ARTICLE IN PRESS Public Health (2006) 120, 953–957
An assessment of oral self-care in the student population of a Turkish university ¨ mit Sait Yavuz ˘rul Kırtılog ˘lu, U Tug Department of Periodontology, Faculty of Dentistry, University of Ondokuz Mayis, 55139 Kurupelit-Samsun, Turkey Received 22 March 2005; received in revised form 16 March 2006; accepted 12 May 2006 Available online 7 July 2006
KEYWORDS Oral hygiene; Oral health; Tooth brushing; Flossing; Self-care
Summary Objectives: The aim of this study was to determine the oral health behavior of Turkish non-dental university students. Study design and methods: A sample of 610 non-dental university students attending the University of Ondokuz Mayis in Samsun were randomly selected from the whole student population (n ¼ 12 604) via the random number method. The students were asked to fill out a standardized self-completion questionnaire about daily frequency of toothbrushing, kind of toothbrush, frequency of toothbrush replacement, frequency of dental flossing, use of antibacterial rinse, or any other oral hygiene aid, receiving of oral hygiene instruction and frequency of oral checkup. The data were analysed using the SPSS version 12.0.1 statistical software package. Results: Sixty-eight per cent of the students brushed their teeth two or more times per day. Two or more times a day toothbrushing was more common among females than males (Po0.001). Few subjects (3%) used dental floss daily. Forty per cent of students used only the toothpick as an interdental oral hygiene device. Thirty per cent of the students visited a dentist for preventive treatment at least once a year. There was no significant difference in regularity of visits to the dentist between females and males (P40.05). Conclusion: This study indicated that self-preventive oral behaviour of the Turkish university student is at a lower level than in industrialized countries. & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Corresponding author. Tel.: +903 624576000-3001;
fax: +903 624576032. ˘lu). E-mail address: [email protected]
People brush their teeth for a number of reasons: to feel fresh and confident; to have a nice smile; and to avoid bad breath and avoid disease.1 Studies which have investigated the relationship between
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.05.006
ARTICLE IN PRESS ˘lu, U.S. Yavuz T. Kırtılog
954 oral health behaviour and psychological factors have shown that adolescents with higher selfesteem were more likely to brush their teeth regularly, and to make more frequent dental visits than those with lower self-esteem.2,3 Preventive behaviour is significantly associated with oral health.4 An individual’s dental health status is a result of life-long oral self-care behaviour and attitudes.5 The maintenance and improvement in health status are dependent on good health behaviour,6 but toothbrushing among adolescents does not seem to be a strongly health-oriented behaviour.7 Education, socio-economic conditions, acculturation, psychological stress and cultural and religious belief can affect the oral health behaviour and status.8–13 For example, use of miswak as an oral hygiene device is common among the Saudi population (39.9%). This habit can be related to cultural and religious belief or to the use of a cheaper device.13 Most studies about oral hygiene habits have been conducted among children, adolescents, adult and university students. However, few studies have been conducted on non-dental university students.4,14–19 Although some studies have been done on oral health behaviour and status of Turkish children and young adults,20,21 no data were available about oral health behaviour of Turkish university students. The aim of this study was to determine the oral health behaviour of Turkish university students, excluding dental students.
cement, frequency of dental flossing, use of antibacterial rinse, and any other oral hygiene aid, receiving of oral hygiene instruction and frequency of oral check-up was anonymously filled out. The response rate was 100%. The data were analysed using the SPSS version 12.0.1 statistical software package. The categorical data were analysed by using w2 table analyses.
