Conhecimento geral de estudantes de odontologia a respeito de antissépticos bucais

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1 R. Periodontia - Setembro Volume 20 - Número 03 Dental Students Overall Knowledge Regarding Oral Antiseptics Conhecimento geral de estudantes de odontologia a respeito de antissépticos bucais Alex Nogueira Haas 1, Manuela Furtado Flores 2, José Pelino 3, Angela Della Gatta 4 RESUMO O objetivo deste estudo observacional transversal foi avaliar o conhecimento de estudantes de Odontologia a respeito de antissépticos bucais. De um total de 93 estudantes elegíveis, 80 (média de idade 22,3 anos; 66,2% mulheres) participaram respondendo a um questionário estruturado de perguntas fechadas sobre antissépticos bucais. Estudantes do 5 o e 8 o semestres participaram do estudo respondendo ao questionário em sala de aula durante um dia regular de aulas. Os antissépticos avaliados foram clorexidina, óleos essenciais, cloreto de cetilpiridíneo e triclosan por serem dominantes no mercado brasileiro e possuírem maior número de artigos científicos disponíveis na literatura. 46,2% dos estudantes responderam que raramente indicam ou indicariam antissépticos a um paciente com gengivite, sem diferença significativa entre os semestres. Cerca de 85% dos estudantes consideraram clorexidina o agente com maior substantividade, sendo que houve maior variabilidade nas respostas dos alunos do 5 o comparados aos do 8 o semestre (Qui-quadrado p=0,02). Todos os alunos consideraram clorexidina o agente padrão-ouro para prescrição após cirurgias bucais. Triclosan foi considerado por 62,8% dos estudantes como o antisséptico com maior benefício clínico, todavia, mais de um quarto dos estudantes não soube responder qual o agente mais benéfico. Mas 62,5% dos estudantes não souberam responder qual a prescrição correta de óleos essenciais. Pode-se concluir que existiu alta variabilidade no conhecimento de estudantes de odontologia sobre antissépticos bucais. UNITERMOS: antissépticos bucais, estudantes de odontologia, educação em odontologia. R Periodontia 2010; 20: DDS, MSc, PhD. Adjunct Professor of Periodontology, Federal University of Rio Grande do Sul. Porto Alegre, Brazil. 2 DDS. MSc student, Periodontology, Federal University of Rio Grande do Sul. Porto Alegre, Brazil. 3 DDS, MSc, PhD. Scientific and Professional Affairs Manager, Research & Development at Johnson & Johnson, São Paulo, Brazil. 4 DDS, MSc. Dental Science Liason, Johnson & Johnson, São Paulo, Brazil. Assistant Professor of Restorative Dentistry, FMU, São Paulo, Brazil Recebimento: 01/06/10 - Correção: 23/07/10 - Aceite: 30/08/10 INTRODUction Oral antiseptics are recognized to provide clinical benefits in terms of reduction of plaque and gingivitis (Gunsolley, 2006; Stoeken et al., 2007). They are mostly present in mouthwashes for daily use as adjuvants to mechanical plaque control. There are numerous active agents that had been tested over the decades and are available in the market (Barnett, 2006; Silverman & Wilder, 2006). These comprise mainly chlorhexidine, essential oils, triclosan and cetylpirydine chloride. In Brazil, there still are some natural agents claiming to have anti-plaque and anti-gingivitis effects, although the evidences are weak and sparse (Lotufo et al., 2005). Besides there is a plethora of evidence regarding the clinical efficacy of oral antiseptics, personal communications indicate that clinicians still demonstrate some concerns about the clinical relevance of such agents. One of the possible explanations for such concerns may be the lack of knowledge of dentists regarding properties, efficacy, safety and clinical outcomes of oral antiseptics. Nevertheless, this issue has not yet been studied systematically in the literature. Thus, the aim of the present study was to evaluate the knowledge of 47

2 dental students from a public dental school in the south Brazil regarding oral antiseptics. MATERIAL AND METHODS Study design and sample This was a cross-sectional observational study. The sample consisted of dental students from the Faculty of Dentistry of the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil. The course at this public university has 5 years of length and is divided into 10 semesters. Students coursing the 5 th and the 8 th semesters were invited to participate. The reason for selecting students from two distinct moments in the course is that these semesters are composed by the first and the last disciplines, respectively, in which the students attend patients under supervision of professors. As a consequence, the present sample comprises two groups of students with different clinical backgrounds. A total of 93 students were eligible for the study, 53 and 40 from the 5 th and 8 th semesters, respectively. Overall, 