International Journal of Enhanced Research in Medicines & Dental Care (IJERMDC),

ISSN: 2349-1590, Vol. 6 Issue 1, January-2019, Impact Factor: 3.015

Dental Health Knowledge, Attitude, and

Behaviors regarding Oral Hygiene Status among
University Students at Mosul City
Enas A. AL-Raash1, Aisha A. Qasim2
1
B.D.S, Master Student, Ministry of Health, Mosul, Iraq
2
Assist. Prof. College of Dentistry, University of Mosul, Mosul, Iraq

ABSTRACT

Aims: The aim of the present study was to assess self-reported oral health knowledge, attitudes and behavior between
the sample groups of first and final college students in Mosul and to evaluate the impact of academic stage on their
knowledge, attitudes, behavior and oral health status.
Materials and Methods: The study was conducted on samples of (880) college students from University of Mosul,
Iraq, which divided into four groups: Medical college students (240), Dental collegestudents (236), Economic
collegestudents (197) and Education collegestudents (207). Demographic information was obtained for each student,
Dental caries status was evaluated using the World Health Organization (WHO) caries diagnostic criteria for decayed,
missing, and filled teeth and surfaces (DMFT and DMFS), respectively. The plaque index (Silness and Loe) was used
to assess dental plaque, gingival index system (Loe and Silness) was used to assess gingival inflammation, Ramfjord
periodontal disease index-calculus component was used to assess calculus. The respondents’ specific oral health-related
knowledge behavior and attitudes were measured using modified Arabic version Hiroshima University Dental Behavior
Inventory (HU-DBI), developed by Kawamura. The data were analyzed using the SPSS version 19 using Descriptive
Statistics and Student’s t-test.
Results: In general, current study concluded that for Medical and Dental college's studentsfor both first and final stages
filling contributed the major part of DMFT and DMFS for first stage filling followed by decay and last missing teeth.
While for final stage filling followed by missing then decay, but for Education college students, decay contributed the
major part of DMFT and DMFS value, in first stage missing came next followed by filling,forEconomic college
students, missing contributed the major part of DMFT and DMFS values, in first and final stages decay came next
followed by filling. For four college student’s forPI, GI and CALI indices the higher value was observed among first
stage compared to final stage. On the other hand, in all the collegesHU-DBI the higher value was observed among final
stage compared to first stage except the students of Economics college.
Conclusions: With increasing years of the study,some aspects of college student’s oral health Knowledge, attitude and
behavior in addition to oral health status was improved or worsen. On the other hand, some aspects of dental
studentswere improved but this improvement was limited.
Key words: Oral health knowledge, Behavior, Attitudes, College students, HU-DBI, Mosul.

INTRODUCTION

The mouth is the major gateway to the body; whatever affects oral health may also affect general health [1]. The oral
health status of a person is usually determined by the presence or absence of dental caries and periodontal disease as
well as the level of oral hygiene found in the population [2].

Dental caries is still considered one of the most prevalent oral diseases in the world [3], it results from interactions
between acid producing bacteria, fermentable carbohydrates (sugars) capable of being metabolized by the bacteria [4].
But periodontal diseases can be defined as a wide spectrum of diseases that affect the gum and the surrounding
structures of the teeth [5,6].

On the other hand, oral health is an essential aspect of general health, as such, oral health knowledgeis considered to be
an essential prerequisite for health related practice [7] the oral health care of an individual depends on his or her oral
healthattitude and behavior [8].

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Knowledge means that the individual has all data necessary to understand what oral disease is and how it arises, as well
as to understand the protective measures that need to be adopted. This knowledge will, in theory, lead to a change in
attitude, which will in turn lead the individual to make changes in their daily life [9].

Attitude is an acquired characteristic of an individual. People demonstrate a wide variety of attitudes towards teeth,
dental care and dentists [10]. Health behavior is the human action taken to maintain and enhance health. It also helps to
prevent diseases [10,11].

