Unacceptable status of oral and dental health-related

knowledge among Iranian primary school students

Ghaffari Mohtasham

, Nasirzadeh Mostafa*

, Rakhshanderou Sakineh

and

Ramezankhani Ali

1Associate Professor, Department of Public Health, School of Public Health, Shahid Beheshti University of

Medical Sciences, Tehran, Iran

2Ph.D Candidate in Health Education and Health Promotion, Assistant Professor, Department of Public

Health, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3Assistant Professor, Department of Public Health, School of Public Health, Shahid Beheshti University of

Medical Sciences, Tehran, Iran

4Professor, Department of Public Health, School of Public Health, Shahid Beheshti University of Medical

Sciences, Tehran, Iran

ABSTRACT

Oral health as one of the health Criteria of people plays key role in general health. For improvement of oral health, it is necessary

to measure the knowledge level. This study has investigated the Oral health- related knowledge among Rafsanjan City Primary

Schools’ Students. The present descriptive-analytical study has been conducted on 429 primary students (second grade) in Rafsan-

jan, Iran. Samples are selected using random cluster sampling. Data collection method is the researchers’ questionnaire containing

24 items and that validity and reliability was respectively obtained through using opinions of experts and content validity and

test-retest method and extraction of Cronbach’s alpha. After collecting the data, the data are analyzed using SPSS-21 software

using independent t-test, one-way ANOVA and Pearson correlation at the signi cance level of 0.05.Mean score of knowledge of

students is 10.24±3.1 of 24 and 69% of students had knowledge in average level. The most important weakness points included

knowledge of students about mental, psychological and social complications of inadequate oral and dental health. Signi cant

correlation was between knowledge and education of parents and description of oral and dental health status of students excel-

lently and the variable of reporting regular brushing status.Making behavior needs increasing knowledge and changing attitude

in people. Despite to the advancements and communicative technologies, knowledge level of students is in undesirable, low and

unacceptable level. Hence, it would be better to arrange and announce required policy making to design intervention plans.

KEY WORDS: ORAL AND DENTAL HEALTH, KNOWLEDGE, STUDENTS

260

ARTICLE INFORMATION:

*Corresponding Author: mnasirzadeh13@yahoo.com

Received 27

Dec, 2016

Accepted after revision 2

March, 2017

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2017: 4.31 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

Biosci. Biotech. Res. Comm. Special Issue No 1:260-266 (2017)

Ghaffari Mohtasham et al.

INTRODUCTION

Oral and dental health is one of the main health criteria

of the society and plays key role in general health and

quality of life of people and can affect overall public

health (1, 2). In most countries of the world, spread of

oral and dental diseases like Oral Cancer is reported 1-10

cases per 100 thousand people and tooth decay is also

the most common disease across the world and about

100% of adults suffer from it. Moreover, spread of the

disease is reported to 60-90% among school children,

(Daly and Batchelor 2012, WHO 2012, Nurelhuda et al

2009)

Oral and dental diseases like decay and periodontitis,

similar to systemic diseases, have chronic process and

similar behavioral features and multifactorial nature (4).

Urbanization, industrial and mechanized life, change in

nutrition style and poor eating habits, smoking, tobacco

and alcohol are the main factors causing increase in

tooth decay and gum disease. Other factors affecting

oral and dental diseases include change in lifestyle, lim-

ited children’s access to oral care services, social sta-

tus, knowledge, personality and attention to their own

health, poor diet such as eating too much sugar and gen-

erally, no observance of oral and dental hygiene (lack

of brushing and no  ossing. In general, 4 main factors

creating decay include germs, sugar, teeth resistance and

time, (Maltz et al., 2010,Liu et al., 2009 Antonio et al.,

2007, Al Subait et al., 2016, Çolako

glu and Has 2015

Castilho et al., 2015).