Results Sixty-eight per cent of the students brushed their teeth two or more times per day (Table 1). The use of an artificial bristle toothbrush of medium stiffness was 73.8%. As for electrical tooth brushes, 2.3% of students used them. Toothbrush replacement every 3–6 months was 60.2%. Very few of the students (3%) used dental floss daily and the great majority of students (91.1%) had never or sometimes used dental floss (Table 2). Other regular application of oral hygiene aids included toothpick (52.4%), antibacterial rinse (18.8%), chewing-gum (52.9%) and interdental brush (1.6%). The proportion of the use of only toothpick as an interdental oral hygiene device was 40%. Of all the students in the study, 30.3% of the students reported a dental visit for preventive treatment at least once a year. However, 55.1% of students visited a dentist only when they had toothache. More than half of the Table 1
Materials and methods This study, performed in accordance with the Declaration of Helsinki, was conducted at the University of Ondokuz Mayis during the 2003–2004 academic year. Subjects, except for dental students, were randomly selected from the entire student population (n ¼ 12 604) via the random number method from the student lists obtained from the university student affairs. The sample consisted of 610 university students (282 males and 328 females) aged 17–27 years. Sample size was calculated in order to have an estimated error of frequencies less than 5% with a 95% probability. The students, selected by random number method, were approached in classrooms by two dentists, and were asked to remain after lesson if they were willing to complete a survey about their oral health behaviour. The standardized self-completion questionnaire about daily frequency of toothbrushing, kind of toothbrush, frequency of toothbrush repla-
More than 2 a day 2 a day 1 a day More than 2 a week 1 or 2 a week 1 or 2 a month Never Total
84 328 158 11 24 5 0 610
13.8 53.7 25.9 1.8 4 0.8 0 100
1 a day 1 every 2 days 1 a week Sometimes Never Total
18 12 24 165 391 610
3 2 3.9 27 64.1 100
ARTICLE IN PRESS Assessment of oral self-care students (57%) made their last visit for preventive or treatment needs in the previous year. Toothbrushing two or more times a day was more common among females than males (83.2% vs. 49.3%, Po0.001). There was no statistical difference between females and males (3% vs. 2.8%) with respect to the use of dental floss (P40.05). There was no significant difference in regular visits to the dentist between female and male (P40.05). Sixty-one per cent of students had received oral hygiene instructions from a dentist. Seventy-one per cent of the students who had previously received oral hygiene instructions and motivation brushed their teeth two or more times per day. Thirty-four per cent of the students who did not use interdental cleaning devices daily and 24.9% of the students who did not brush their teeth daily reported that they did not have enough time.
Discussion Reduction of plaque accumulation is an important factor for prevention of periodontal disease and dental caries. Therefore, twice a day toothbrushing is recommended as a good dental self-care procedure.22,23 Frequency of toothbrushing and the use of dental floss were investigated in various studies. In most of those studies authors reported that although frequency of toothbrushing was at a high rate of twice a day or more, the use of dental floss was at a low rate.10,17–19,24,25 Investigations showed that there were significant differences between industrialized countries and developing countries with respect to oral health behaviour. Ninety-two percent of university students in Italy brushed their teeth at least twice a day,19 85% of 20–25-year-old Swedes brushed their teeth once or twice a day,17 34% of health sciences college students brushed their teeth twice or more a day in Kuwait26 and in this study 67.6% of students brushed their teeth twice or more a day. Regular dental flossing rate was 14.9% in Italy,19 7% in Sweden,17 28% in the UK27 and 3% in our study. Toothbrushes do not need to be replaced every 3 months.28,29 However, in our study 49% of subjects and in the study by Rimondini et al.19 81.6% of subjects replaced their toothbrushes every 3 months. This behaviour could be the result of the recommendations of dental professionals and toothbrush manufacturers. Cross-cultural studies conducted among the dental students showed that oral health behaviour was very different among countries, which reflected the different culture and/or health education systems of the students.30–33 Cultural belief
955 and economical factors affect oral hygiene behaviour. For example, use of miswak rate was high among young Saudi school students (39.9%), especially among governmental school students.13 In our study, 52% of the students used the toothpick daily and 40% of the students used only the toothpick as an interdental cleaning device because of its easy use and low cost. Few subjects used the toothpick daily in other studies.17,24 Studies showed that most of the children (81%) did not have a regular brushing habit and 72% of high school students needed oral hygiene education in Turkey.20,21 In the present study, 61% of students had received oral hygiene instructions. However, 5.2% of those students did not want to practice them regularly. This behaviour is an important problem to solve. Those students may not have been informed sufficiently about the relationship between poor oral health and gingivitis, periodontitis and caries. Dental hygienists specialize in the area of preventive information33 and play a key role in oral health.34 The presence of a dental hygienist in health centres would improve the dental health of the population,35 but there are no dental hygiene schools in Turkey. In Japan, the dental hygienist to dental practitioner ratio was 1:1.3 in 2000.36 The lack of dental hygienists could be one of the reasons for the differences in oral health behaviour between Turkey and countries demonstrating better oral health behaviour. Systematic oral health education programs should be implemented in respect to all educational levels and ages to support the improvement of regular oral self-care practices. Dental behaviour is mostly determined by gender.37 Females exhibited significantly higher rates of good oral health behaviour.11,18 Astrom reported that the rates of flossing and toothbrushing were significantly higher in females.38 The results of the present study showed that females brushing their teeth twice or more per day was significantly greater than males (Po0.001), but there was no statistical differences with respect to using dental floss (P40.05). Results of the present study indicated that attendance of students at a dental clinic for preventive check-up was lower (30.3%) than in an Italian university (59.9%).19 There was no significant difference in the regularity of visits to the dentist between females and males (P40.05). Moreover, a study conducted in Turkey reported that most of the patients visiting the outpatient clinic were highly educated and middle-aged people, but no gender differences were observed.39 Daily tooth brushing and flossing are easy, effective and low cost practices for removing the
ARTICLE IN PRESS 956 microbial dental plaque which is an important factor in the development of caries and periodontal disease. This study revealed that these practices were neglected by a substantial number of respondents. Their self-preventive oral behaviour is therefore at a lower level than in industrialized countries.