13 (14%) students were absent in the day of the study, resulting in a sample of 80 (86%) students. Table 1 describes age, gender and the distribution of students according to semester. Questionnaire A structured questionnaire (Table 2) was applied to evaluate students self-reported knowledge regarding oral antiseptics. End-closed questions were formulated. The questionnaire approached indication/recommendation, posology, the concept of substantivity, clinical outcomes of agents, and the link between antiseptics and brands. Target oral antiseptics The Brazilian market of oral antiseptics has a broad spectrum of active agents, including industrialized and natural agents. It would be not feasible to evaluate knowledge regarding all possibilities in the market. Thus, we developed questions about agents presenting the highest amount of evidence and also dominating the market in the country: chlorhexidine, essential oils, triclosan and cetylpirydine chloride. Setting Students answered the questionnaire into a classroom in the Faculty in an ordinary class day. They were informed that participation in the study would not imply in any negative impact in their grades during the semester. Each participant Table 1 Characteristics of study participants according to semester of dental education Variable 5 th semester 8 th semester Total N 46 (57.5%) 34 (42.5%) 80 (100%) Age 21.5 ± ± ± 2.1 Gender Male 32 (69.6%) 21 (61.8%) 53 (66.2%) Female 14 (30.4%) 13 (38.2%) 23 (33.8%) Table 2 End-closed questions included in the questionnaire. Questions 1- Do you or would you recommend daily use oral antiseptics to a patient with gingivitis? 2- Which of the following active agents demonstrates the highest substantivity? 3- Which of the following active agents is considered the gold-standard to be used after oral surgery? 4- Which of the following active agents is present in (BRAND NAMES)? 5- Which of the following active agents demonstrates the largest clinical benefit according to the scientific literature? 6- Which of the bellow prescriptions does the manufacturer of essential oils recommend? 48

3 was voluntary and the present study followed the ethical guidelines. They were distributed in the room to avoid any discussion between one to each other in case of doubts. Students names were not provided in the questionnaire. Statistical analysis Data were presented in percentage distributions and cross tabulation. Comparisons between the 5 th and 8 th semesters were made by the Chi-square and Fisher s exact test whenever indicated. The level of significance was set at 5%. RESULTS The answers regarding indication of oral antiseptics were provided in a Likert scale (question 1; Table 3). The majority of students (46.2%) answered that they rarely indicate an oral antiseptic for a patient with gingivitis. Similar percentages of students reported sometimes (24.4%) and never (28.4%). None of the students reported to always indicate an oral antiseptic. There was no significant difference between students in the 5 th and 8 th semester in the distribution of answers regarding indication for patients with gingivitis. The majority of students (85%) considered chlorhexidine the agent with the highest substantivity (question 2; Table 4). However, students from the 5 th semester demonstrated higher variability in the answers compared to those from the 8 th semester (p=0.02). 15.2% of the students from the 5 th semester did not know to answer the question about substantivity. On the contrary, independently of the semester all students agreed to answer that chlorhexidine should be the gold-standard alternative for post-operative prescription after oral surgery (question 3). Table 3 Students knowledge regarding recommendation of oral antiseptics for gingivitis patients according to semester of dental education. Answers 5 th semester 8 th semester Total Always 0% 0% 0% Sometimes 27.3% 20.6% 24.4% Rarely 47.7% 44.1% 46.2% Never 22.7% 35.3% 28.2% Don t know 2.3% 0% 1.2% Chi-square: p=0.52 Table 4 Students knowledge regarding substantivity of oral antiseptics according to semester of dental education. Answers 5 th semester 8 th semester Total Essential oils 0% 0% 0% Chlorhexidine 73.9% 100% 85% Cetylpirydine chloride 2.2% 0% 1.3% Triclosan 8.7% 0% 5.0% Don t know 15.2% 0% 8.7% Chi square: p= 0.02 Table 5 Students knowledge regarding the link between active agents and brands of oral antiseptics (percentage of right answers according to semester of dental education). Answers 5 th semester 8 th semester p* Plax 54.4% 85.3% Listerine 45.4% 78.8% Periogard 89.1% 94.1% 0.69 Cepacol 37.0% 52.9% 0.18 *Between groups comparison, Fisher s exact test. 49

