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provided by Elsevier - Publisher Connector The Saudi Journal for Dental Research (2016) 7, 45–50

King Saud University The Saudi Journal for Dental Research

www.ksu.edu.sa www.sciencedirect.com

ORIGINAL ARTICLE Oral health knowledge, attitude and behavior among students of age 10–18 years old attending Jenadriyah festival ; a cross-sectional study

Abeer A. Al Subait a,c, Mohammed Alousaimi a,c, Amritha Geeverghese a, Anna Ali b,*, Ashraf El Metwally b

a College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, b College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia c Dental Service, King Abdulaziz Medical City, Ministry of National guard, Riyadh, Saudi Arabia

Received 25 January 2015; revised 3 May 2015; accepted 5 May 2015 Available online 19 May 2015

KEYWORDS Abstract Introduction: Several studies have documented a high prevalence of dental problems Oral health; among Saudi youth. In order to plan successful public health awareness campaigns it is essential Dental caries; to evaluate three domains related to oral health at the population level, namely knowledge, atti- Knowledge; tudes and behavior. Objective: To assess the level and aspects of knowledge, attitudes, and behav- Attitude; iors related to oral health among school students who attended a major festival in the City of Saudi Riyadh. Methods: This survey followed a cross sectional study design. Study subjects were recruited randomly among Saudi nationals attending the Jenadriyah festival in Riyadh City in the year 2013. Results: The study population was composed of 287 participants of age 10–18 years. Around 67% students reported brushing their teeth daily. We found significant difference in brushing habit between genders (P = 0.001) with girls showing a better dental practice. Compared to boys, girls were more aware about bleeding gums (P value 6 0.001), oral health effects general health (P value = 0.004) and importance of dental check-up (P value 6 0.001). Compared to boys’ girls were significantly more conscious about tooth color (P value = 0.05). Other attitudes toward dental health were not significantly different in-between genders. Conclusion: This population-based study among 15–18-year old students found that around two third of Saudi youth brush their teeth pro- portion which is similar to that reported among similar age groups 10 years ago. Through this study we recommended that evidenced-based effective dental awareness programs are needed in order to improve dental-related practice among that age group. Evaluations of ongoing campaigns in

* Corresponding author. E-mail address: [email protected] (A. Ali). Peer review under responsibility of King Saud University.

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http://dx.doi.org/10.1016/j.sjdr.2015.05.001 2352-0035 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 46 A.A. Al Subait et al.