Acknowledgements The authors thank Prof. Dr. Yu ¨ksel Bek of Ondokuz Mayis University in Samsun for his help with the statistical analyses and Gregory T. Sullivan for his assistance in completing this translation.
References 1. Deery C, Heanue M, Deacon S, Robinson PG, Walmsley AD, Worthington H, et al. The effectiveness of manual versus powered toothbrushes for dental health: a systematic review. J Dent 2004;32:197–211. 2. Macgregor IDM, Balding JW. Self-esteem as a predictor of toothbrusing behavior in young adolescents. J Clin Periodontol 1991;18:312–6. 3. Macgregor IDM, Regis D, Balding JW. Self-concept and dental health behaviors in adolescents. J Clin Periodontol 1997; 24:335–9. 4. Boehmer U, Kressin NR, Spiro III A. Preventive dental behaviors and their association with oral health status in older white man. J Dent Res 1999;78:869–77. 5. Inglehart M, Tedesco LA. Behavioral research related to oral hygiene practices: a new century model of oral health promotion. Periodontol 2000 1995;8:15–23. 6. Pellmar TC, Brandt Jr EN, Baird MA. Health and behavior: the interplay of biological, behavioral, and social influences: summary of an Institute of Medicine report. Am J Health Promot 2002;16:206–19. 7. Kallio PJ. Health promotion and behavioral approaches in the prevention of periodontal disease in children and adolescents. Periodontol 2000 2001;26:135–45. 8. Koivusilta L, Honkala S, Honkala E, Rimpela A. Toothbrushing as part of the adolescent lifestyle predicts education level. J Dent Res 2003;82:361–6. 9. Cruz GD, Shore R, Le Geros RZ, Tavares M. Effect of acculturation on objective measures of oral health in Haitian immigrants in New York city. J Dent Res 2004;83:180–4. 10. Paulander J, Axelsson P, Lindhe J. Association between level of education and oral health status in 35-, 50-, 65- and 75year-olds. J Clin Periodontol 2003;30:697–704. 11. Kassak KM, Dagher R, Doughan B. Oral hygiene and lifestyle correlates among new undergraduate university students in Lebanon. J Am Coll Health 2001;50:15–20. 12. Esa R, Razak IA, Jallaudin RL, Jaafar N. A survey on oral hygiene practices among Malaysian adults. Clin Prev Dent 1992;14:23–7. 13. Farsi JMA, Farghaly MM, Farsi N. Oral health knowledge, attitude and behaviour among Saudi school students in Jeddah city. J Dent 2004;32:47–53. 14. Freire MCM, Sheiham A, Hardy R. Adolescents’ sense of coherence, oral health status, and oral health-related behaviours. Commun Dent Oral Epidemiol 2001;29:204–12.