4 Table 5 demonstrates the distribution of answers about the knowledge of students regarding the link between active agents and brands in the two semesters (question 4). Most of the students in the two semesters gave the right answer for a brand of antiseptic with chlorhexidine (89.1% and 94.1% for the 5 th and 8 th semester, respectively; p=0.69). Although there was no significant difference between the two semesters, the lowest percentages of right answers were observed for an antiseptic with cetylpirydine chloride (37% and 52.9%; p=0.18). Significant differences were observed between the 5 th and 8 th semesters regarding triclosan (p=0.004) and essential oils (p=0.005), with higher percentages of students from the 8 th semester answering correctly about these two agents (85.3% and 78.8%, respectively). For the question about the largest clinical benefit observed in the literature (question 5), essential oils, cetylpirydine chloride, triclosan and hydrogen peroxide were included as possible answers (Table 6). The majority of students (62.8%) answered that triclosan has the largest clinical effect. More than one fourth of them did not know what to answer. None of the students answered considered hydrogen peroxide to have the best clinical benefit. No significant difference was observed between semesters (p=0.26). To evaluate the knowledge regarding posology, question 6 was formulated taking essential oils as an example. 62.5% of the students did not know the correct answer (Table 7). Only 8.8% provided the right answer, and a statistically significant difference was observed between semesters (p=0.03). Table 6 Students knowledge regarding clinical benefit of oral antiseptics observed in the literature according to semester of dental education. Answers 5 th semester 8 th semester Total Hydrogen peroxide 0% 0% 0% Essential oils 6.8% 5.9% 6.4% Cetylpirydine chloride 4.6% 5.9% 5.1% Triclosan 54.5% 73.5% 62.8% Don t know 34.1% 14.7% 25.7% Chi -square: p= 0.26 Table 7 Students knowledge regarding posology of essential oils according to semester of dental education. Answers 5th semester 8th semester Total 15ml, 1min, 12/12h 6.5% 17.7% 11.3% 10ml, 1min, 12/12h 19.6% 5.9% 13.7% 20ml, 30s, 12/12h 13.0% 2.9% 8.8% 10 ml diluted 6.5% 0% 3.7% Don t know 54.3% 73.5% 62.5% Chi-square: p=0.03 DISCUSSION The present cross-sectional study demonstrated that the knowledge of dental students from a Brazilian dental school regarding some issues about oral antiseptics varies consistently. Students demonstrated good knowledge about chlorhexidine. On the contrary, a high proportion of students demonstrated lack of knowledge about essential oils, cetylpirydine chloride and triclosan. Moreover, some differences were observed between more and less experienced students. A search in the literature for studies that evaluated knowledge regarding oral antiseptics by dental professionals and students retrieved no results in medline and Lilacs. To the best of our knowledge, this study seems to be the first to be published. As a consequence, there are no data available in the literature for comparisons. Contrarily, other studies that 50

5 evaluated knowledge regarding caries management (Nainar & Straffon, 2006), prevention (Tseveenjav et al., 2003; Khami et al., 2007; Autio-Gold & Tomar, 2008) and medical emergencies (Carvalho et al., 2008) could be found. This may indicate a lack of interest of the dental scientific and academic community to study knowledge and perceptions of the dental professionals. Dental students demonstrated lack of knowledge regarding the indication/recommendation of oral antiseptics for patients with gingivitis. The majority of the students answered that rarely indicate an oral antiseptic for gingivitis patients. Additionally, almost one third of them answered that never indicate an oral antiseptic in this situation. This attitude is in contrast to what has been demonstrated in the literature. It is well documented that gingivitis patients benefit from oral antiseptics use (Gunsolley, 2006; Stoeken et al., 2007). Chlorhexidine is considered the gold-standard agent for chemical control of the dental biofilm. One of the reasons why chlorhexidine has the highest anti-plaque and antigingivitis effect is its high substantivity (Gjermo et al., 1970; Gjermo, 1974). These concepts were well demonstrated by the participants of this study. All students answered that chlorhexidine is the first choice agent for prescription after oral surgery and 85% of the students answered that chlorhexidine has the highest substantivity. Moreover, most students (89.1% and 94.1% in 5 th and 8 th semesters respectively) knew to link chlorhexidine to one of its brands in Brazil. According to these data, it may be suggested that the highest knowledge about an agent, the more the students knew how, when and why to use it. Dental students consistently demonstrated