLJDWLQJNQRZOHGJHDQGDZDUHQHVVDERXWSHULRGRQWDOGLVHDVHVDPRQJWKHJHQHUDOSXEOLFZLOOEH FRQVLGHUHG 3DSHUVIRFXVLQJRQULVNJURXSVRUUHSRUWLQJRQFRQYHQLHQFHVDPSOHVZLOOEHH[FOXGHGDVZHOODVUHVHDUFKRQ Page: 1 / 3 PEDRO DIZ IGLESIAS ! 84! ! Annexes ! ! 85! ! PEDRO DIZ IGLESIAS ! 86! Annex 5. Report from the Committee of Ethics in Research! The research protocol was approved by the Santiago-Lugo Committee on Research Ethics (#2014/600). Annexes ! ! 87! Secretaria Técnica Comité Autonómico de Ética da Investigación de Galicia Secretaria Xeral. Consellería de Sanidade Edificio Administrativo San Lázaro 15703 SANTIAGO DE COMPOSTELA Tel: 881 546425; [email protected] DITAME DO COMITÉ DE ÉTICA DA INVESTIGACIÓN DE SANTIAGO-LUGO Juan Manuel Vázquez Lago, Secretario do Comité de Ética da Investigación de Santiago-Lugo CERTIFICA: Que este Comité avaliou na súa reunión do día 17/12/2014 o estudo: Título: Conocimientos sobre cáncer oral y enfermedad periodontal en Galicia Promotor : Pablo Ignacio Varela Centelles Tipo de estudo: Outros Versión: Código do Promotor: Código de Rexistro: 2014/600 E, tomando en consideración as seguintes cuestións: - A pertinencia do estudo, tendo en conta o coñecemento dispoñible, así coma os requisitos legais aplicables, e en particular a Lei 14/2007, de investigación biomédica, o Real Decreto 1716/2011, de 18 de novembro, polo que se establecen os requisitos básicos de autorización e funcionamento dos biobancos con fins de investigación biomédica e do tratamento das mostras biolóxicas de orixe humana, e se regula o funcionamento e organización do Rexistro Nacional de Biobancos para investigación biomédica, a ORDE SAS/3470/2009, de 16 de decembro, pola que se publican as Directrices sobre estudos Posautorización de Tipo Observacional para medicamentos de uso humano, e a Circular nº 07/2004, investigacións clínicas con produtos sanitarios. - A idoneidade do protocolo en relación cos obxectivos do estudo, xustificación dos riscos e molestias previsibles para o suxeito, así coma os beneficios esperados. - Os principios éticos da Declaración de Helsinki vixente. - Os Procedementos Normalizados de Traballo do Comité. Emite un INFORME FAVORABLE para a realización do estudo polo/a investigador/a do centro: Centros Investigadores Principais C.S. Praza do Ferrol Pablo Ignacio Varela Centelles En Santiago de Compostela, a 18 de decembro de 2014 O secretario Juan M. Vázquez Lago PEDRO DIZ IGLESIAS ! 88! Annex$6.$$Research$Funding $ Annexes ! ! 89! ! PEDRO DIZ IGLESIAS ! 90! Annex 7. Secondary$products$from$this$PhD$project Annexes ! ! 91! Artículos originales 17 PABLO VARELA-CENTELLES y col. Antecedentes:La pobre conciencia sobre la enfermedad periodontal y sus consecuencias ha sido reportada como la razón más frecuente de fracaso de tratamiento en la comunidad. Este estudio apunta a identificar las brechas más importantes en el conocimiento sobre Enfermedad Periodontal dentro del público general y averiguar si éstas son consistentes culturalmente. Métodos:Las búsquedas sistemáticas fueron llevadas a cabo en las bases de datos EMBASE, PubMed, and SciELO (1998 a Noviembre 2014). La estrategia de búsqueda fue ''periodontitis o enfermedad periodontal'' y ''conocimiento o conciencia) como palabras clave y texto libre. Los artículos fueron incluídos si reportaban sobre comunidades, estudios cuantitativos en individuos adultos. Resultados: Un total de 2330 referencia fueron identificadas (1567 artículos) y