Oral Health and Hygiene among Nursing Staff: A Knowledge, Attitude, and Practice Study

ABSTRACT

Introduction:

An individual’s quality of life is dependent on the overall health and well-being. Due to the interdependence of oral health and systemic health, the oral cavity has been called as the mirror to the general health. Educative oral health measures are extremely important as major oral diseases can be deterred by appropriate knowledge and practice of good oral hygiene.

Methodology:

This web-questionnaire-based descriptive cross-sectional study included nursing staff of the institute for whom a pre-validated questionnaire as used by Tadin et al. was used to assess their knowledge about oral health and oral hygiene techniques. A sample size of 160 was obtained. Knowledge, practice, and attitude scores were calculated. Independent sample t-test was conducted for the test of significance.

Results:

The role of fluoride in the development of dental caries was known to 100 (62.5%) of the respondents, whereas reimplantation of an avulsed tooth was unknown to the similar percentage. The knowledge score obtained had a mean value of 12.74 (84.93%), the mean attitude score was 4.28 (42.8%), and the mean practice score was 4.51 (50.1%).

Conclusion:

This study provided us with an insight of the knowledge of oral health and awareness about the oral hygiene techniques and its practice among the nursing staff of the institute.

INTRODUCTION

The awareness about oral health is a basic for an individual to have a healthy life.[1] It has been observed that there is an increase in the awareness of health-related behavior or activities which are undertaken to prevent disease with age.[2] World Health Organisation (WHO) specifies that for an improvement of oral health, our focus requires a shift in the oral health care from invasive procedures toward prevention which is possible through education.[3] Oral diseases have been depicted as a major public health challenge. Among the most prevalent oral health concerns around the globe is dental caries followed by periodontal disease and malocclusion.[4] According to a report of the surgeon general on the oral health in America,[5] there are safe and effective measures to prevent the most common dental diseases—dental caries and periodontal diseases. Lifestyle behaviors, such as tobacco use, excessive alcohol use, and poor dietary choices, affect both general, oral and craniofacial health. Dental plaque is the major etiological factor behind both periodontitis and dental caries,[6] the two of them being preventable by establishing simple oral hygiene practices. Physicians and nurses have the opportunity to provide oral screening seven times more frequently than dentists.[7] Nursing officers deal with a lot of people of different ages, cultures, and backgrounds on a daily basis. They also act as role models to the patients and the community,[8] so their knowledge about oral health and hygiene is important for their personal hygiene as well as to encourage others and also for appropriate referral. A knowledge about the oral health status leads to better oral hygiene practices. Also, having a proper attitude and practice of it is important as in the absence of application, mere knowledge is of no use. Hence, the purpose of this study is to evaluate the knowledge, attitude, and practice of oral hygiene and oral health among nursing staff of the institute.

MATERIALS AND METHODOLOGY

Study design

This is a descriptive cross-sectional study which had been designed to understand the level of knowledge and attitude of the nursing staff of the institute toward oral health and hygiene. Based on findings of this study, educative programs on oral health measures can be planned and implemented. Clearance was obtained from the institutional research and ethical committee. (2023-1-IMP-EXP-5)

Study population

All 400-nursing staff of the institute were selected for the study. Those who did not consent were excluded later. So, the total number of responses recorded and analyzed was 160.

Data collection procedure

To understand the knowledge and attitude about various aspects of oral health, hygiene, and its various practices, an online survey form based on a pre-validated questionnaire as used by Tadin et al.[1] was designed on Google Forms. The link to the form was shared with the nursing officers via email. The research objectives were explained to all participants at the beginning of the questionnaire. Participation was entirely voluntary and anonymous. Reminder emails were sent thrice at an interval of a week to each for participation in the study. After a duration of one month, data were recorded as per the responses received.

Questionnaire contents

The multiple-choice questionnaire consisted of 36 questions divided into four parts. The first part consists of demographic details. The second part addresses the oral health knowledge. The third part gathers knowledge about the attitude toward the practice of different types of oral hygiene measures being used along with their frequency and duration. The fourth part talks about the use of dental service and helps in self-assessment of oral health using nine questions. The questions are enumerated in Table 1.

Table 1.