Oral and dental diseases can result in various compli-

cations including chewing food disorders, gastrointesti-

nal problems, bad breath, major social problems, cancer

and oral carcinomas and reduced life expectancy, speech

problems, mental disorders, in ammation of the gums,

tooth irregularity, low self-esteem, poor quality of life,

impaired nutritional status, reducing the growth of chil-

dren, the loss of more than 50 million hours of school

curriculum (10-15).

Torabi et al., 2009, Zeidi et al., 2013, Morowatishari-

fabad et al., 2011, Rahimi et al., 2011) Feldens et al., 207

and Peterson et al., 2008).

The most important strategies of WHO to prevent the

problems and to improve oral and dental health include

reducing load of unacceptable oral and dental health-

related disorders, promoting healthy lifestyles and

reducing risk factors (environmental, economic, social

and behavioral), development of health service provider

systems and arrangement of policies to promote oral and

dental health, WHO (2015).

The only effective and ef cient strategy to solve

problems related to oral and dental health is prevention

and various collections of activities in individual, job

and social level WHO (2015).

For effective improvement of oral and dental health-

related behaviors and planning in this  eld, people

should have complete and comprehensive information

about factors affecting decision making, assessment

of nutrition status, measurement of public knowledge,

evaluation of health status and information, size of

tooth decays, assessing the status of self-case behaviors,

brushing and  ossing, (Pakpour et al 2011 Pishva and

Asefzadeh 2010).

One of the most important and also initial steps in

 eld of the process of changing behavior is assessing

knowledge in this  eld and such knowledge can pave

the way for formation of attitude and improvement of

behavior. Studies have reported high level of knowledge

of children in  eld of oral and dental health. Gao et

al (2014) has reported the amount of spread of tooth

decay among 12-15 years old children to 24% and has

also reported knowledge of students in undesirable level

and has reported no signi cant correlation between the

two variables. The status of this index is also reported

in undesirable level in Iranian children (Moeini et al.,

2013). For example, Moeini et al (2013) have studied the

knowledge level of primary students of Sanandaj to 8.5

of 20 and in undesirable level and have claimed that it

can pave the way for formation of other attitude vari-

ables such as sensitivity and perceived intensity. But

most of these studies have not analyzed the weaknesses

of children’s knowledge.

Children and adolescents are the large capital sources

and the most valuable resources of a society and the

more the society tries to save the resources, the society

can be more successful and healthy in future. Therefore,

according to role of knowledge in formation of behav-

ior, this study has been conducted with the purpose of

determining the knowledge level of students as one of

the determinants of behavior and Analysis of strengths

and weaknesses in  eld of oral and dental health.

MATERIALS AND METHODS

The descriptive-analytical study has been conducted on

429 primary students of second period (fourth,  fth and

sixth grade) in Rafsanjan (6 schools; 3 for girls and 3

for boys). Sampling is done using cluster sampling and

classes in each school are selected randomly. Data col-

lection instrument is formed of 2 parts of demographic

questions (9 questions) and researchers’ questionnaire

(using review of studies and scienti c references). Valid-

ity of the questionnaire was measured based on opinion

of 10 experts and adjustment of the results with Lavs-

heh table using test-retest approach among 57 students

and the Cronbach’s alpha was obtained to 0.74. Number

of questions in second part on measuring knowledge

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS UNACCEPTABLE STATUS OF ORAL AND DENTAL HEALTH-RELATED KNOWLEDGE 261

Ghaffari Mohtasham et al.

FIGURE 1. Frequency distribution of the state of

knowledge

of students includes 24 items, in which 11 questions

are 3-option for (true, false and I do not know) and 13

questions are 4-option items with self-report answering

method and with score range of (0-24). The true answers

were scored with point 1, false and I do not know answer

were scored with point 0. The inclusion criterion in this

study was the consent of participants and exclusion cri-

terion was incomplete responding to the questions. The

data processing and analysis was done using SPSS-21

software and using independent t-test, one-way ANOVA

and Pearson Correlation at the signi cance level of 0.05.

