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KNOWLEDGE, ATTITUDES AND PRACTICES TOWARDS ORAL HYGIENE AND DENTAL CARE AMONG 10-YEAR-OLD PRIMARY SCHOOL CHILDREN IN KITWE, ZAMBIA

Placide Ngoma1,Lilian Chambisha2,Crecious Phiri4and Gabriel Mpundui3,5*

1Mwachichisompola Rural Health Centre, Chisamba, Zambia
2Dental Surgeon, Kitwe Teaching Hospital, Dental Department
3Dental Surgeon, Levy Mwanawasa University Teaching Hospital
4Lecturer, Levy Mwanawasa Medical University, School of Public Health
5Lecturer, Levy Mwananwasa Medical University, School of Medicine and Clinical Sciences

*Corresponding author

*Gabriel Mpundu, Dental Surgeon, Levy Mwanawasa University Teaching Hospital, School of Medicine and Clinical Sciences

Abstract

BACKGROUND: Dental diseases are among the major problems that the world has to face today. Even with technological advances made in the field of dental health, the incidence of dental diseases is still very high. The people affected most are those living in third world countries like Zambia where the knowledge and attitudes that people have towards oral hygiene are worrisome. This study was conducted to determine the levels of knowledge, attitudes and practices towards oral hygiene and asses their correlation to dental health.

METHODOLOGY: This baseline cross sectional study was based on interviewing 400 ten year old primary school pupils in grades 1 through 7 at eight randomly selected primary schools in Kitwe to determine the knowledge attitudes and practices that primary school pupils have towards oral hygiene. Stratified sampling was used to select 8 random schools from the 8 zones of primary schools in Kitwe. Random sampling was used to select participants from the participating primary schools. Data was collected with Open Data Kit and analysed with Statistical Package for Social Sciences version 21.

RESULTS: From the assessment, most pupils demonstrated that they had bad oral healthcare practice (68.9%). Some pupils only brushed their teeth once a day (14%) or never (n = 4, 1%). Only a small number of them have been to the dentist (36%). More than half (63.9%) of the students had good knowledge. 86% knew the importance of brushing teeth. 70 % knew the bad effects of sweets on their teeth. The majority knew the importance of using a toothpaste with calcium (60%) and fluoride (49%). Most participants had a good attitude towards oral hygiene (77.7%) and prevention of dental curies (89%).

CONCLUSION AND RECOMMENDATIONS: The levels of knowledge and attitude where high. The most alarming finding was the fact that most pupils don’t have regular dental check-ups. The oral hygiene practices where generally poor among the participants. There is need for oral hygiene to emphasise more on the need to have regular dental check-ups. This will prevent patients only visiting the dental clinics with advanced dental complications

Keywords: Periodontal, Halitosis, Oral Hygiene, Dental sealant.

INTRODUCTION

  1. BACKGROUND INFORMATION

    A smile is good for the soul. What is a smile without clean and healthy teeth? The World Health Organisation (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,(WHO, 2015a). Risk factors for oral diseases include unhealthy diet, tobacco use, harmful alcohol use, and poor oral hygiene,” (WHO, 2015b).

    Oral hygiene on the other is the practice of keeping the teeth and mouth clean to prevent dental problems, most commonly, gingivitis, periodontal diseases, bad breath and dental cavities(WHO, 2017). Healing and regeneration of oral tissues in many oral pathologic conditions requires good oral hygiene(Zadik, 2008). Some practices of oral hygiene that have been found to be extremely helpful in preventing oral disease include brushing teeth after every meal, flossing, eating oral friendly foods and drinking fluoridated water. The Fédération Dentaire Internationale (FDI-World Dental Federation) has recommended the consumption of foods such as raw vegetables, plain yoghurt cheese or fruit as a good oral hygiene practice. The same has also been echoed by the American Dental Association(Inc, 2016).

