|Year : 2021 | Volume
| Issue : 5 | Page : 449-455
Oral health practice of primary school children in the region of Madinah, Saudi Arabia: A cross-sectional study
Danya Hashem1, Osama Abdalla Abu Hammad2, Jana Farran3, Anmar Faran3, Najla Dar Odeh4
1 Department of Restorative Dental Sciences, Taibah University, Madinah, Saudi Arabia
2 Department of Prosthodontic Dental Sciences, Taibah University, Madinah, Saudi Arabia; School of Dentistry, University of Jordan, , Jordan
3 General Dental Practitioner, Ministry of Health, , Saudi Arabia
4 School of Dentistry, University of Jordan, Jordan; Department of Oral Medicine, Taibah University, Madinah, Saudi Arabia
|Date of Submission||01-Apr-2021|
|Date of Decision||18-Jun-2021|
|Date of Acceptance||02-Jul-2021|
|Date of Web Publication||11-Oct-2021|
Dr. Danya Hashem
Department of Restorative Dental Sciences, College of Dentistry, Taibah University, Madinah.
Source of Support: None, Conflict of Interest: None
Aim: This large-scale study explores oral hygiene practices (OHPs) of primary school children in the region of Madinah as reported by their parents and evaluates different contributing factors on OHPs. Materials and Methods: This is a cross-sectional study in which questionnaires were distributed through the Ministry of Education’s online education platform Madrasati to parents of primary school children in the region of Madinah. Various sociodemographic factors related to OHPs were calculated. Factors related to good OHP were given one mark with the maximum score of 8 marks. The multivariate analysis of variance (Manova) test was used to explore the effect of socio-economic status on scores of OHP and age of onset of tooth brushing. Results: There were a total of 2690 respondents, mostly, mothers (72.2%), Saudi nationals (84.4%), parents of children enrolled in public schools (92.8%), and those living in Al Madinah city (89.9%). OHP scores ranged between 0 and 8 with an average of 4. Means of scores were compared for various variables and were found to be significantly higher for female parents, less than 40 years of age, children in private schools, schools within the city of Madinah, parents with higher education and income, employed mothers, and parents with medical and dental insurance. The Manova test revealed significantly higher OHP scores and significantly lower age of onset of tooth brushing for higher socio-economic groups. Conclusion: Parents’ perceptions on oral health practices need improvement, which is best addressed by oral health awareness programs. Results of this large-scale study can help plan oral health services and organization of oral public health intervention programs in the region. These programs should primarily target families of the low socioeconomic status, particularly those with insufficiently educated parents who reside outside the city of Madinah.
Keywords: Dental Caries, Oral Health, Oral Hygiene Practices, Primary School Children, Social Determinants of Oral Health, Tooth Brushing
|How to cite this article:|
Hashem D, Abu Hammad OA, Farran J, Faran A, Odeh ND. Oral health practice of primary school children in the region of Madinah, Saudi Arabia: A cross-sectional study. J Int Oral Health 2021;13:449-55
|How to cite this URL:|
Hashem D, Abu Hammad OA, Farran J, Faran A, Odeh ND. Oral health practice of primary school children in the region of Madinah, Saudi Arabia: A cross-sectional study. J Int Oral Health [serial online] 2021 [cited 2021 Dec 6];13:449-55. Available from: https://www.jioh.org/text.asp?2021/13/5/449/327871
| Introduction|| |
Oral disease is one of the most common non-communicable diseases affecting a substantial proportion of the world’s population. Dental caries represents the most common disease of childhood wherein over 400 million children suffer from teeth caries. In 2010, untreated deciduous teeth caries was one of the most prevalent conditions globally, affecting a wide range of children, with a prevalence of 9% of the population. Dental caries can start at an early age and can progress rapidly in children with high risk for dental caries, and those are usually left without treatment. Dental health is closely related to functional, psychological, and social aspects of a child’s well-being. In Saudi Arabia, previous studies reported a high prevalence of early childhood caries of around 73%. Dental caries can be controlled by prevention whereby awareness and knowledge of parents are one of the basic components of a child’s oral health, thereby providing a preventive measure and maintaining good oral health in their child. Dental caries have been reported to be higher in children whose parents lack oral health awareness and knowledge. The main resources of parents’ knowledge and awareness have been received through primary health care. Studies have shown a correlation between parental education and socio-economics and oral health knowledge and awareness. Parents with high education and socio-economic status had good oral health; whereas lower levels of education and low monthly income had a negative effect on the knowledge and awareness of the oral health of their children. Recent studies that evaluated parent’s knowledge and awareness of their children’s oral health reported variable degrees of their knowledge and awareness.