schools are needed to better understand factors that can facilitate translating improved knowledge and attitudes into changing practice. ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Jeddah city was poor. The study also projected gender differ- ences in various issues. Females scored more favorably in 24 A good oral health is the state of mouth free of any disease knowledge and behaviors concerning periodontal health. affecting the oral cavity and its surrounding structures.1 Oral Information about the oral health knowledge, attitudes, health has remained as an integral part of an individual’s gen- and behavior among Saudi students is still limited. It is impor- eral health and over all well-being.2–4 Maintaining good oral tant to consider the fact that students can contribute in health hygiene is one of the most important things for healthy teeth promotion and in spreading preventive information broadcast and gums. Good oral health not only enables a person to look among their family and the society. Previous studies have and feel good, it is equally important in maintaining oral shown inconsistent results with respect to students’ levels of functions.5,6 knowledge, attitudes and behavior. This might be attributed In spite of the great triumphs in oral health, burden of oral to the differences in socio-demographic characteristics of sur- health diseases remains high all over the world. This could be veyed student populations. A national festival, such as mainly because of the lack of acceptance of healthy oral habits Jenadriyah, which is open to all Saudis from different socio- that are crucial in controlling the most common oral diseases economic classes, offers a unique opportunity to conduct like, dental caries and periodontal disease which are mainly health-related surveys with a higher level of external validity. considered as behavioral disease.7 Countries where the oral Thus, the objective of this study was to assess the oral health disease preventive programs have not been implemented still knowledge, attitudes, and behavior among students who remain in the shadow of high prevalence of dental caries. attended Jenadriyah festival in Riyadh City in the year 2013. In a study on dental caries prevalence among 12–14 year- old schoolchildren in Riyadh it was observed that of the total 2. Methods sample, only 6.3% were caries-free with an estimated caries prevalence to be 93.7%.8 This survey followed a cross sectional study design. The sub- From the published literature, it is evident that socio- jects comprising the population of this study were recruited behavioral and environmental factors play an important role randomly among Saudi national’s attending the Jenadriyah in maintaining good oral health.9 This includes nutritional sta- festival 2013. This festival shows the Saudi Arabia’s heritage tus, tobacco smoking, alcohol, hygiene, stress, systemic condi- and culture; with an estimated attendance of more than 2.5 tions, etc.10,11 Since the mouth is regarded as the mirror of the million populations. This festival represents a diverse cross- body, it is very important to have a good oral health for main- section of the Saudi Arabian population that captures children taining a good general health. Oral health, directly or indi- of diverse age group attending national and private schools rectly influences the quality of life of a person. Especially in thus having a wider representative of students across the children the negative impact of oral diseases, on quality of life region of Riyadh. has been reported since many years.12,13 In young children the The selection criteria were Saudi subjects’ within the age burden of oral disease restricts activities in school, work, and range of 8–18 years. To minimize selection bias, recruiters home leading to loss of many potential working hours.14,15 had used tables containing a randomly generated list of the The practice of maintaining the mouth clean and healthy by numbers 1 through 5 and had approached those whose order brushing and flossing to prevent tooth decay and gum disease matches with the next number on the table. For example, if is described as Oral hygiene.16 Maintaining good oral hygiene the number was 2, the recruiter chose the second child to walk is considered a lifelong habit. Moreover, these oral health past the dental stall. Study subjects were briefed on the study habits are said to begin in an early stage of life.17 In order to details before being asked to complete the self-administrated follow healthy oral habits, it is important to have good knowl- questionnaire. Informed consent was obtained from the edge and attitude toward oral health.10,18 The knowledge is selected child’s guardian accompanying them in the festival. derived from information and the information, when accepted All study participants had requested to complete a compre- and believed will be translated into an action which in turn hensive questionnaire adopted and modified from Al- becomes a habit. Parents, siblings and schoolteachers play an Omirietal, Frsi et al and Peterson et al.25–27 The questionnaire important role in grooming healthy habits in young chil- was in language and included twenty-five items dren.19–22 A good knowledge about oral health is essential designed to evaluate the demographic details and the knowl- for oral health related behavior. edge, attitudes, and behavior of young school children regard- The results from a study on Oral health practices and diet- ing their oral health and dental treatment. Subjects received ary habits of intermediate schoolchildren in Riyadh, Saudi detailed explanation of how to mark their responses. One of Arabia, concluded that interest in dental health care and