seis artículos fueron finalmente seleccionados. La información fue dividida en nueve dimensiones de conocimiento periodontal: 1) conciencia, 2) etiología, 3) riesgos asociados, 4) signos y síntomas, 5) factores de riesgo, 6) tratamiento, 7) conocimiento general, 8) prevención y 9) actitudes. Esta clasificación reconoció conciencia de la enfermedad (80%), etiología (75%) y riesgos relacionados (71,43%) como los déficits más importantes del conocimiento dentro del público general. Estos hallazgos fueron confirmados mediante análisis. Conclusiones: El número disponible de investigaciones basadas en la comunidad sobre conocimiento periodontal es escaso y restringido a áreas con un muy alto nivel de desarrollo humano. Las brechas de conocimiento existen en todas las áreas geográficas, con mayor relevancia sobre la baja conciencia y el pobre conocimiento sobre la etiología de las enfermedades periodontales y su relación con desórdenes sistémicos. Estos resultados destacan la necesidad de investigaciones locales, basadas en la comunidad sobre el conocimiento periodontal y las barreras que impiden el diagnóstico temprano, así como para intervenciones adecuadas centradas en estos temas. J Periodontol 2016; 87: 403-415. Palabras Clave:Conocimiento de la salud, actitudes y práctica. Promoción de la salud; enfermedades periodontales; periodontitis; población; revisión. Conciencia sobre periodontitis entre el público general: una revisión sistemática crítica para identificar brechas en el conocimiento Pablo Varela-Centelles*†; Pedro Diz-Iglesias†; Ana Estany-Gestal‡; Juan M. Seoane-Romero†; Rosendo Bugarín-González* and Juan Seoane† Dra. NATALIA ASQUINO Docente Grado Uno. Facultad Odontología Universidad de la República del Uruguay. PEDRO DIZ IGLESIAS ! 92! Annexes ! ! 93! PEDRO DIZ IGLESIAS ! 100! Annex 8. Original articles The four original articles included in this PhD work. ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Annexes ! ! 101! ! PEDRO DIZ IGLESIAS ! 102! ! Annexes ! ! 103! ! PEDRO DIZ IGLESIAS ! 104! ! Annexes ! ! 105! ! PEDRO DIZ IGLESIAS ! 106! ! Annexes ! ! 107! ! PEDRO DIZ IGLESIAS ! 108! ! ! Annexes ! ! 109! ! PEDRO DIZ IGLESIAS ! 116! ! Annexes ! ! 117! ! PEDRO DIZ IGLESIAS ! 118! ! Annexes ! ! 119! ! PEDRO DIZ IGLESIAS ! 120! ! Annexes ! ! 121! ! PEDRO DIZ IGLESIAS ! 122! ! Annexes ! ! 123! ! Oral Diseases. 2019;1–8.  | 1 wileyonlinelibrary.com/journal/odi 1 | INTRODUCTION Periodontal diseases can be broadly defined as inflammatory disorders affecting the tooth supporting apparatus including a mild, reversible form (gingivitis), and periodontitis, an inflammation progressing deeper into the tissues causing progressive loss of attachment and bone damage (Pihlstrom, Michalowicz, & Johnson, 2005). Although the prevalence and severity of periodontitis have decreased over the last 50–60 years (Page & Eke, 2007), these improvements tend to be restricted to gingivitis and mild/moderate forms of periodontitis (Demmer & Papapanou, 2010). Overall prevalence of periodontitis remains high (Bourgeois, Bouchard, & Mattout, 2007), and an increment among elder groups may be expected in the near future due to an increased number of retained Received:24July2018 | Revised:26November2018 | Accepted:16December2018 DOI: 10.1111/odi.13026 ORIGINAL ARTICLE Periodontal awareness and what it actually means: A crosssectional study Pablo Varela‐Centelles 1,2 | Pedro Diz‐Iglesias 2 | Ana Estany‐Gestal 3 | Andrés Blanco-Hortas 3 | Rosendo Bugarín‐González 1 | Juan M. Seoane‐Romero 4 | Juan Blanco 2 © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved 1 Primary Care Clinics, Galician Health Service, EOXI Lugo, Cervo e Monforte, Lugo, Spain 2 Department of Surgery and MedicalSurgical Specialities, School of Medicine and Dentistry, University of Santiago de Compostela, Santiago de Compostela, Spain 3 Epidemiology, Statistics and Research Methodology Unit, Santiago de Compostela Institute for Research Foundation (FIDIS), Santiago de Compostela and Lugo University Hospitals, Lugo, Spain 4 Department of Surgery and MedicalSurgical Specialities, School of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain Correspondence Pablo Varela-Centelles, C.S. Praza do Ferrol, EOXI Lugo, Cervo e Monforte, Galician Health Service, Lugo, Spain. Email: [email protected] Funding information The Health Research Institution Foundation of Santiago de Compostela (FIDIS); The Ramón Domínguez Foundation R+D+i Biomedical Research and Development; Call for Aids to Biomedical Research 2014 Abstract Objectives: To assess periodontal awareness among laypersons, to characterize the very aware of periodontitis and to disclose whether high awareness implies sufficient periodontal knowledge. Subjects and methods: Cross-sectional study on laypersons randomly selected by quota sampling from March 2015 to June 2016. The questionnaire of periodontal awareness included aspects of aetiology, risk factors, signs and symptoms, related risks, prevention, treatment and related attitudes. It was applied by 12 interviewers in the community in each four province capitals, in a sort of pathfinder survey method. Results: A 43.3% response rate was obtained, and 3,553 people entered the study. “Veryaware”:19.4%.“Aware”:42.7%.“Notaware”:37.9%.Age,oralself‐careand educational achievements characterized those “very aware.” Any additional degree beyond compulsory education halves the chances for being “not periodontally aware.” Very aware people likely to have periodontitis were elder, less educated, with a smoking history and less knowledge of the disease. Gaps of knowledge among the “very aware” were identified in all aspects except for “prevention” and “treatment.”. Conclusions: Very periodontally aware people were in their late 40–60 s, followed sound oral care routines and held a degree but elicited insufficient knowledge about aetiology, signs-symptoms, related risks or periodontal risk factors. KEYWORDS awareness, cross-sectional, dental health surveys, general population, periodontitis PEDRO DIZ IGLESIAS ! 124! ! Annexes ! ! 125! ! PEDRO DIZ IGLESIAS ! 132! ! Annexes ! ! 133! ! PEDRO DIZ IGLESIAS ! 134! ! Annexes ! ! 135! ! PEDRO DIZ IGLESIAS ! 136! ! Annexes ! ! 137! ! PEDRO DIZ IGLESIAS ! 138! ! Annexes ! ! 139! ! PEDRO DIZ IGLESIAS ! 140! ! ! Article!1.!Periodontitis!awareness!amongst!the!general!public:!A! critical!systematic!review!to!identify!gaps!of!knowledge! ! https://pubmed.ncbi.nlm.nih.gov/26545044/! ! Article!2.!Periodontal!awareness!and!what!it!actually!means:!A! cross-sectional!study! ! https://pubmed.ncbi.nlm.nih.gov/30582873/! ! Article!3.!Primary!care!physicians!and!nurses:!Targets!for!basic! periodontal!education! ! https://pubmed.ncbi.nlm.nih.gov/29603221/! ! ! Article!4.!Regular!dental!attendance!and!periodontal!health! knowledge:!a!cross-sectional!survey! ! https://pubmed.ncbi.nlm.nih.gov/31785179/! ! ! ! ! ! !