lack of knowledge regarding oral antiseptics for daily use such as essential oils, cetylpirydine chloride and triclosan. The majority of participating students answered that triclosan is the agent that provides the largest clinical benefit observed in the literature. On the contrary, meta-analyses have demonstrated that the use of essential oils gives the highest anti-plaque and anti-gingivitis effect (Gunsolley, 2006; Stoeken et al., 2007; Gunsolley, 2010). Additionally, most of the students did not know to answer how to prescribe one of the daily use oral antiseptics. Another interesting finding of the present study was the significant differences observed between students from 5 th and 8 th semesters for answers about the link between active agents and brands of Plax and Listerine. High percentages of students from the 8 th semester knew the exact agent present in these two brands of oral antiseptics. This may indicate that accumulating clinical expertise may influence in the knowledge of these students. It can be concluded from the present study that dental students present high variability regarding the knowledge about oral antiseptics. The findings from the present study suggest the need for a revision of concepts of oral antiseptics and chemical control of dental biofilm teached in this and similar dental schools in Brazil. ABSTRACT The aim of the present cross-sectional observational study was to evaluate the knowledge of dental students regarding oral antiseptics. From a total of 93 students, 80 (mean age 22.3 years; 66.2% women) participated in the study by answering to a structured questionnaire with closed questions regarding oral antiseptics. Students from the 5 th and 8 th semesters participated by answering the questionnaire into the classroom in an ordinary class day. Evaluated antiseptics were chlorhexidine, essential oils, cetylpyridine chloride and triclosan, since these agents dominate the Brazilian market and have the highest number of published scientific papers in the literature. 46.2% of the students answered that they rarely indicate an oral antiseptic for a patient with gingivitis, whit no significant difference between semesters. Approximately 85% considered chlorhexidine the agent with the largest substantivity, and a higher variability of answers was observed in the 5 th compared to the 8 th semester (Chi-square p=0.02). All students considered chlorhexidine the gold-standard agent to be prescribed after oral surgery. Triclosan was considered by 62.8% of students as the antiseptic with the largest clinical benefit, although more than one fourth of them did not know to answer. 62.5% of the students did not know the correct posology of essential oils. It can be concluded from the present study that dental students present high variability regarding the knowledge about oral antiseptics. UNITERMS: oral antiseptics, dental students, dental education 51

6 REFERENCES 1- Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. J Am Dent Assoc Dec;137(12): Stoeken JE, Paraskevas S, van der Weijden GA. The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review. J Periodontol Jul;78(7): Barnett ML. The rationale for the daily use of an antimicrobial mouthrinse. J Am Dent Assoc Nov;137 Suppl:16S-21S. 4- Silverman S, Jr., Wilder R. Antimicrobial mouthrinse as part of a comprehensive oral care regimen. Safety and compliance factors. J Am Dent Assoc Nov;137 Suppl:22S-6S. 5- Lotufo RFM, Haas AN, Rodrigues AS, Pannuti CM, Pustiglioni FE, Nogueira-filho GR, et al. Tratamento antimicrobiano em periodontia - Tratamento não-cirúrgico. Revista Periodontia. 2005;15: Nainar SM, Straffon LH. Predoctoral dental student evaluation of American Academy of Pediatric Dentistry s Caries-Risk Assessment Tool. J Dent Educ Mar;70(3): Tseveenjav B, Vehkalahti M, Murtomaa H. Time and cohort changes in preventive practice among Mongolian dental students. Eur J Dent Educ Nov;7(4): Khami MR, Murtomaa H, Jafarian M, Virtanen JI. Knowledge and attitude of Iranian dental school educators towards prevention. Oral Health Prev Dent. 2007;5(3): Autio-Gold JT, Tomar SL. Dental students opinions and knowledge about caries management and prevention. J Dent Educ Jan;72(1): Carvalho RM, Costa LR, Marcelo VC. Brazilian dental students perceptions about medical emergencies: a qualitative exploratory study. J Dent Educ Nov;72(11): Gjermo P, Baastad KL, Rolla G. The plaque=inhibiting capacity of 11 antibacterial compounds. Journal of periodontal research. 1970;5(2): Gjermo P. Chlorhexidine in dental practice. J Clin Periodontol. 1974;1(3): Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent Jun;38 Suppl 1:S6-10. Corresponding author: Alex Nogueira Haas Rua Corte Real, 82/801 CEP: Bairro Petrópolis, Porto Alegre-RS alexnhaas@gmail.com 52