In terms of ethical considerations in this study, one can

refer to being ensured of secrecy and privacy of infor-

mation and anonymity of questionnaires, presenting the

results to the relevant parties, preservation of material

and spiritual rights of research team and considering the

contrast of interests of research team members.

RESULTS

The number of participants was 429 students (179 girls

and 250 boys). Education level of about one third of par-

ents was diploma and about 40% of fathers had free jobs

and 65.7% of mothers were housekeeper. About 17% of

participants reported excellent level of oral and dental

health and 45% reported that they brush their teeth reg-

ularly. The highest level of knowledge was reported in

student in sixth grade and the difference between classes

was signi cant (p<0.001) (table 1). Mean score knowl-

edge of students was 10.24±3.1 of 24 and only Less than

2% of students had desirable and acceptable knowl-

edge level ( gure 1). Mean score of knowledge level

was equal to 11±2.9 for girls and to 9.6±3.2 for boys

and the difference between two groups was signi cant

(p<0.001). In this study, no signi cant correlation was

observed between mean score of knowledge level of stu-

dents with age and parent’s job (P>0.05). However, there

was signi cant correlation between higher education

(academic education) of parents and description of oral

and dental health status and report of regular brushing

(P<0.01). Educational needs based on analysis of items

in the questionnaire are reported in table 1. As it is clear,

3 preferred educational needs of students are in  eld

of knowledge in  eld of beginning time of observing

Table 1. Distribution of demographic characteristics of students and its relationship with knowledge

Variable

variable modes P- Value

Illiterate Elementary Guidance Diploma Academic

P=0.03

Number

(Percent)

Number

(Percent)

Number

(Percent)

Number

(Percent)

Number

(Percent)

Father’s education 6 (1.6) 26 (7) 67 (18.2) 155 (42) 115 (31.2)

P=0.001

Mother’s education 2 (0.5) 41 (11) 59 (15.9) 149 (40.1) 131 (32.5)

Father’s job Unemployed Worker Employee Self-employed Retired

P=0.1

8 (1.9) 59 (14.1) 160 (38.5) 173 (41.6) 16 (3.8)

Mother’s job Housewife Employed

P=0.08

282 (65.9) 146 (34.1)

Describe the state of oral

health

Excellent Very good Good Average Weak

P<0.001

75 (17.7) 90 (21.2) 156 (36.8) 88 (20.8) 15 (3.5)

Describe the brushing Never Rarely Sometimes Regularly & Always

P=0.002

13 (3) 30 (7) 189 (44.1) 197 (945.9)

Grade Fourth (M±D) Fifth (M±D) Sixth (M±D)

P<0.001

9.5±3 10.5±3.2 11.03±3.06

262 UNACCEPTABLE STATUS OF ORAL AND DENTAL HEALTH-RELATED KNOWLEDGE BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Ghaffari Mohtasham et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS UNACCEPTABLE STATUS OF ORAL AND DENTAL HEALTH-RELATED KNOWLEDGE 263

Table 2. check the status of responding to awareness questions and education priorities