    The emergence of a vast field of medicine dealing with dental problems and technological advancements that have made possible for one be able to access oral health care services like tooth whitening, cavity filling, extraction, replacement of a rotting tooth and placement of braces has made oral health management easier than it has ever been. Sadly though is that this trend is not uniform; The third world countries and the marginalized population are still far from benefiting from these developments. Among the major public health problems facing the world, dental related problems are in the frontier of those affecting particularly the underprivileged areas of the world. Having a clean and healthy set of teeth is not just a health issue but also a factor that affects the social wellbeing of an individual. Halitosis, pain and discomfort are among the day-to-day dental problems faced by the majority of the marginalized population. On a world scale, the two leading oral problems are dental carries and periodontal disease (Petersen, 2003).

    In addition to poor oral hygiene, certain disease affecting ones immune system lowers the body’s resistance to infection. Such an example is HIV/AIDS, which has 60% of its victims with oral fungal, viral and bacterial infection (WHO, 2015a). With HIV/AIDS having a prevalence of 13% of the adult population (ZDHS, 2013-2014), the occurrence of dental related infections is strikingly high due to oral manifestations of HIV/ AIDS related conditions.

    The impact of poor oral hygiene begins at childhood and lasts a lifetime. Unattended dental problems can really have a toll on a child’s health and performance at school and social relations. This may result in a child not attending class. In addition to that, it is financially demanding. This is why low-income families would rather not spend the little they earn on seeking professional help (CDC, 2017).

    In Zambia, the foundation of a profound academia lies in a quality primary school education. The primary school curriculum should be kneaded to teach about the importance of preventive oral hygiene and dental care to pupils while they are still in the primes of their life. Fluoride and dental sealants can be made available to children from lower income families via Government implemented school- based oral health services (Holt K, 2013). The use of sealants alone has been shown to reduce the incidence of dental cavities by 80% for two years and 04% for 4 years(CDC, 2016)

    Most oral diseases are preventable and treatable by adopting health oral, and implementation of preventive oral health practices (Schou, 2000). In the light of vast preventive literature, halitosis, malocclusions and, dental caries, facial injuries and oral tumours continue to affect the country affecting over 80% of the population (Mwaba, 2012). Dental carries, being a big oral health problem in developing countries, affect 60-90% children (Petersen, et al., 2005). Studies done in similar areas attribute these statistics to the scanty knowledge children have on oral hygiene. One such a study revealed that only 19% of children between 5-17 years go for a dental check-up and furthermore, only less than half brush their teeth on a daily basis (Simushi, 2018). This goes on to highlight the poor attitudes and practices children have towards oral hygiene.

    GLOBAL PERSPECTIVE

    On a global perspective, oral health problems have contributed greatly to morbidity rates leading to poor performance at work, school and social activities. The Knowledge attitudes and practices of oral health are still very poor in many areas of the world and oral healthcare coverage is low in middle-income and low-income countries (WHO, 2017).

    A cross sectional study conducted on 1030 individuals in Tehran, Iran to evaluate oral health literacy, independent of other oral health determinants, as a risk indicator for self-reported oral health. The study showed that women scored higher on oral health literacy with a mean OHL-AQ score of 10.9 as compared to the men’s score of 10.2 (Mohammad Mehdi Naghibi Sistani, 2013). This was alluded to the finding that women brushed their teeth more times, than men did. This study elucidated the link between Oral hygiene literacy and oral health. It shows the importance of evaluating the level of knowledge people have about oral health and hygiene.

    Having established the strong link between oral health and oral hygiene literacy, another cross sectional KAP study about oral hygiene among school going children was conducted in Iran in the year 2013. The survey involved 440 participants aged between 10 and 15 from five different schools in Khorramabad city. When subjects where asked about the role of fluoride in their teeth 16% had no knowledge about the effect of fluoride on teeth. In addition to that the majority of participants (81%) believed that health teeth means white and shiny teeth while only 18% believed that having health teeth means having strong and caries-free teeth. Unfortunately, about 0.9% had no idea what having healthy teeth meant(Aziz Kamran, 2014). Knowing that oral hygiene and oral health are closely related, it is very cardinal for pupils to understand the basics of oral health in order to implement effective oral hygiene practices. Such a study would indeed benefit Zambia because there is limited knowledge about the level of understanding pupils have towards oral hygiene and oral health.