pre- the investigators was always available during the completion ventive measures among the study sample were low.23 of the questionnaire, and the participants were encouraged Another study conducted in another major city in Saudi to approach him/her if any clarification was required. In order Arabia reported that knowledge and behavior concerning peri- to improve the quality and efficiency of the large study, a pilot odontal health among young Saudi school students living in study was conducted in prior on a random sample of 20 male Oral health among Saudi Students 47 and 20 female students studying in a school funded by the completing the questionnaire and 50% attributed the visits Saudi National Guards (who did not participate in the actual to dental pain. Out of total, 97% of participants reported study). To ensure the maximum face validity of the question- being non-smokers. One third of participants had heard about naire, students were asked about the clarity of the questions. dental caries and knew that sweet intake is linked to dental car- Results of the pilot phase showed an acceptable face validity ies. More than half of the participants were unaware about of the questionnaire items although minor editing was needed role of fluoride in caries prevention. Fifty-six percent of partic- on few items based on students comments. ipants were aware that dental bleeding is a primary sign of The study had obtained ethical clearance from Institutional poor oral health and more than half considered that poor oral Review Board and Ethical Approval Committee at KMARC health can affect general health. Sixty six percent of partici- KSAUH and college of dentistry KSAUHS NGHA.IBM pants considered that it is necessary to visit the dentist every SPSS 20 was used to analyze the data of 287 participants. 6 months (Table 3). Chi square was run to estimate the signif- Descriptive statistical analysis was employed to evaluate stu- icance of association between knowledge about oral health and dents’ level of knowledge attitude and behavior. Results were gender. There was a statistically significant difference (in favor depicted in frequency tables and bar charts. of females) related to the knowledge about bleeding gums, oral health effects general health and dental visit in 6 months with 3. Results the P value of <0.001, <0.05 and 0.017, respectively (Table 2). Out of 287 participants in the survey, 61% were boys and Our study also showed that 69% of participants were satis- 63.4% were aged between 15 and 18 years. Around 64% of fied with their dentist. Out of 287 participants, 59% had heard participants were students enrolled in governmental schools about dentist and oral health from families and more than half (Table 1). Out of total participants, 191 were brushing and had never used the internet to search for information about 96 were not. Significantly more girls reported brushing their oral health (Fig. 1). teeth. The habit of daily brushing was more prevalent in the Three third of the participants were worried about teeth young age group when compared to students of age 15– color and halitosis. More than half considered healthy teeth 18 years but the difference was not significant statistically. means strong and caries-free teeth. When we compared gen- The difference in students being enrolled in public versus pri- ders with respect to attitudes regarding dental health we found vate schools with respect to self-report of tooth brushing was that three fourth of the girls were worried about bad breath not statistically significant (Table 1). and tooth color (Table 3). Boys and girls reported similar Out of total participants, 66.5% reported brushing their levels of attitudes toward dental health. One exception was teeth daily. Three fourth of the participants were using tooth- brush as a brushing tool and very few participants were using miswak and toothpick. More than half participants were not Table 2 Relationship between knowledge of study partici- using any dental floss and mouth rinses. pants about oral hygiene (OH) and gender (n = 287). Three quarters of the participants reported visiting the den- Knowledge Frequency Frequency among gender P value* tist. Out of those who reported never visiting the dentist, 12% of OH (%) (%) attributed this to dental fear while the rest attributed this to the Boys Girls fact that they never felt pain. Of those who reported visiting (n = 176) (n = 111) the dentist, 50% did so during the 6 months prior to Fluoride strengthens teeth Agree 85(29.6) 45(25.6) 40(36.4) 0.095 Disagree 36(12.5) 26(14.8) 10(9.1) Do not know 166(57.8) 105(59.7) 61(54.5) Table 1 Relationship between demographic variables and tooth brushing (n = 287). Bleeding is a primary sign of poor OH Agree 162(56.4) 81(46.0) 81(73.0) <0.001 Socio demographic Frequency Brushing daily P value* Disagree 36(12.5) 26(14.8) 10(9.0) variables (%) (n = 191) (%) Do not know 89(31.0) 69(39.2) 20(18.0) Gender Oral health affects general health Boy 176(61.3) 101(57.4) 0.001 Agree 189(65.9) 103(58.5) 86(77.5) 0.004 Girl 111(38.7) 90(81.1) Disagree 27(9.4) 21(11.9) 6(5.4) Age Do not know 71(24.7) 52(29.6) 19(17.1) 10-14 105(36.6) 71(67.6) 0.771 Dental visit every 6 months 15-18 182(63.4) 120(65.9) Agree 189(65.9) 106(60.2) 83(74.8) 0.017 School Disagree 46(16) 36(20.5) 10(9.0) Government 183(63.8) 116(63.4) 0.132 Do not know 52(18.1) 34(19.3) 18(16.2) Private 104(36.2) 75(72.1) Healthy teeth means caries free Using tooth brush Agree 152(53.0) 92(52.3) 60(54.1) 0.033 Yes 251(87.5) 187(74.5) <0.001 Disagree 96(33.4) 56(31.8) 40(36.0) No 36(12.5) 4(11.1) Do not know 39(13.6) 28(15.9) 11(9.9) * Estimated using Chi-Squared test. * Estimated using Chi-Squared test. 48 A.A. Al Subait et al.