In the city of Madinah in Saudi Arabia, a study was conducted to assess the oral health knowledge and practice of 276 schoolchildren aged between 9 and 12 years and its impact on the prevalence of dental caries. An average knowledge was found, which however showed that higher numbers of females tend to have better oral health knowledge. This was the first study to investigate oral health knowledge and practice among 9–12-year-old schoolchildren in the region of Madinah, Saudi Arabia. The included numbers were small and the study was implemented in the major city of Madinah only.
There are currently no large-scale studies to measure the oral health practices of primary school children in Saudi Arabia, particularly Al Madinah province, which includes the city of Madinah and several other suburban cities surrounding it located in the western area of the kingdom. Therefore, the aim of this study was to assess oral hygiene practices (OHPs) of primary school children in the Al Madinah region as perceived by their parents. This study also aimed to evaluate different contributing factors on OHPs. It is hoped that this research study will strengthen the evidence base available to support initiatives and translational efforts for improving children’s oral health care in the region. The null hypothesis is that no differences exist.
| Materials and Methods|| |
This is a cross-sectional observational analytic study carried out between December 2020 and January 2021. It was ethically reviewed and approved by the Taibah University College of Dentistry Research Ethics Committee.
The questionnaire was designed based on a previous similar study. The questionnaire started with a description of the study including confirmation that participation was completely voluntary. After consenting to participate, participants were given 45 close-ended questions addressing demographics and socioeconomic factors related to the participant, OHPs of the participant’s primary school children, oral health knowledge, and utilization of dental services. The questionnaire was constructed in English before being translated into Arabic, which is the local language in Saudi Arabia. The Arabic questionnaire instrument was pre-tested for accuracy on a sample of 30 parents with demographic characteristics similar to those of the test population and repeated after 2 weeks on the same sample. Whenever participants provided different responses to a given question, it was revised and necessary rephrasing was carried out to ensure clarity and simplicity. These participants were excluded from the main study.
Study population and sample size calculation
Inclusion criteria for the study were primary care givers of children attending primary schools in the Al Madinah Al Munawwarah region, including the cities of Madinah, Badr, Khaibar, Alhanakiah, and Mahd Althahab. Sample size determination was carried out using Epi Info software (Center for Diseases Control, USA) and was calculated to be 2332 participants associated with a confidence interval of 99.99% based on a population size set at 161,327, which is the total number of current primary school students enrolled in the year 2020–2021 in the region according to the Ministry of Education. Expected frequency of 50%, margin of error of 4%, design effect, and cluster size were set at 1. Although an initial random sample of 2332 was determined for a 99.99% power of study, there were no easy methods to send to particular schools, and the Ministry of Education distributed the questionnaire to all primary schools in the Al Madinah Al Munawwarah region through the Ministry’s formal online school platform “Madrasati.” The primary outcome measures included: OHPs of primary school children including age of onset of tooth brushing, frequency and duration of tooth brushing, use of toothpaste, mouthwash and floss, utilization of dental services, and reasons for not utilizing these services. Secondary outcome measures include the effect of different sociodemographic variables on these OHPs.