    Another cross-sectional study was conducted in United Arab Emirates to find the association between knowledge and practice concerning oral hygiene among school going children. One Hundred and Seventy-Five schoolchildren participated and all were Arab nationals. A chi square test was later done to determine the association between oral health measures and the practices of the participants. Statistically significant association was determined between knowledge of oral hygiene and practicing (p≤0.001) (Sara Dakhili, 2014). This study was conducted at a single school in addition to which its selection was biased with respect to its distance from the University through which the research was conducted. Conducted properly, such a study would benefit Zambia considering the different geographical, socio-demographic and economic statuses of the two countries.

    REGIONAL PERSPECTIVE

    Children attending school with dental caries face a level of social discrimination and stigma. This in turn can result in self-rejection and loss of self-esteem. Knowing that good self-esteem is one of the key elements a child needs to have in order to excel in school, these children face many challenges thriving in a competitive school environment, (Asiimwe, 2007).

    LOCAL PERSPECTIVE

    A study conducted in Livingstone, Southern Province and Sesheke, Western Province to investigate the level knowledge and experiences that secondary school students have about oral health in Zambia. The study reviewed that more than 50% of the students received information about oral disease and dental health care from their teachers and parents. From the same study, it was concluded that only about 26% of the participating pupils understood that dental carries is tooth decay. When asked about the means of which they cleaned their teeth, 17% said they used a stick and 6% said that they used a finger while the rest used a toothbrush. Furthermore, only 74% gave the correct answer pertaining the cause of dental caries (Linda Hagberg, 2007). These levels of knowledge are very scanty and leave one question to be answered: “If the above statistics represent the levels of knowledge of secondary school pupils, how worse are the levels of knowledge levels among primary school pupils?”

    Another cross sectional knowledge attitudes and practice study was conducted in Luanshya to among twelve year olds based on oral health. The study revealed that the awareness of oral health at the selected schools was adequate, (Abel, 2015). This study evaluated oral health and not oral hygiene as well. Despite the two being closely related, there is little literature concerning oral hygiene among primary school pupils in Zambia. In as much as knowledge of the levels of understanding that primary school pupils have towards oral health is important, it is equally important to assess their knowledge based on oral hygiene because it is oral hygiene that leads to good oral health

RESULTS

  1. Kitwe is a densely populated town in the Copperbelt province. With 44 primary schools divided into 8 zones at the time of the study. The zones where geographically demarcated and encompass different sociodemographic characteristics.

    Using Open data Kit, a total 399 pupils where interviewed with a response rate of 100%. It was noted that the majority of the participants where males (n = 231). The study only interviewed ten year olds and the majority of them had employed parents (59.1%) while the rest had unemployed parents. Most of the students live within 1 hour walk to the nearest oral health facility (63.9%) while a few live more than an hour away. The ratio of those that came from urban to peri-urban areas was 1:1.

     

    The study found that most students had good attitude (77.7%) and good knowledge (63.9%) but more than half or the pupils had bad oral hygiene practices (68.9%).

    KNOWLEDGE

    More than half (63.9%) of the students had good knowledge. 86% knew the importance of brushing teeth. 70 % knew the bad effects of sweets on their teeth. The majority knew the importance of using a toothpaste with calcium (60%) and fluoride (49%). The majority knew that they need to brush their teeth at least twice a day (87%) while only a few knew that they were supposed to visit a dentist at least twice a year (44%) (Table 4).