Table 3 Relationship between attitude of study participants toward oral health and gender (n = 287). Attitude for OH Frequency Frequency among P Value* (%) gender (%) Boys Girls (n = 176) (n = 111) Ever visited 222(77.4) 137(77.8) 85(76.6) 0.803 dentist Worried about 212(73.9) 123(69.9) 89(80.2) 0.053 tooth color Worried about 218(76.0) 131(74.4) 87(78.4) 0.446 bad breath Satisfied from 196(68.3) 119(67.6) 77(69.4) 0.756 dentist * Estimated using Chi-Squared test. Figure 2 Bar graph showing places where participants had attended any OH program.

reduce the dental diseases.34–36 In our study the prevalence of daily brushing is reported as 66.5%. A figure which is similar to that reported in a Saudi study conducted in 2003 and found that 65% of students were doing brushing at least once.23 The same study reported that private school students had a better dental hygiene practice and that age was inversely related to oral health practices.23 While in our study, we found that both age and type of schooling were not significantly related to the Figure 1 Bar graph showing from where participants had heard habit of tooth brushing. Our results are consistent with a about dental health, 2013. Chinese study that assessed oral health behavior in schoolchil- dren and reported that, around 22% of the 12-year-old group being worried about tooth color, which was reported more brushed at least twice a day, 62% reported brushing frequency among females with chi-squared test showing a borderline sig- to be once a day and it was observed that 16% never brushed nificance for such difference (Table 3). Around half of the par- or brushed less frequently.37 ticipants reported attending oral health education programs Our study reported that three fourth of students were using and 40% reported attending such events in their own schools tooth brush as a tool for brushing and use of miswak was not (Fig. 2). very commonly used by the study participants while a study conducted in 2008 among 1115 male students in Al Hasa 4. Discussion Saudi Arab reported that 45% of students were using miswak as a brushing tool.38 This might be attributed to either differ- This cross-sectional study aims to study the knowledge, atti- ence in either venues or the timings in both studies. Our study tude and practices of 287 students who were randomly selected reported that the study participants did not frequently use oral from the festival. Our study reports that 66.5% of study par- rinses and floss. The results are consistent with the findings of a ticipants were brushing daily. Knowledge related to fluoride study conducted in 2003 in Riyadh, which reported that only application, bleeding from gums, general effects of oral health 5.1% of students were using dental floss, indicating that and importance of dental visit was comparatively higher in importance of the use of floss and mouth rinses is still under- girls. In addition girls were more conscious about teeth color estimated among Saudi young population.23 Our results than boys. Except for the poor knowledge about the role of showed that more than half of the students consider that den- fluoride, more than half of the students had fair knowledge tal visits should be conducted every 6 months and three fourth and good attitude toward healthy oral hygiene. of the student had visited the dentist. Our results showed In literature, knowledge and awareness about oral health is growth in the knowledge and practices related to oral health reported to be very low and marked differences in oral hygiene when comparing with the findings of studies conducted in past habits, depending on age and educational levels were observed. year, although this might be attributed to differences in demo- Studies conducted in Spain and Kuwait showed an association graphics (mainly geographic regions) of population studies. A between increased knowledge and better oral health.28,29 Good study conducted in 2011 in Madina among 240-student chil- oral health practice can be accomplished mainly through self- dren reported less than half of the participant (45%) visits den- induced habits like maintenance of dental hygiene, restriction tist annually.39 of diet especially reduced sugar intake, use of fluoridated prod- The oral health apprehension of an individual is reflected ucts and also with the help of available dental services, which on the attitude of a person. The attitude toward having a good includes, regular dental checkup, utilization of primary and oral health will be influenced by one’s own experiences, cul- preventive care and dental health education.30–33 It is impor- tural, familial practice, religious beliefs, and other life situa- tant to prevent dental problems before they start. 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