questions Correct answers Incorrect answers Educational

priority

Number Percent Number Percent

the time of beginning observance of oral and dental hygiene 26 6.1 403 93.9 1

Mental complications of tooth decay (being ashamed, etc.) 49 11.4 380 88.6 2

right time to change the brush 60 14 369 86 3

right time to appoint a dentist for examination 89 20.7 340 79.3 4

least times of using  oss per day 91 21.2 338 78.8 5

minimum brushing time 99 23.1 330 76.9 6

time of using mouthwash in children 106 24.7 323 75.3 7

type of teeth and their effect on decay 112 26.1 317 73.9 8

dental sensitivity to heat and cold (a sign of decay) 113 26.3 316 73.7 9

brushing style of outer surface of upper teeth 117 27.3 312 72.7 10

toothache or bleeding while brushing (a sign of decay) 151 35.2 278 64.8 11

task of teeth in speaking 181 42.2 248 57.8 12

the amount of using toothpaste in children 185 43.1 244 56.9 13

the time that food residuals remain on tooth and its effect on

decay

205 47.8 224 52.2 14

frequency of brushing behavior in day and night 222 51.7 207 48.3 15

the best way to clean the space between teeth 237 55.2 192 44.8 16

physical complications of decay (bad breath, etc.) 250 58.3 179 41.7 17

germs and their impact on decay 272 63.4 157 36.6 18

sugar and its impact on decay 281 65.5 148 34.5 19

task of teeth in protecting face beauty 286 66.7 143 33.3 20

brown and black spots on tooth (a sign of decay) 292 68.1 137 31.9 21

right times of brushing 295 68.8 134 31.2 22

task of teeth in chewing food 297 69.2 132 30.8 23

the time of beginning observance of oral and dental hygiene 377 87.9 52 12.1 24

oral and dental hygiene, mental complications of tooth

decay and the right time to change the brush.

DISCUSSION

Undoubtedly, to arrange interventions and educational

plans, comprehensive recognition of determinants of the

behavior is required, so that the arranged planning and

intervention could have the highest effect and result.

One of the most important and initial steps in  eld of

process of changing behavior is measurement of knowl-

edge of individuals in  eld of the studied issue. In this

study, mean value of total knowledge level of students

is obtained to 10.24±3.1 of 24 and majority had unac-

ceptable knowledge level. In other studies, knowledge

level of students was reported in weak level (Paula et

al., 2013). In a study conducted by Haleem et al (2013),

mean score of knowledge level of 10-12 years old stu-

dents in  eld of oral and dental health was reported to

2.5 from12.

About 95% of students in this study reported that the

beginning time of oral and dental health behaviors was

from eruption time. It is necessary to provide required

information for them and their families in  eld of obser-

vance of oral and dental health before eruption time.

Majority of the students were aware of physical com-

plications of lack of observing oral hygiene; although

majority of them were unaware of mental and psycho-

logical complications and social complications like self-

con dence, being ashamed and losing friends. This issue

is one of the most important issues to make children

sensitive and pave the way for them to begin oral health

behaviors, since having information about outcomes of

a phenomenon can lead to formation of attitudes and

encouraging children to take health behaviors. In the

study of Haleem A, it was reported that children have

unacceptable knowledge in  eld of complications of no

observance of oral and dental health Haleem et al (2013).

Therefore, it is suggested to planners and designers of

intervention plans to consider this issue seriously, so

that the sensitivity of perceived intensity is formed in

Ghaffari Mohtasham et al.

264 UNACCEPTABLE STATUS OF ORAL AND DENTAL HEALTH-RELATED KNOWLEDGE BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

children to take healthy, rapid and sustainable behav-

iors. In this study, the students had acceptable knowl-

edge level about functions of teeth; although more than

half of them were unaware of tasks of teeth and their

role in speaking. Their knowledge in this  eld can pave

the way to encourage them to take preventive behaviors.

Another issue to encourage children to take preven-

tive behaviors is having knowledge about the factors

creating tooth decay. According to report of WHO, 4

factors including sugar, germs, resistance and time (the

time that food remains in mouth) can affect teeth decay.

The knowledge of students about effects of sugar and

germs on decay was acceptable; although it was unac-

ceptable in  eld of effect of type and resistance of teeth

and time. Knowledge of children about the philosophy

of teeth decay and role of important variable like time

and the time that food remains on teeth can be one of

the most effective factors in brushing behavior and these

results are in consistence with  ndings of Gao et al.

(2014) reported signi cantly unacceptable knowledge of

12-15 years old children in  eld of spread of teeth decay

and reported the value about 24% for it and mentioned

that this variable is one of the most effective variables in

decay and dental diseases.