    ATTITUDE

    Assessment of attitude showed that majority of participants had a good attitude towards oral hygiene (77.7%), prevention of dental curies (89%) and the importance of oral health education at their school (88%). (Table 5)

    PRACTICES

    Notably, most pupils demonstrated that they had bad oral healthcare practice (68.9%). Most pupils practiced brushing teeth 3 times a day (32%) while some only once (14%) or never (n = 4, 1%). Majority of the pupils were helped by their parents to brush their teeth actively (30%) and passively (28%) while a few were not supervised (30%). Only a small number of them had been to the dentist (n = 144, 36%) and of those 73% liked the service they received. The few that did not like the service attributed it to pain (n = 18), fear (n = 16) and time wastage (n = 3). (Table 6)

    SOURCE OF ORAL HYGIENE INFORMATION

    Looking at the distribution of sources of information, the biggest source of information was their parents (38%). The pie chart illustrates the distribution in percentages. (Table 7, Figure 3)

    It was noted that there was no significant correlation between the level of knowledge and the attitude (p=0.331). (Table 8)

    DISCUSSION

    Knowledge on oral hygiene among 10-year-old primary school pupils was high. The reason for this could have been the increased awareness and improved primary school curriculum to inculcate good oral hygiene knowledge into the primary school pupil in Kitwe. This was in contrast to a study done in Mangalore, India, where only 45.5% of the participants demonstrated adequate knowledge. More than half of the pupils knew the importance of using a toothpaste that contains fluoride. Another study in Saudi in 2015 showed that only 29.6% of the participants knew the importance of fluoride in prevention of dental carries (Suprabha, et al., 2013). Another similar study in Nepal showed worse results of only 18% of the participants having adequate oral hygiene levels (Subait, et al., 2017). More than half of the pupils showed interest in oral health education being integrated into their curriculum.

    Most pupils demonstrated a good attitude towards oral hygiene. The pupils knew that it is their responsibility to ensure that they had good oral hygiene. There was no significant correlation between the level of knowledge and their attitudes (p = 0.331) and this contradicts a study done in Manipur where there was a positive linear correlation (r = 0.369, p < 0.01) (Pragya, et al., 2016).

    Oral hygiene practices were generally poor despite the high levels of knowledge. The area lucking most is the proportion of pupils that visited oral health care centres (46%). This is comparable to 30% and 32% in studies conducted in Bangalore, India and Saudi (Parker & Alkurt, 2011) (Neeraja, et al., 2009). It was very low compared to a similar study conducted in eastern India (92%) (Al-Shadan, 2016). This could be due to the pain associated to dental procedures like tooth extraction. More than half of the pupils brushed their two to three times a day. A study done in north Jordan yielded contrasting results stating that most of the pupils brushed their teeth once a day (Al-Omar, et al., 2006).

Table 1: Distribution Of Study Participants By Demographic Characteristics (N=399).

Table 2

Table 3: Frequency distribution of participants according to knowledge on oral hygiene

Table 4: Frequency distribution according TO ORAL hygiene attitude

Table 5: Frequency distribution of participants according to oral hygiene practice

Table 6: sources of knowledge.

Table 7: RELATIONSHIP BETWEEN LEVEL OF KNOWLEDGE AND ORAL HEALTH PRACTICES

Figure 1:Distribution of study participants by demographic characteristics (n=399).

Figure 2: distribution of sources of information on oral hygiene

Conclusion

The most alarming finding was the fact that most pupils did not have regular dental check-ups. The oral hygiene practices where generally poor among the participants. Otherwise, the levels of knowledge and attitude where high.

RECOMMENDATIONS

There is need for parents, teachers and the public media to emphasise more on the need to have regular dental check-ups. This will prevent patients from only visiting the dental clinics with advanced dental complications. There is also need for school curriculum to focus more on the practical aspect of oral hygiene like showing pupils how to brush their teeth correctly instead of just focusing on the theoretical aspect.

There is also need to educate parents and to-be parents on the importance of teaching their children good oral hygiene practices since parents are their main source of primary information about oral hygiene.

Conflict of Interest: The authors declare no conflict of interest

Funding: None

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