The collected data were statistically analyzed using IBM-SPSS Statistics for Windows, Version 21.0 (IBM Corp., Released 2012, Armonk, NY, USA). Various sociodemographics of parents and their children and factors related to OHPs were calculated and presented as absolute numbers and percentages. Factors related to good OHP were given one mark with the maximum score of 8 marks. OHP scores obtained by different participant groups were expressed in means and standard deviations along with significance. Statistical significance was set at P ≤ 0.05. T-test and analysis of variance (ANOVA) [with least significant difference (LSD) post hoc test] were calculated to explore significant differences in means of OHP scores of different groups of participants. Multiple linear regression analysis was carried out to determine significant variables that could be used to predict values of OHP scores. Multivariate analysis of variance (Manova) was used to explore the effect of socio-economic status on OHP scores and age of onset of tooth brushing adopting Wilks’ lambda test, followed by LSD post hoc test. Here socio-economic status was defined by adding scores of maternal and paternal education and family income.
| Results|| |
A total of 3292 parents were invited to participate; however, a total of 602 declined to participate giving a total of 2690 responses and constituting a response rate of 81.7%. Respondents were mostly mothers (72.2%) and Saudi nationals (84.4%). The majority of the participants were recruited from public schools (92.8%) and Al Madinah city (89.9%).
[Table 1] shows OHPs of children as perceived by their parents displayed in numbers of respondents and their percentages. Factors related to good OHP were given one mark and are determined with an asterisk in [Table 1]. Regarding age of onset of tooth brushing, the majority of parents reported that their children started brushing when they were 3–4 years (37.8%). Frequency of tooth brushing was reported to be once a day (37.4%) followed closely by twice a day (34.2%), whereas duration of tooth brushing was reported to be 1–2 min (52.3%). When asked about assisting their child/children with brushing, the majority confirmed that they assisted with brushing (83.2%). The majority of the parents confirmed that their child/children used children toothpaste (54.5%) or adult tooth paste (29.7%) or both (9.9%). Although the majority of parents reported that their children did not use floss (84.9%), they did confirm using mouthwash (77.7%). When asked about utilization of dental services, the majority of the parents confirmed that their child/children have either never visited the dentist (24.3%) or visited only when in pain (57.5%). Reasons for this have been reported to be due to high cost of dental interventions (39.7%), child’s fear of dental interventions (29.4%), milk teeth “do not require treatment as they will change” (14.4%), and distance barrier to dental surgeries (10.2%).
OHP scores obtained by the parents ranged between 0 and 8, with “zero” being the lowest score obtained by (0.9%) the respondents whereas “eight” the highest score obtained by (0.3%) the respondents. The majority of respondents had a score of “4” (30.4%) indicating average OHP measures [Table 2].
Significantly higher OHP scores were obtained when respondents were females, parents who were less than 40 years of age, with a higher education, higher income, and with medical or dental insurance, employed mothers, children enrolled in private schools and those enrolled in schools within the city of Madinah (P-values are shown in [Table 3]).
|Table 3: Comparison of OHP scores of different socioeconomic variable groups|
Click here to view
Significant predictors for higher OHP scores in the multiple linear regression model were presence of insurance, higher paternal and maternal education, female parent respondents, children enrolled in a private or mixed school sector, and lower number of children in primary education, as shown in [Table 4]. In this regression model, R =0.204, R2 =0.042, adjusted R2=0.040, and ANOVA of the regression model was highly significant (P = 0.000). Thus the model is capable of predicting 4.2% of the variance of OHP scores. However, the Durban–Watson test (=0.067) points to possible serial correlation. [Table 4] shows coefficients used to build the model. All of these variables shared in the model are significant with P-value <0.05; 95% confidence interval shows valid limits of different independent variables where predictions of the regression model are most accurate. Tolerance (Tol.) shows values more than 0.8 for all the variables, indicating no serious multicollinearity.
|Table 4: Coefficients of regression modela of OHP scores, their significance, and results of collinearity statistics|
Click here to view
Results of the Manova model with LSD post hoc test indicated that the higher the socio-economic status, the higher the OHP scores and the lower age of onset of tooth brushing. All differences between the compared groups were significant. Wilks’ lambda test was significant with P < 0.001 [Table 5]. An exception was found which shows non-significant differences in the age of onset of tooth brushing for high socio-economic group when compared with the middle socio-economic group.