College life is a crucial period of transition with personal responsibility. Students in this period can be targeted for
preventing dental disease and building future oral health [12]. College students are not different from others in their age
group. They are risk takers. They no longer have parents in their immediate presence to remind them to brush their
teeth [13].In many countries, university students play a significant role in public life, eventually becoming future leaders
[14]
.

Knowledge is usually obtained from information which subsequently translates intoan action.Attitudes toward oral
health determine the condition of the oral cavity[15]. Students of medical sciences should possess high level of
awarenessof self-oral health care, so that this attitude can be instilled amongpatients and community at large [16].

Since knowledge and awareness are associated with oral hygiene habits and health, it is important that dental students
have positive attitudes towards preventive dentistry [17] than other college students.

Comparison between different academic years the differencein the attitude, behavior and oral hygiene status
betweendifferent academic years were statically significant 3rdyeardental students shown to have better behavior
level ascompared to other academic years. Difference was notsignificant between other academic years [18].
Other studies confirmed that dental health attitudes become more positive with increasing age and education level [14,19-
21]
.

The aim of the present study was to assess self-reported oral health knowledge, attitudes and behavior between the
sample groups of first and final college students in Mosul using the Hiroshima University Dental Behavioral Inventory
(HU-DBI), and to evaluate the impact of academic stage on their knowledge, attitudes, behavior and oral health status.

MATERIAL AND METHODS

This study was conducted during the 2017-2018academic year, it was consisted of a cross-sectional survey of two
medical (Dental and Medical) and two non-medical (Economic and Education) college students attending University of
Mosul - Iraqi.

The study was conducted on sample of (880) college students, which divided into four groups:Medical collegestudents
(240),Dental collegestudents (236) , Economy collegestudents (197) and Education collegestudents (207).Demographic
information was obtained for each student;caries prevalence and severity were analyzed using the DMFT and DMFS
index. DMFT and DMFS index calculated according to WHO criteria for diagnosis and recording of dental caries.The
plaque index [22]was used to assess dental plaque,gingival index system [23]was used to assess gingival inflammation,
Ramfjord periodontal disease index- calculus component [24] was used to assess calculus.

The respondents’ specific oral health-related knowledge behavior and attitudes were measured using Hiroshima
University Dental Behavior Inventory (HU-DBI), developed by [25]which is a questionnaire to understand patients’
perception of oral health.In current study, used the Arabic version of the modified HU-DBI, which was also used in
previous studies. [26,27]Statistical analysis was performed with the help of SPSS version 19 using Descriptive Statistics ,
Student’s t-test .

RESULTS

This research include a total of (880)subjects whose participate in this study from four colleges (College of Dentistry
236students which represent 26.81% , College of Medicine 240 students which represent 27.27% , College of
Administration and Economics 197 student which represent 22.38% andCollege of Education 207 students which
represent23.5% , as shown in (Table 1)
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Table (1) Number and percentage for distribution of the subjects by academic stage, gender and collages

Medicin Educatio
stage sex Dental Economic
% e % % n %
M 17 % 1.93 13 % 1.07 41 % 4.65 48 % 5.05
1
F 36 % 4.09 29 % 3.29 24 % 2.72 12 % 1.36
M 23 % 2.61 30 % 3.40 29 % 3.29 41 % 4.65
2
F 27 % 3.06 26 % 2.95 11 % 1.25 18 % 2.04
M 23 % 2.61 25 % 2.84 34 % 3.86 9 % 1.02
3
F 36 % 4.09 31 % 3.52 9 % 1.02 33 % 3.75
M 13 % 1.07 17 % 1.93 35 % 3.97 20 % 2.27
4
F 36 % 4.09 19 % 2.15 13 % 1.07 26 % 2.95
M 8 % 0.909 18 % 2.04
5
F 17 % 1.93 31 % 3.52
% 26.81 27.27 22.38 % 23.5
Total 236 240 197 207
% %

(Table 2) illustrates the mean value of the total DMFT, DMFS and by fractions in addition to plaque index, gingival
index, calculus index and HU-DBI in the Dental college students.

