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 Table of Contents  
ORIGINAL RESEARCH
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 1-7

Oral health-related behaviors and dental pain among children in Saudi Arabia


Department of Public Health, College of Public Health, Imam Abdulrahman Bin Faisal University, Dammam, KSA

Date of Web Publication27-Feb-2019

Correspondence Address:
Dr. Ali Saad R. Alsubaie
Associate Professor, Department of Public Health, College of Public Health, Imam Abdulrahman Bin Faisal University, Dammam
KSA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_253_18

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  Abstract 

Aims: Dental hygiene and oral health status are essential components of health throughout life. The purpose of the study was to investigate the oral health-related behaviors and experienced teeth pain, as well as their correlates, among male schoolchildren in Saudi Arabia. Material and Methods: A cross-sectional study was conducted recruiting 10 elementary schools, Saudi Arabia. The total sample size was 725 schoolchildren (aged 7–12 years). Pretested structured questionnaire was used to collect the data using a multistage stratified-random sampling procedure. Univariate and multivariate regression analyses were used to examine the association between variables. Results: All of the children (100%) did not have the habit of using tooth flossing regularly. The majority (62.5%) of the children did not have the habit of daily brushing, and only 11.8% brushed their teeth twice or more daily. About 56% missed/skipped visiting dentists in the past 12 months and 34.5% of the children complained a frequent toothache. Daily teeth brushing was significantly associated with young age (odds ratio [OR] = 0.5; P < 0.001), consuming fruits daily (OR = 2.3; P < 0.001) consuming vegetables daily (OR = 2.1; P < 0.001), and visit to dentist in the past 12 months (OR = 1.6; P = 0.010). The frequent toothache was positively associated with daily consumption of carbonated drinks (OR = 1.6; P = 0.005), sweets (OR = 1.8; P = 0.009), and visit to dentist (OR = 1.5; P = 0.010), and inversely associated with daily dairy products consumption (OR = 0.7; P = 0.020). Conclusions: Children's oral hygiene and oral health status were found to be poor and associated with their dietary habits. Preventive school health programs are required for better adaption of oral health behaviors and to maintain good oral health status among children.

Keywords: Dental pain, dietary behaviors, oral health, public health, school health


How to cite this article:
Alsubaie AS. Oral health-related behaviors and dental pain among children in Saudi Arabia. J Int Oral Health 2019;11:1-7

How to cite this URL:
Alsubaie AS. Oral health-related behaviors and dental pain among children in Saudi Arabia. J Int Oral Health [serial online] 2019 [cited 2019 Mar 20];11:1-7. Available from: http://www.jioh.org/text.asp?2019/11/1/1/253140


  Introduction Top


Poor oral health status, poor dental hygiene, and dental caries are major public health problem worldwide. For this purpose, appropriate oral health status is significantly necessary, which can be attained by proper brushing and flossing to limit bacterial infection. The World Health Organization (WHO) defines oral health as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity.”[1] Behavioral risk factors for oral diseases are shared with other major noncommunicable diseases (NCDs), such as an unhealthy diet high in free sugars, and tobacco use.[2] Indeed, appropriate oral hygiene is one of the most important health behaviors and essential aspects for healthy teeth and gums. In general, the term “oral health behavior” describes the complex effects of oral hygiene habits on the individual's oral health, nutritional preferences, and the pattern of a person's utilization of dental services. The most obvious oral hygiene behaviors include tooth brushing, flossing, seeking care, and visiting dentist for periodic check-up. It is well known that poor oral hygienic behaviors are key risk factors for oral diseases, which mainly include dental caries.

According to the WHO, oral diseases are the most common NCDs and affect people throughout their lifetime, causing pain, discomfort, disfigurement, and even death.[2] It is important to be noted that untreated dental caries have many negative consequences among children, including dental pain, difficulty eating, poor sleep, poor appearance, and avoiding smiling because of how the teeth looked, school absences and difficulty concentrating.[3],[4]

Reportedly, in Saudi Arabia, teeth caries among a sample of primary schoolchildren was as high as 99%, and only 30.5% children had a regular brushing habit.[5] Another study revealed that the prevalence of caries among children was 94.4%.[6] Furthermore, it has been found that the prevalence of dental caries among the 6–9-year-old was 78%; whereas, it was approximately 68% among the 10–12-year-old in Saudi Arabia.[7] In Riyadh, Saudi Arabia, it was observed that only 6.3% of participants were caries free with an estimated caries prevalence to be 93.7% among children.[8] However, it was revealed that brushing teeth once a day or less than once a day results in the formation of plaque which is a main risk for dental caries.[9] It has been concluded that the development of dental caries may be controlled by a balance of healthier habits of good oral hygiene behaviors and consuming low cariogenic foods,[9] implying that oral hygiene behaviors and dietary behaviors may interact in oral health status in individuals.