|Table 5: Effect of socio-economic status on OHP scores and age of onset of tooth brushing using a Manova model with LSD post hoc test|
Click here to view
| Discussion|| |
This study aimed to explore children’s OHPs and dental attendance patterns as perceived by their parents. Parents’ perceptions are important to consider when developing caries preventive interventions. Good oral hygiene combined by a non-cariogenic diet counteracts bacteria that cause dental caries. The most preferable way to motivate young children to practice good OHPs is through their parents as they influence the psychosocial aspects of their children. The influence of parents in shaping oral hygiene habits of their children has been considered a major determinant of the future of their children’s oral health. A high response rate was noticed in this study with an expectedly higher proportion of mothers participating. Influence of parents can be jeopardized by their insufficient OHPs as was shown by previous studies in this region. Furthermore, false beliefs reported by parents about oral health of their children can represent another obstacle in this process.
Substantial numbers of children started the toothbrushing practice at 3–4 years of age with a frequency of once or twice a day. Guidelines recommend that parents brush their children’s teeth and supervise tooth brushing until children are 10 years old. Oral hygiene behavior should begin with eruption of the first tooth of a child, which can take place in the first year of life. Twice daily tooth brushing from an early age using a fluoride toothpaste represents a key factor in the prevention of childhood caries; however, it has to be a consistent and dedicated behavior to produce the maximum efficiency. OHPs should start as early as the first year of children’s life, and this is best accomplished by improving access to oral health care and providing counseling and guidance in oral hygiene for children aged 6 months to 5 years.
One in two children brushed their teeth for 1–2 min, wherein the majority of parents assisted their children in the practice of brushing and where children and/or adult toothpaste was invariably used by the study sample. The use of mouthwash but not dental floss was reported by the majority of respondents. Neglecting the use of a dental floss was also reported by recent studies in Saudi Arabia. Kannan et al. reported that as low as 2% of school children aged 6–12 years used the dental floss. Additionally, their findings indicated the low use of mouth wash which is not comparable to our study in which the majority used the mouth wash.
Parents generally have adequate knowledge to practice tooth brushing for their child; yet many face obstacles to actually implement the practice. In this study, we found several parent- and family-related socioeconomic factors that influenced the OHPs of children. Mothers, especially employed ones, and parents younger than 40 years, who had university or higher education and who had high monthly income, were significantly associated with better practices. Previous studies have confirmed that socioeconomic status and parents’ education are correlated to each other and also to child’s oral health. Factors of income, occupation, and educational attainment level are major determinants of socioeconomic status. Low education attainment and socioeconomic status of parents contribute to poor dietary habits and unhealthy lifestyles, which adversely affect oral health of their children. Furthermore, this study found differences in oral health practice among families living in urban cities and suburban or rural areas represented by children going to schools in the main city of Madinah and other suburban cities in the regions such as Badr, Khaibar, Alhanakiah, and Mahd Althahab. This may be due to difficulties in accessing oral health services, lower oral health literacy, lower family income, and lack of insurance. Increasing oral health education and promotion programs and fluoride community programs may be employed to reduce oral health disparities among children. One in four children has never visited the dentist, and one in two visited the dentist only when in pain. A recent study conducted in this geographic area among pregnant women concluded that their knowledge on aspects of oral health care in infants is satisfactorily sufficient except for the aspect related to dental visitation as only a minority believed that visiting the dentist is essential upon eruption of first teeth. The role of dentists in developing countries is often portrayed as a therapist rather than a practitioner involved in preventive oral health activities, and this highlights the importance of periodic dental visits in contributing to the prevention and control of many oral bacterial infections. Dental practitioners can provide parents with advice regarding prevention of early childhood caries by motivating and educating them to practice effective oral hygiene; consequently, risk of caries in permanent dentition is mitigated.