For both first and final stages filling contributed the major part of DMFT and DMFS value. For first stage filling
followed by decay and last missing teeth. While for final stage filling followed by missing then decay

The mean value for filling showed higher value in first stage = 3.1509 in comparison with final stage =2.7600 and the
difference were statically significant (p ≤ 0.05).

The mean value of plaque (PI first = 0.2592 and PI final = 0.0833), Gingival (GI first = 0.2264 and GI final =0.1600),
Calculus (CALI first = 0.1711 and final =0.0333) and (HU-DBI first = 5.1321and HU-DBI final =5.8000) were shown,
for both PI and GI indices, the higher value was observed among first stage in comparison to finalstage.
Statically, a highly significant difference was observed in CALI indices (p ≤ 0.01).
HU-DBI was higher in final stage but not significant (P≥0.05).

Table (2) Distribution of subjects according to academic years for Dental college students.

Variable No. Mean Std. Deviation T-value P-value

First 53 2.5600 2.14112 2.12 0.979
D
Final 25 1.3200 2.91147
First 53 1.6981 3.79060 0.20 0.905
M
Final 25 1.6800 3.37540
First 53 3.1509 4.13892 0.42 0.044*
F
Final 25 2.7600 2.96198
First 53 5.3019 3.33735 1.56 0.322
DMFT
Final 25 4.0400 3.28481
First 53 7.3962 5.99468 1.20 0.322
DMFS
Final 25 5.7600 4.58512
First 53 0.2592 0.44734 1.86 0.719
PI
Final 25 0.0833 0.21649
First 53 0.2264 0.41065 0.71 0.648
GI
Final 25 0.1600 0.44622
First 53 0.1711 0.28460 2.35 0.003**
CALI
Final 25 0.0333 0.09616
HU- First 53 5.1321 1.78711 1.53 0.870
DBI Final 25 5.8000 1.82574
**p≤0.01 highly significant and *P≤0.05; statistical significant difference
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(Table 3) illustrates the mean value of the total DMFT, DMFS and by fractions in addition to plaque index, gingival
index, calculus index and HU-DBI for the Medical college students. For both first and final stages filling contributed
the major part of DMFT and DMFS value flowed by decay and last missing teeth.The mean value for filling shows
higher value in first stage= 2.7381 in comparison with final stage= 2.5000 and the difference were statically significant
(p≤0.05).

The mean value of plaque (PI),Gingival (GI),Calculus (CALI) and HU-DBI were shown, for PI index, the higher value
was observed among first stage =0.1386 compared with final stage = 0.1141. Statically, asignificant difference was
observed in GI at (p ≤ 0.05) and CALI indices at (p ≤ 0.01).HU-DBI was higher in final stage = 1.71857 but not
significant (P≥0.05).

Table (3) Distribution of subjects according to academic years for Medical college students.

T-Value P-value
Variable
No. Mean Std. Deviation
First 42 2.0000 3.43582 0.38 0.218
D
Final 50 2.2200 2.03329

First 42 0.4762 1.85101 0.31 0.561

M
Final 50 0.6000 1.92725

First 42 2.7381 4.52667 0.32 0.045*

F
Final 50 2.5000 2.47642

First 42 3.8810 2.87294 1.178 0.474

DMFT
Final 50 4.5000 2.15946

First 42 5.2143 5.24770 0.02 0.138

DMFS
Final 50 5.2400 3.55459

First 42 0.1386 0.23349 0.60 0.159

PI
Final 50 0.1141 0.15566

First 42 0.2251 0.36863 1.32 0.011*

GI
Final 50 0.1416 0.23036

First 42 0.1358 0.27767 1.33 0.002**

CALI
Final 50 0.0782 0.11466

First 42 4.5238 1.54979 0.91 0.853

HU-DBI
Final 50 4.8400 1.71857

**p≤0.01 highly significant and *P≤0.05; statistical significant difference

(Table 4) illustrates the mean value of the total DMFT, DMFS and by fractions in addition to plaque index, gingival
index, calculus index and HU-DBI in the Education college students.For both first and final stage decay contributed the
major part of DMFT and DMFS value, in first stage missing =2.0000 came next followed by filling =1.7231but in final
stage it opposite filling = 2.1458 higher than missing = 1.7708.