In this study, variables such as brown and black and

white spots on teeth and dental sensitivity to heat and

cold, gum bleeding and perforated teeth are investigated

that are counted as signs of teeth decay in other studies

(Herendon et al., 2010). The knowledge of majority of

students about these signs was poor. However, aware-

ness of signs of decay and examination of these signs

by the person can be the most important factor encour-

aging in  eld of formation of beliefs and intention of

behavior and pave the way for seriously formation of

preventive behaviors and urgent referral to dentist to get

preventive services in secondary level. In other studies,

insuf cient knowledge of children about signs of teeth

decay is reported.

Al-Darwish (2016) has reported in a study that only

25% of 12-14 year old students in Qatar have accept-

able knowledge level in  eld of oral and dental health.

The students have poor knowledge about variables such

as decay signs, regular appointment of dentist with the

purpose of care and examination, role of  uoride and

consumption of sweet drinks and foods and plaque. Only

3.7% of children brush their teeth regularly after eat-

ing food and this has been in direct correlation with

formation of brushing behavior Al-Darwish (2016). The

suggestion here is to provide required empowerments to

introduce the signs of teeth decay to children, so that

self-care and control behaviors are facilitated.

Another weakness in  eld of knowledge of children is

being unaware of information of a well-designed brush,

time of changing it, role and effect of toothpaste and

 ossing on improvement of oral and dental health, refer-

ring to dentist for regular examinations. As formation

of behavior was growing and promotion of knowledge

level is at the beginning of this process, it seems nec-

essary to arrange and implement comprehensive plans

by health authorities like school-oriented interventions

and family-oriented intervention’s in  eld of increasing

knowledge of students.

In this study, girls had higher knowledge and aware-

ness than boys and this was proved in the study con-

ducted by Al-Subait et al (2015). The reasons for this

issue could be more sensitivity of girls to health issues,

especially oral and dental health. Moreover, signi cant

correlation was observed between knowledge level of

students and some demographic variables such as edu-

cation level of parents and beliefs and wrong descrip-

tions of oral and dental health and the result has been

in consistence with  ndings of other studies (Anne

et al., 2016).

In a study conducted by Nurdan and Ethem (2015),

social-demographic variables had direct and signi cant

effect on oral and dental health. In the study, the status

of germ plaque was signi cantly correlated to the moth-

er’s job, family income, insurance status, family mem-

bers, number of children, educational level of mother,

caregiver, supervision of parents on oral health of chil-

dren and regular appointment of dentist and brushing

behavior in parents. In the study conducted by Alin-

Rogeria et al (2013), variables such as parent’s behav-

iors, parent’s positive attitude, supervision and control

of parents on health behaviors of children are reported.

Hence, it is suggested to consider the family as the main

and the  rst center for education of children.

LIMITATIONS OF THE STUDY

The limitations with the present study include the way

of answering questions (self-report) and the strengths

in this study include partial consideration of the issue

of knowledge and its orientations in  eld of oral and

dental health, which can be helpful for the interventions.

CONCLUSION

Taking behavior needs improving knowledge and infor-

mation and changing attitudes of people towards each

 eld and issue. The results obtained from this study

showed that despite to advancement of modern tech-

nologies and increased amount of communications, still

some issues such as oral and dental health and aware-

ness of the causes and complications of teeth decay,

Ghaffari Mohtasham et al.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS UNACCEPTABLE STATUS OF ORAL AND DENTAL HEALTH-RELATED KNOWLEDGE 265

decay signs and preventive behaviors are in unaccepta-

ble and undesirable level and this can be the main rea-

son for lack of achievement to desirable indices among

students. Designing, implementing and valuating the

health interventions and promotion of health in  eld of

oral and dental health is suggested to improve knowl-

edge and improve relevant behaviors.

ACKNOWLEDGMENTS

At the end, the author would like to appreciate authori-

ties in Shahid Beheshti University of Medical Sciences

Tehran and Rafsanjan, the Education and Training Min-

istry of Rafsanjan, managers of schools and the students

who helped implementation of this research project

under the code 8555 in Shahid Beheshti University of

medical Sciences extracted from Ph.D thesis.

CONFLICT OF INTEREST

There is no con ict of interest.

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