The most important cited reason for poor dental attendance was the high cost of dental treatment. It is intriguing to explain this finding as the healthcare system represented by the Ministry of Health in Saudi Arabia provides free healthcare services to the population. This may be partially explained by analyzing the remainder of cited reasons for failed dental visitation which include fear of dentist, parents’ belief that milk teeth do not require treatment, and distance barriers to dental practices. Dental fear among children is considered a global problem, and unfortunately, it may persist for later periods of life. Dental fear and delayed dental treatment are two closely related factors. It is argued that early dental intervention reduces the treatment burden and costs in children with high risk for caries. Delayed treatment, in contrast, may be followed by the need for more advanced dental treatment including sedation or general anesthesia, which may not be available in public healthcare services. Furthermore, emergency department visits for dental caries-related complications may add to the cost.
Understanding OHPs of primary school children and evaluating different contributing factors on OHPs will strengthen the evidence base available to support initiatives and translational efforts for improving children’s oral health care. This study has limitations. Evaluation of parents’ knowledge perceptions on oral health aspects of their children may not be a transparent reflection of the actual oral health status of children. However, this study reported an OHP which is expected to give an accurate idea on this aspect of oral health care. This study has also relied on self-perceived data, which could be a source of bias. The sample size was large and was mostly composed of Saudi nationals; hence, it can be considered representative of the Saudi community.
| Conclusion|| |
Parents’ perceptions on oral health practices need improvement which is best addressed by oral health awareness programs. Results of this large-scale study can help plan oral health services and organization of public health intervention programs in the region. These programs should primarily target families of the low socioeconomic status, particularly those with insufficiently educated parents who reside outside the major cities.
The authors would like to thank the Ministry of Education represented by the General Administration for Education in the Al Madinah Al Munawwarah region for their assistance in distributing the questionnaire through their online education platform.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
D.H. conceived and designed the study, conducted research, provided research materials, collected and organized data, and wrote the final draft. O.A.A.H. analyzed and interpreted data. J.F. collected and organized data and wrote initial draft of the article. A.F. collected and organized data and wrote initial draft of the article. N.D.O. wrote, reviewed, and edited the final draft. All authors have critically reviewed and approved the final draft. All authors have verified the underlying data.
Ethical policy and institutional review board statement
The study protocol has been approved by Taibah University College of Dentistry Research Ethics Committee (TUCDREC/19092020/DHashem) Date: 30/09/2020. All the procedures have been performed as per the ethical guidelines laid down by Declaration of Helsinki (1975).
Patient declaration of consent
Participants have given their written informed consent to participate in the questionnaire.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
| References|| |
Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, et al
. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1211-59.
Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of untreated caries: A systematic review and metaregression. J Dent Res 2015;94:650-8.
Prakash P, Lawrence HP, Harvey BJ, McIsaac WJ, Limeback H, Leake JL. Early childhood caries and infant oral health: Paediatricians’ and family physicians’ knowledge, practices and training. Paediatr Child Health 2006;11:151-7.
Al-Malik MI, Holt RD, Bedi R. The relationship between erosion, caries and rampant caries and dietary habits in preschool children in Saudi Arabia. Int J Paediatr Dent 2001;11:430-9.
Okada M, Kawamura M, Kaihara Y, Matsuzaki Y, Kuwahara S, Ishidori H, et al
. Influence of parents’ oral health behaviour on oral health status of their school children: An exploratory study employing a causal modelling technique. Int J Paediatr Dent 2002;12:101-8.
Chhabra N, Chhabra A. Parental knowledge, attitudes and cultural beliefs regarding oral health and dental care of preschool children in an Indian population: A quantitative study. Eur Arch Paediatr Dent 2012;13:76-82.
Abu Hammad OA, Binsaad SM, Gasim RA, Jambi S, Haidary R, Afandi A, et al
. Assessing expectant mothers’ knowledge and beliefs about oral healthcare during infancy and pregnancy: A cross sectional survey in Saudi Arabia. Pesquisa Brasileira em Odontopediatria e Clinica Integrada 2018;18:e4027.
Al-Samadani K, Ahmad M, Bakeer H, Elanbya M. Oral health knowledge and practice among 9-12-year-old schoolchildren in the region of Madinah, Saudi Arabia, and its impact on the prevalence of dental caries. Eur J Gen Dent 2017;6:54. [Full text]
Alkhtib A, Morawala A. Knowledge, attitudes, and practices of mothers of preschool children about oral health in Qatar: A cross-sectional survey. Dent J (Basel)2018;6:51.