Frequency of knowledge, attitude, and practice responses

Frequency of knowledge responses	Level	Counts	Total	Proportion
1. Oral health is closely related to an individual’s general health.	Correct reply	159	160	0.994
	Wrong reply	1	160	0.006
2. Certain systemic diseases can manifest in the oral cavity	Correct reply	152	160	0.950
	Wrong reply	8	160	0.050
3. Oral health is closely related to an individual’s quality of life.	Correct reply	155	160	0.969
	Wrong reply	5	160	0.031
4. The most common oral diseases are dental caries, periodontitis, and oral cancer.	Correct reply	145	160	0.906
	Wrong reply	15	160	0.094
5. Poor oral hygiene can lead to the development of dental caries and periodontitis.	Correct reply	159	160	0.994
	Wrong reply	1	160	0.006
6. Diet affects the development of dental caries, periodontitis, and oral cancer.	Correct reply	144	160	0.900
	Wrong reply	16	160	0.100
7. Smoking is associated with the occurrence of oral cancer and periodontitis.	Correct reply	147	160	0.919
	Wrong reply	13	160	0.081
8. High alcohol intake is associated with an increased risk of developing oral cancer, periodontitis, and dental caries.	Correct reply	104	160	0.650
	Wrong reply	56	160	0.350
9. The hygiene and health of deciduous teeth are just as important as permanent dentition.	Correct reply	145	160	0.906
	Wrong reply	15	160	0.094
10. Proper oral hygiene can prevent dental caries and periodontitis.	Correct reply	160	160	1.000
11. Fluorides have a protective role in the development of dental caries.	Correct reply	100	160	0.625
	Wrong reply	60	160	0.375
12. Mouth-guards can prevent sports-related injuries to the teeth and soft tissues.	Correct reply	152	160	0.950
	Wrong reply	8	160	0.050
13. A permanent tooth avulsed from the mouth due to dental trauma can be returned to the oral cavity.	Correct reply	59	160	0.369
	Wrong reply	101	160	0.631
14. Sports drinks and energy drinks can damage the tooth surface and cause erosion.	Correct reply	132	160	0.825
	Wrong reply	28	160	0.175
15. Loss of teeth due to ageing is a physiological phenomenon that is not possible to prevent.	Correct reply	125	160	0.781
	Wrong reply	35	160	0.219
Frequency of Attitude responses	Level	Counts	Total	Proportion
1) How often do you brush your teeth with a toothbrush and toothpaste?	Correct attitude	33	160	0.206
	Wrong attitude	127	160	0.794
2) How often do you use fluoride toothpaste?	Correct attitude	5	160	0.031
	Wrong attitude	155	160	0.969
3) How long do you brush your teeth?	Correct attitude	86	160	0.537
	Wrong attitude	74	160	0.463
4) Toothbrush-hardness you use:	Correct attitude	91	160	0.569
	Wrong attitude	69	160	0.431
5) How often do you change your toothbrush?	Correct attitude	89	160	0.556
	Wrong attitude	71	160	0.444
6) What brushing technique you use?	Correct attitude	97	160	0.606
	Wrong attitude	63	160	0.394
7) How often do you use dental floss?	Correct attitude	26	160	0.163
	Wrong attitude	134	160	0.838
8) How often do you use interdental brushes?	Correct attitude	19	160	0.119
	Wrong attitude	141	160	0.881
9) How often do you use mouth rinse?	Correct attitude	99	160	0.619
	Wrong attitude	61	160	0.381
10) How often do you brush your tongue?	Correct attitude	140	160	0.875
	Wrong attitude	20	160	0.125
Frequency of Practice responses	Level	Counts	Total	Proportion
1) Frequency of visit to the dentist:	Bad practice	133	160	0.831
	Good practice	27	160	0.169
2) The reason for the last visit to the dentist:	Bad practice	124	160	0.775
	Good practice	36	160	0.225
3) Time of last visit to the dentist	Bad practice	124	160	0.775
	Good practice	36	160	0.225
4) Number of fillings (self-assessment)	Bad practice	64	160	0.400
	Good practice	96	160	0.600
5) Number of extracted teeth (self-assessment)	Bad practice	40	160	0.250
	Good practice	120	160	0.750
6) Number of endodontically treated teeth (RCT). (self-assessment)	Bad practice	48	160	0.300
	Good practice	112	160	0.700
7) Have you ever had bleeding gums?	Bad practice	50	160	0.313
	Good practice	110	160	0.688
8) Have you ever smelled an unpleasant breath from your mouth?	Bad practice	52	160	0.325
	Good practice	108	160	0.675
9) Have you ever felt tooth hypersensitivity?	Bad practice	76	160	0.475
	Good practice	84	160	0.525