In Saudi Arabia, there is a major gap in the available literature of oral health status and oral health behaviors. Despite the fact that poor oral health behaviors, unhealthy dietary behaviors, and caries are affecting majority of the children, little attention has been paid to investigate these issues in Saudi Arabia. Therefore, the purpose of this study was to explore the oral health-related behaviors and dental pain experienced, and the associated dietary correlates among primary Saudi schoolchildren. The major contribution of this study will be in public health dentistry domain for better awareness of oral health-related factors among school-aged children.


  Materials and Methods Top


A cross-sectional study was carried out to assess the oral health behaviors and perceived teeth pain and their correlates among male school children. The study was conducted among elementary schools in Al Baha city, Southwestern Saudi Arabia in 2013. This study was approved by the Ethics Committee of Southwestern Saudi Arabia University (SWSAU/4792/2018) with its later amendments or comparable ethical standards. A random sample of 725 schoolchildren, aged between 7 and 12 years, were selected from 10 elementary male schools. The sample was drawn from the schools using multistage probability proportional to size sampling technique. The minimum required sample size was determined; so that, the sample proportion would be within ±0.05 of the population proportion, with a 95% confidence level. At the first stage, a systematic random sampling procedure was used to select the schools (n = 10). At the second stage, classes were selected at each grade (level) from fourth, fifth, and sixth grades using a simple random sampling design. Thus, a total selection of at least three classes from each school was obtained.

A list of all the schools, with the children aged 7–12 years, situated in Al Baha province was obtained from Al Baha Education Directorate. All participants were interested and informed consents were taken from each students. To collect the representative sample, a multistage sampling procedure was performed. None of the schools refused to participate. The questionnaire development was based on the Global School-Based Student Health Survey.[10] The questionnaires were administered to assess the oral health-care behaviors of the children including brushing teeth daily, using flossing daily, visiting dentist in the past 12 months before the survey, and feeling teeth pain frequently in the past 6 months. With regard to the main question: “How many times per day do you usually brush your teeth?”; students were given the option of replying: never; sometimes but not every day; one time per day; two times per day; 3 or more times per day. All respondents who reported “Never” and “Sometimes but not every day” were grouped as not brushing teeth daily versus brushing teeth daily (1or more times per day). Furthermore, dietary behaviors were assessed. The consumption of healthy food (e.g., fruit, vegetable, and dairy product) and sugary food (e.g., sweets food, carbonated beverages, and energy drinks) were collected to investigate its association with oral health (i.e., brushing teeth and perceived feeling teeth pain frequently).

The questionnaire was tested in a pilot phase to ensure the quality and face validity of the data collection tool. The study was piloted among small sample of school children (n = 32) and was not included in the main study. The study ensured that anonymity and confidentiality were prioritized for the responses; therefore, it can be assumed that the validity of responses was accurate. The pilot study revealed that the children were found to be not aware of their family socioeconomic status, such as their family income and their parents' education level, which limited the analysis and findings.

Students were informed that their contribution to the study is totally voluntary and they could quit at any time. Questionnaires were administered in the classrooms, and the questions were read aloud for children to fill in the questionnaires. To prevent the tendency to answer the questionnaire in favor of socially acceptable behavior, confidentiality was ensured, and school staff was asked to not enter the classrooms where the children filled the questionnaire. In addition, students were assured that the information they provide would remain confidential and thus were encouraged to be truthful in their responses. The participants were encouraged to approach the examiner whenever they needed clarification at any issues. The data were collected anonymously, and confidentiality of data was strictly maintained.