Duijster D, de Jong-Lenters M, Verrips E, van Loveren C. Establishing oral health promoting behaviours in children–parents’ views on barriers, facilitators and professional support: A qualitative study. BMC Oral Health 2015;15:157.
Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: A systematic review of the literature. Community Dent Health 2004;21:71-85.
Faldl Trindade AV, Andrade MRTC, Tannure PN, Antonio AG, Fidalgo TKS. Knowledge and practices of parents and guardians regarding the oral health of children from a shelter and a university in Rio de Janeiro, Brazil. Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2014;14:293-302.
de Jong-Lenters M, L’Hoir M, Polak E, Duijster D. Promoting parenting strategies to improve tooth brushing in children: Design of a non-randomised cluster-controlled trial. BMC Oral Health 2019;19:210.
Dar-Odeh NS, Aleithan FA, Alnazzawi AA, Al-Shayyab MH, Abu-Hammad SO, Abu-Hammad OA. Factors affecting oral health determinants in female university students: A cross-sectional survey in Saudi Arabia. Int J Adolesc Med Health 2017;32:20170084.
N Dar-Odeh SB, Gasim RA, Haidary R, Afandi A, Hammad SA, Hammad OA. Why do women avoid dental visits during pregnancy? A crosssectional survey in Al Madinah, Western Saudi Arabia. Pesquisa Brasileira em Odontopediatria E Clínica Integrada 2018;18:3934.
Ismail AI. Prevention of early childhood caries. Community Dent Oral Epidemiol 1998;26:49-61.
Li Y, Zhang Y, Yang R, Zhang Q, Zou J, Kang D. Associations of social and behavioural factors with early childhood caries in Xiamen city in China. Int J Paediatr Dent 2011;21:103-11.
Kannan SP, Alfahaid SF, Alharbi AS, Almutairi BS, Alanazi AH, Alsaab FA, et al
. Oral hygiene behavior of school children in Saudi Arabia: A descriptive cross-sectional survey. Int J Clin Pediatr Dent 2020;13:66-71.
Pizzo G, Piscopo MR, Matranga D, Luparello M, Pizzo I, Giuliana G. Prevalence and socio-behavioral determinants of dental caries in Sicilian schoolchildren. Med Sci Monit 2010;16:PH83-9.
Koposova N, Widström E, Eisemann M, Koposov R, Eriksen HM. Oral health and quality of life in Norwegian and Russian school children: A pilot study. Stomatologija 2010;12:10-6.
Kim HN, Kim JH, Kim SY, Kim JB. Associations of community water fluoridation with caries prevalence and oral health inequality in children. Int J Environ Res Public Health 2017;14:631.
Dar-Odeh N, Alnazzawi A, Shoqair N, Al-Shayyab MH, Abu-Hammad O. Waterpipe tobacco smoking among dental practitioners: Prevalence and health perceptions. Tob Use Insights 2016;9:29-33.
Dar-Odeh N, Fadel HT, Abu-Hammad S, Abdeljawad R, Abu-Hammad OA. Antibiotic prescribing for oro-facial infections in the paediatric outpatient: A review. Antibiotics (Basel) 2018;7:38.
Almeida AG, Roseman MM, Sheff M, Huntington N, Hughes CV. Future caries susceptibility in children with early childhood caries following treatment under general anesthesia. Pediatr Dent 2000;22:302-6.
Cianetti S, Lombardo G, Lupatelli E, Pagano S, Abraha I, Montedori A, et al
. Dental fear/anxiety among children and adolescents. A systematic review. Eur J Paediatr Dent2017;18:121-30.
Thomson WM, Broadbent JM, Locker D, Poulton R. Trajectories of dental anxiety in a birth cohort. Community Dent Oral Epidemiol 2009;37:209-19.
Nowak AJ, Casamassimo PS, Scott J, Moulton R. Do early dental visits reduce treatment and treatment costs for children? Pediatr Dent 2014;36:489-93.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]