˘lu, U.S. Yavuz T. Kırtılog 15. Kuusela S, Honkala E, Kannas L, Tynjala J, Wold B. Oral hygiene habits of 11-year-old schoolchildren in 22 European countries and Canada in 1993/1994. J Dent Res 1997;76: 1602–9. 16. Astrøm AN, Samdal O. Time trends in oral health behaviors among Norwegian adolescents 1985–97. Acta Odontol Scand 2001;59:193–200. 17. Stenberg P, Hakansson J, Akerman S. Attitudes to dental health and care among 20 to 25-year-old Swedes: results from a questionnaire. Acta Odontol Scand 2000;58:102–6. 18. Tada A, Hanada N. Sexual differences in oral health behaviour and factors associated with oral health behaviour in Japanese young adults. Public Health 2004;118:104–9. 19. Rimondini L, Zolfanelli B, Bernardi F, Bez C. Self-preventive oral behavior in an Italian University student population. J Clin Periodontol 2001;28:207–11. ¨ lmez S, Uzamıs- M, Erdem G. Association between early 20. O childhood caries and clinical, microbiological, oral hygiene and dietary variables in rural Turkish children. Turk J Pediatr 2003;45:231–6. 21. Kulak-Ozkan Y, Ozkan Y, Kazazoglu E, Arikan A. Dental caries prevalence, tooth brushing and periodontal status in 150 young people in Istanbul: a pilot study. Int Dent J 2001;51: 451–6. 22. Davies RM, Davies GM, Ellwood RP, Kay EJ. Prevention. Part 4: Toothbrushing: what advice should be given to patients? Br Dent J 2003;195:135–41. 23. Brothwell DJ, Jutai DK, Hawkins RJ. An update of mechanical oral hygiene practices: evidence-based recommendations for disease prevention. J Can Dent Assoc 1998;64: 295–306. 24. Astrøm AN, Rise J. Socio-economic differences in patterns of health and oral health behaviour in 25 year old Norwegians. Clinil Oral Invest 2001;5:122–8. 25. Al-Hussainia R, Al-Kandaria M, Hamadia T, Al-Mutawaa A, Honkalab S, Memona A. Dental health knowledge, attitudes and behaviour among students at the Kuwait University Health Sciences Centre. Med Prin Pract 2003;12:260–5. 26. Al-Ansari J, Honkala E, Honkala S. Oral health knowledge and behavior among male health sciences college students in Kuwait. BMC Oral Health 2003 [WWW document]. URL http://www.biomedcentral.com/1472-6831/3/2 27. Bradnock G, White DA, Nuttall NM, Morris AJ, Treasure ET, Pine CM. Dental attitudes and behaviours in 1998 and implications for the future. Br Dental J 2001;190:228–32. 28. Tan E, Daly C. Comparison of new and 3-month-old toothbrushes in plaque removal. J Clin Periodontol 2002;29: 645–50. 29. Sforza NM, Rimondini L, di Menna F, Camorali C. Plaque removal by worn toothbrush. J Clin Periodontol 2000;27: 212–6. 30. Kawamura M, Iwamoto Y, Wright FA. A comparison of selfreported dental health attitudes and behavior between selected Japanese and Australian students. J Dent Educ 1997;61:354–60. 31. Kawamura M, Honkala E, Widstrom E, Komabayashi T. Crosscultural differences of self-reported oral health behaviour in Japanese and Finnish dental students. Int Dent J 2000; 50:46–50. 32. Kawamura M, Yip HK, Hu DY, Komabayashi T. A cross-cultural comparison of dental health attitudes and behaviour among freshman dental students in Japan, Hong Kong and West China. Int Dent J 2001;51:159–63. 33. Kawamura M, Ikeda-Nakaoka Y, Sasahara H. An assessment of oral self-care level among Japanese dental hygiene students and general nursing students using the Hiroshima
ARTICLE IN PRESS Assessment of oral self-care University—Dental Behavioural Inventory (HU-DBI): Surveys in 1990/1999. Eur J Dent Educ 2000;4:82–8. 34. Luciak-Donsberger C. Origins and benefits of dental hygiene practice in Europe. Int J Dent Hyg 2003;1: 29–42. 35. Luis HS, Riberio S, Albuquerque T. The dental hygiene program in Portugal. Int J Dent Hyg 2003;1:223–6. 36. Yoshida N, Endo K, Komaki M. Dental hygiene education in Japan: present status and future directions. Int J Dent Hyg 2004;2:179–84.
957 37. Ylo ¨stalo P, Ek E, Knuuttila M. Coping and optimism in relation to dental health behaviour—a study among Finnish young adults. Eur J Oral Sci 2003;111:477–82. 38. Astrøm AN. Stability of oral health-related behaviour in a Norwegian cohort between the ages of 15 and 23 years. Communi Dent Oral Epidemiol 2004;32:354–62. ¨ nem E, Dinc- er S, Yilmaz T. Factors of 39. Gu ¨rdal P, C - ankaya H, O patient satisfaction/ dissatisfaction in a dental faculty outpatient clinic in Turkey. Communi Dent Oral Epidemiol 2000;28:461–9.