The Statistical Package for the Social Sciences (SPSS) version 22.0 (Armonk, NY: IBM Corp.) was used for the analysis. Frequencies of all responses were calculated. Chi-square test was used to determine the pattern of oral health-related behaviors with regards to students' age specific. Moreover, two models of binary regression analyses for brushing teeth as well as feeling toothache with regard to food consumption were performed to investigate the associations. Odds ratio (OR) with 95% confidence interval (CI) was computed to assess the presence and degree of association between dependent and independent variables. The cutoff point for statistical significance was set at the 5% level.


  Results Top


[Table 1] presents the age distribution of participated schoolchildren by years and age groups. A total of 725 male school children aged between 7 and 12-year-old were recruited with a mean age of 9.8 ± 1.6 years. [Table 2] shows that the majority of the participants (62.5%) did not brush their teeth regularly (at least one time/every day), 25.7% brushed their teeth once a day and only 11.8% brushed their teeth twice or more a day. Surprisingly, this study revealed that all students (100%) did not use tooth flossing regularly. Visiting dentists during the past 12 months was reported by 43.9% of the students; while the majority (56.1%) did not visit dentistry clinics. On the other hand, frequent toothache during the past 6 months before the survey was reported by 34.5% of the schoolchildren.
Table 1: Students age distributions

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Table 2: Distributions of oral health-related measures among male schoolchildren 7-12 years of age in Al Baha city, Saudi Arabia, 2013 (n=725)

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[Table 3] demonstrates the pattern of oral health-care beahvior among children by age. It has been shown that daily teeth brushing decreased with increasing age groups in a negative linear pattern (P = 0.001). Among the age group of 7–8 years, about 49.4% of participants brushed teeth every day, while the percentage of brushed teeth pattern among the age group of 9–10 years was decreased to 41%, and 26.3% among the age group of 11–12 years.
Table 3: Associations and distributions of oral health measure with regards to age among male schoolchildren in Al Baha city, Saudi Arabia, 2013

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Visiting dentists in the past 12 months before the survey was also found to be statistically significant (P = 0.047), as the older age group (11–12 years) reported the highest percentage (48.9%) of reporting teeth pain among all groups. Although toothache during the past 6 months was not significantly associated with age; however, it was reported less among younger age in comparison with older age since 30% and 35.8% of 7–8 and 9–10 years, respectively.

[Table 4] presents the binary logistic regression analysis of tooth brushing and other oral health-related factors and dietary behaviors. It shows that brushing teeth regularly was associated with younger age (OR = 0.8, 95% CI: 0.7–0.9, P = 0.01), visiting dentist in past 12 months (OR = 1.6, 95% CI: 1.1–2.2, P = 0.01), consuming vegetables everyday (OR = 1.6, 95% CI: 1.1–2.2, P = 0.01), and consuming fruits daily (OR = 2.3, 95% CI: 1.6–3.3, P = 0.001). There was also a borderline statistically significant inverse association between brushing teeth daily and sweet foods (OR = 0.7, 95% CI: 0.5-1.0, P = 0.079) and soft drinks daily consumption (OR = 0.9, 95% CI: 0.6–1.4, P = 0.075). On the other hand, the relationship of brushing teeth daily and consuming milk daily (OR = 1.0, 95% CI: 0.7–1.5, P = 0.819), daily sweets consumption (OR = 0.7, 95% CI: 0.5–1.0, P = 0.079), daily soft drinks consumption (OR = 0.6, 95% CI: 0.4–0.9, P = 0.377), eating fast food (OR = 1.4, 95% CI: 0.9–2.2, P = 0.143), and high fat diet (OR = 1.2, 95% CI: 0.9–1.8, P = 0.201) were found out to be statistically insignificant.
Table 4: Regression analysis of brushing teeth every day and related factors among male schoolchildren 7–12 years of age in Al Baha city, Saudi Arabia, 2013 (n=725)

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[Table 5] demonstrates the results of the multivariate regression analysis of teeth pain experience and OR. It has been found that perceived frequent teeth pain in the past 6 months before the survey among children was associated positively with visiting dentist (OR: 1.5, 95% CI: 1.1–2.1, P = 0.010), daily soft drinks consumption (OR: 1.8, 95% CI: 1.2–2.9, P = 0.005), daily sweets consumption (OR 1.6, 95% CI: 1.1–2.3, P = 0.009), and reversely with consuming dairy products (OR: 0.7, 95% CI: 0.5–0.9, P = 0.020).
Table 5: Regression analysis of perceived teeth pain and related factors among male schoolchildren in Al Baha city, Saudi Arabia, 2013

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  Discussion Top


Good oral health requires healthy practices, which mainly include daily teeth brushing, regular visits to the dentist and beside a healthy diet. This study found that children had poor oral health hygiene behaviors in general (e.g., not brushing teeth, never flossing, skipping dental checkup, and frequent dental pain). Moreover, various risk factors (e.g., students' age, dental variables, and dietary behaviors) for oral health behavior and dental pain were identified and associated, which can be utilized for intervention programs.