The mean value for decay showed higher value in first stage = 4.7077 in comparison with final stage = 3.4167 and the
difference were statically non-significant (p ≥ 0.05). The mean value of plaque (PI),Gingival (GI),Calculus (CALI) and
HU-DBI were shown, for PI index, slightly higher value was observed among first stage = 0.3160 compared with final
stage = 0.3158. Statically, no significant difference was observed in GI, PI, HU-DBI and CALI indices.

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Table (4) Distribution of subjects according to academic years of study for Education college students.

Variable N Mean Std. Deviation T-Value P-value

First 65 4.7077 4.24162 1.61 0.495
D
Final 48 3.4167 4.14541

First 65 2.0000 5.71456 0.25 0.444

M
Final 48 1.7708 3.17731

First 65 1.7231 2.29475 0.82 0.015*

F
Final 48 2.1458 3.12838

First 65 5.5846 2.56717 1.77 0.142

DMFT
Final 48 4.6250 3.17319

First 65 8.4308 6.91911 0.78 0.796

DMFS
Final 48 7.4583 5.82350

First 65 0.3160 0.42116 0.002 0.315

PI
Final 48 0.3158 0.35544

First 65 0.5102 0.54866 0.99 0.066

GI
Final 48 0.4113 0.47913

First 65 0.1619 0.23181 0.37 0.314

CALI
Final 48 0.1777 0.20378

First 65 4.5077 1.65947 0.76 0.777

HU-DBI
Final 48 4.7500 1.68220

*P≤0.05; statistical significant difference.

(Table 5) illustrates the mean value of the total DMFT, DMFS and by fractions in addition to plaque index, gingival
index, calculus index and HU-DBI for the Economic college students.

For both first and final stages missing contributed the major part of DMFT and DMFS value. In first and final stages
decay came next followed by filling.

The mean value for decay in first stage = 3.0167 while final stage decay =2.0213 and the difference were statically
significant at (p ≤0.05). Also missing = 3.8333 show higher value in first stage in comparison with final stage missing
= 2.0213 and the difference were statically significant at (p ≤0.01).

According to this study the mean value of PI,GI, CALI indices and HU-DBI have higher value among first stage =
4.8167 compared to final stage = 4.3830. Statically no significant difference was observed in GI, PI, HU-DBI and
CALI indices.

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Table (5) Distribution of subjects according to academic years of study for Economic college students.

Variabl T-Value P-value

e No. Mean Std. Deviation
First 60 3.0167 2.99995 1.91 0.038*
D
Final 47 2.0213 2.19178
First 60 3.8333 6.40224 1.77 0.001**
M
Final 47 2.0213 3.24030
First 60 1.1833 2.31056 0.99 0.183
F
Final 47 1.6809 2.85981
First 60 4.8000 4.25779 1.70 0.283
DMFT
Final 47 3.5532 3.00585
First 60 7.4833 6.36061 1.49 0.314
DMFS
Final 47 5.7234 5.61327
First 60 0.3492 0.37796 2.29 0.218
PI
Final 47 0.1960 0.29313
First 60 0.4318 0.43113 1.63 0.379
GI
Final 47 0.2976 0.40643
First 60 0.1381 0.24222 0.27 0.404
CAL I
Final 47 0.1265 0.17737
First 60 4.8167 1.65183 1.35 0.945
HU-DBI
Final 47 4.3830 1.63592
**p≤0.01 highly significant and *P≤0.05; statistical significant difference

DISCUSSION

Health is a universal human need. It has been established that optimal health cannot be attained independent of oral
health. The result of current study showed that themean value ofdental college students for total DMFT, DMFS and by
fractions in addition to plaque index, gingival index, calculus index and HU-DBI for both first and final stages filling
contributed the major part of DMFT and DMFS value. For first stage filling followed by decay and last missing teeth.
While for final stage filling followed by missing then decay.

While Medical college students showed that for both first and final stages filling contributed the major part of DMFT
and DMFS value followed by decay and last missing teethand the difference was statically significant (p ≤ 0.05).