This study revealed that the majority of the students (62.5%) did not brush their teeth daily, 25.7% and 11.8% brushed their teeth once and twice a day, respectively. The low tooth brushing behavior among schoolchildren was documented in Saudi Arabia. It has been reported, and only 30.5% children had a regular brushing habit.[5] Furthermore, it has been reported that only 24.5% of the primary school students brushed their teeth twice or more daily.[11] This oral health behavior problem should be tackled seriously by Saudi community and policymakers. Therefore, it is essential to establish a proper oral hygiene routine early in life to help ensure healthy teeth. Toothbrushing should be presented as a habit and an integral part of the daily hygiene routine. It has been reported that children who brush daily with fluoride toothpaste will have less tooth decay.[12]

Surprisingly, all the students in this study (100%) did not use tooth flossing. It may seem that the use of dental floss is not common in Saudi society. However, a study from a nearby neighboring country concluded that very few children were using dental floss.[13] The use of dental floss care may not be widely used by people especially among children and developing countries.

In addition, this study revealed that a high proportion of the students (43.9%) did not visit the dentist for more than 12 months, which indicated that skipping dental visits was prevalent among Saudi children. This finding is consistent with the outcomes of other studies in Saudi Arabia. For instance, Farsi[14] reported that only 55.9% of the male students visited dentists during the past 12 months before the study and about one-fourth of the students sampled had never visited a dentist. Another study concluded that the percentage of children with no previous visits was high.[15] Findings from neighborhood country also reported similar results of high skipping visiting dental clinics.[13] On the other hand, in Finland, it has been found that 95% of schoolchildren between 12 and 18 years of age visited a dentist at least every 2nd year.[16] However, there are many factors related skipping dental checkup and low utilization of dental health services including; the cost of dental care and lack of dental coverage, acceptability of the services, and the lack of oral health literacy.[17] Cultural, family/parental factors, low oral health awareness, and lack of the availability of the dental services in the community, might be considered among the major barriers for low utilization of dental services and not visiting a dentist on a regular basis for regular checkups in Saudi Arabia. In Finland, all young people under the age of 19 years are eligible to free dental checkups and dental care by the Public Dental Health Services.[16] Therefore, more emphasis should be placed on efforts to provide sufficient dental health services in schools and community without financial burden and to encourage children to visit a dentist regularly.

In addition, this study found that high proportion of the children (34.5%) had suffered from teeth pain frequently during the past 6 months before the survey, which may reflected the high prevalence of dental caries and poor oral health status among children in Saudi Arabia. Moreover, it has been documented in many studies that the prevalence of caries among primary school children was ranged between 68% and 99%.[5],[6],[7],[11] In addition, this finding enforces the validity of the findings of this study, which revealed that the majority did not brush their teeth daily and not visiting dentist, as well as never practicing teeth flossing.

The binary logistic regression analysis demonstrated that brushing teeth daily was independently associated with younger age and visiting dentist during the past 12 months, as well as with eating fruits and vegetables daily. Furthermore, a borderline statistically significant of inverse association was documented between brushing teeth daily and the daily consumption of sweet foods and soft drinks. Similarly, Alzahrani et al. found a cluster pattern between low fruit consumption and less frequent tooth brushing.[18] Suggesting that health behaviors are interrelated and connected.

In addition, this study found that perceived teeth pain in the past 6 months prior to the survey was associated positively with visiting dentist, suggesting that students seek dentist when they feel pain as for curative purpose and not for routine checkups, indicating that dental visits are often driven by pain and discomfort rather than for regular preventive checkup. Similarly, it has been previously documented in Saudi Arabia that children visit a dentist mainly under the condition of pain.[14],[15],[19]

This study also revealed that a regular toothache/dental pain was found to be associated positively with daily soft drinks consumption and daily sweets consumption. It has been reported that the risk of caries is higher with consuming sugars at high frequency.[20] Moreover, the study from Saudi Arabia has reported that self-reported cariogenic food consumption such as sweets/candy, carbonated soft drinks were significantly greater among children with dental caries.[11] Lim et al.[21] concluded that there is greater possibility to develop dental caries among the individuals who consumed more soft drinks relative to fresh juices and milk during their childhood. It has been documented that high proportion of children in Saudi Arabia did consume sweets products and soft drinks frequently.[22] However, a systematic review concluded, that controlling the consumption of sugar remains a justifiable part of caries prevention.[23]

In addition, this study revealed that students, who reported frequent teeth pain, were less likely to consume milk and dairy products daily. In line with that, a study by Sohn et al.[24] have concluded that children who consume diet high in milk and dairy products were less complain of dental caries with compare to other children.[24] Similarly, it has been reported that increased consumption of milk and dairy products was associated with lower caries experience.[25] In addition, Alzahrani et al. reported an inverse relationship between the prevalence of periodontal diseases and dairy products consumption.[18] It has been found that consuming milk and dairy products on a regular basis can be a protective factor because it contains essential minerals, which mainly include calcium and Vitamin D.[18],[26],[27] In addition, a randomized control study also mentioned that milk and dairy products may have beneficial effects on children's dental health due to its probiotic effects.[28] However, among the same sample, it has been found that a high proportion of children did not consume dairy products on a daily basis.[29] In line with that, it has been reported that systematic nutrition education and supervision are lacking in Saudi Arabia.[30]

The information from this study emphasized the need for promoting oral health-related behaviors in children. There is a clear need to establish and enhance regular oral health assessment and comprehensive dental health services for children in Saudi Arabia to prevent poor oral health status and dental diseases. Moreover, indeed, schools can provide a supportive environment for promoting health. Consequently, promoting healthier oral health status and behaviors in children may require a multi-faceted approach including parents, families, schools, dental health preventive services, and community's stakeholders. Thus, school-based oral health services should be reinforced and improved including preventive services such as screening, education, behavioral modification, and dental referral. The importance of the utilization of dental services should be enhanced and emphasized through various channels, including school health services, enhancing family awareness, effective mass media, and the oral health providers. Surveys carried out in many countries have shown that the children oral health status and related behaviors are influenced by parental background and socioeconomic status.[8],[31],[32],[33] Several previous studies have reported that school children in Saudi Arabia engaged in many risk behaviors and recommended that comprehensive school health prevention programs are required to improve their health.[34],[35],[36],[37],[38]

The strengths of the study are the large study sample size of schools and participants. Moreover, the selection of participants was random, and an appropriate stratified sampling strategy was ensured. On the other hand, there are few limitations that should be highlighted. The findings of the study were limited by its cross-sectional design, which could not explain causation. Self-reporting may be an imperfect tool for assessing oral health behavior and may be biased by social expectations or recall. In addition, there are few factors which might be significant to children oral health status and behaviors such as family oral health habits, economic status, and parental background, but could not be collected as the pilot study revealed that children were more likely to provide inaccurate response to these factors. In addition, according to Saudi culture and education system, male and female are separated in schools; consequently, it was not allowed for male investigator to access female schools or contact female students. Therefore, female students were not included in this study.


  Conclusions Top


Poor oral health behaviors and teeth status can have a significant negative impact on individuals health and quality of life. This study has shown that oral health-related behaviors and teeth health status among school children were unhealthy. Similarly, the study also provides clear evidence of the relationship between oral health behavior and teeth pain with dietary habits (e.g., daily consumption of fruit, vegetables, dairy products, and sugary foods).

Knowledge about the epidemiology of oral health behaviors and related factors in Saudi Arabia would help to establish baseline data and inform policymakers for effective actions. Since children oral health status and oral health behaviors are affected by many factors such as family backgrounds and behaviors, socioeconomic status, and cultural determinants; future comprehensive research addressing these determinants are recommended for well understanding and to design effective multidimensional public health intervention.

Acknowledgments

The authors would like to acknowledge all school principals and teachers who facilitated the survey and extended the needed support. High appreciation is also given to my colleagues who facilitated the preparation of this paper, Dr. Eltigani Omer, Mr. Muhamed Shehri and Mr. Othmen Bakry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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