This result in agreement with the Drachev et al.[28]which showed high dental caries prevalence and high dental caries
experience with dominance of FT among undergraduate medical and dental Russian students aged 18–25 years in
North-West Russia. Our finding may be explained by the fact that dental caries is a slow disease and its development
may start long before persons decide on dental or medical education also could be attributed to ineffective preventive
measures and brings forward the problem of dental professionals focusing on treatment rather than effective prevention.
[10]

In the current study, FT constituted the main fraction of the DMFT index for both dental and medical students, this
result is in disagreement with other study which concluded that filled component (FT), 4.11 vs. 2.04 (p=0.001), was
significantly higher in dental students, but for medical students,the DT index showed that the medical students
presented more active untreated caries. This reflecting that dental students received more dental treatment than
theirmedicalpeers. [29]

The mean value for filling showed higher value in first stage in comparison with final stage. This may be partly
because students of the last stage are busy with the load of study and have no time for consulting dentist or taking care
of their teeth while the students of first stage have more time for this.

For both PI and GI indices, the higher value was observed among first stage in comparison to final stage. This result is
in disagreement withTen Cate et al.,[30]study which showed that final-year students had a significantly higher plaque
index than in their first-year counterparts.

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HU-DBI was higher in final stage than first stage, this result is in agreement with Yildiz and Dogan[21] studywhich
concluded that the mean HU-DBI score of the clinical students was significantly higher than the preclinical ones
(7.47±1.86, and 6.00±1.86, respectively). Also in agreement with a study done in India which showed that final-year
medical students had a significantly higher score for oral health knowledge, attitude, and behavior than first-year
medical students (p<0.01).[31]

The same pattern was observed in other countries where Dental students at different levels of their training were
compared regarding oral health behavior and attitude. [10,21,29,32,33] But in contrast to our result, the study from Indian
Dental students showed no difference between the clinical and the preclinical studentsregarding to their HU-DBI
scores.[21,34]

Vangipuram et al. [35] showed that the substantial differences in oral health behavior and attitudes between different
levels of academic education were not observed.

ForEducation college students, both first and final stages decay contributed the major part of DMFT and DMFS value,
in first stage missing came next followed by filling but in final stage it opposite filling higher than missing.

Östberg et al.[36] reportedthat adolescents usually gave insufficient priority to oral health, e.g. tooth cleaning, fluoride
supplements and diet habits, being unaware of their own respectively regarding oral health. On the other hand, people
do not consider caries to be a serious condition and usually manage pain or swelling arising from decay through self-
care strategies to a point where the carious tooth becomes grossly decayed and tooth removal remains the only
option.[37]

For PI index, the higher value was observed among first stage compared with final stage. This may be due to majority
of college students more likely to have positive self-care attitudes in order to improve their appearance and self-esteem,
teeth play a major role in overall facial appearance therefore they became concerned about the appearance and esthetics
of their teeth.

In Economic college students, both first and final stages missing contributed the major part of DMFT and DMFS
values, in first and final stages decay came next followed by filling. This in agreement with Kahar et al.[37]For PI, GI
and CALI indices the higher value were observed among first stage compared to final stage. This may be related to the
fact that most of people are not able to achieve optimum dental plaque removal this could be attributed to the lack of
oral health education. Therefore, tooth brushing recommended by most dentists in order to improve plaque control.This
result is in agreement with Tanny et al. [38]studywhich expected that as the academic year advances, students become
more self-aware about their own deleterious attitudes to health. HU-DBI the higher value was observed among first
stage compared to final stage. This in constant with Nigeria study result which concluded that older students had better
oral health, attitude, knowledge, and practice as compared to younger students. [39]

CONCLUSION

With increasing years of the study, some aspects of college student’s oral health Knowledge, attitude and behavior in
addition to oral health status was improved or worsen. On the other hand, some aspects of dental student’s oral health
Knowledge, attitude and behavior in addition to oral health status were improved but this improvement was limited.
Thus, the students should get better comprehensive dental education and motivated to become an example of oral
health for their society.

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