Statistical analysis

Data collected were transferred to Microsoft Excel. The analysis of the data was performed by SPSS IBM software version 23.0. Descriptive analysis was conducted and frequency tables were made. Knowledge, practice, and attitude scores were calculated. Independent sample t-test was conducted for the test of significance and P value of <0.05 was considered statistically significant.

RESULTS

83.8% of the participants were more than 25 years of age, while 16.3% of the respondents were between 23 and 25 years. 71.9% of the respondents were females and 28.1% were males. Ten out of 15 questions were answered correctly by 90% or more of the participants. The role of fluoride in the development of dental caries was known to 100 (62.5%) of the respondents, whereas reimplantation of an avulsed tooth was unknown to the similar percentage. A total of 123 (77.4%) individuals brushed their teeth only once daily in the morning, whereas research recommends night time brushing as well. 16.4% have never visited a dentist contrary to 22% who visited for regular checkups. The self-assessment part of the questionnaire revealed that 20–32% had Decayed Missing Filled Teeth (DMFT) score of ≥3. 32% of the respondents complained of having bleeding gums and unpleasant breath while 47.5% showed tooth hypersensitivity [Table 1]. The knowledge score obtained had a mean value of 12.74 (84.93%), the mean attitude score was 4.28 (42.8%), and the mean practice score was 4.51 (50.1%). P value was obtained for these scores based on age ranges and gender which was significant for attitude score gender wise [Table 2].

Table 2.

Knowledge, attitude, and practice scores

	n	Minimum	Maximum	Mean	Std. deviation	P based on age	P based on gender
Knowledge score	160	7.00	15.00	12.7438	1.84373	0.263	0.810
Attitude score	160	1.00	9.00	4.2813	1.48015	0.335	0.001
Practice score	160	1.00	9.00	4.5125	2.05884	0.333	0.447

DISCUSSION

To have a good oral hygiene, the practice of toothbrushing twice daily with multiple aids has been advised. For the healthy gingiva, American Dental Association (ADA) recommends the placement of toothbrush at a 45-degree angulation to the tooth surface and gum line and giving short back and forth strokes.[9] Use of adjuncts like tongue brushing and mouthwash along with daily tooth brushing and flossing increases oral hygiene. Use of fluoridated mouthwash prevents the decay of teeth.[10] Although a good knowledge of oral hygiene is necessary for better practice, the attitude toward it also plays an important role. WHO recommended dentist to population ratio for developing countries is 1:7500 while the same recorded for the state of Uttar Pradesh in India in the year 2019 is 1:12000 in the urban areas, while in rural areas it ranges from 1:30,000 to 1:1,00,000.[11] Due to this insufficiency, all health personnel should have a basic knowledge about oral hygiene so that they can spread awareness in the community. Also, the nursing staff tends to spend more time in the care of admitted patients in a hospital setting and has more chances of educating them for their oral hygiene care. Hence, the knowledge and attitude of the nursing officers toward oral hygiene is of great importance.

All the respondents agreed that oral health is closely related to general health and poor oral hygiene can lead to the development of dental caries and periodontitis. Also, taking proper care of oral hygiene will help prevent them. Ninety-five percent or more concur that certain systemic diseases manifest in the oral cavity; therefore, oral health is closely related to individuals’ quality of life.

More than 90% of the respondents have knowledge that most common oral diseases are dental caries, periodontitis, and oral cancer and also that diet affects their development. They also accord that smoking is associated with the occurrence of oral cancer and periodontitis and that the hygiene and health of deciduous teeth are as important as permanent dentition. Our results are similar to the study of Karaca and Bakir[12] who recorded smoking to be a risk factor by 81.9% of individuals. 65.4% responded agreed for high alcohol intake association with increased risk of oral cancer, periodontitis, and dental caries. Rai et al.[13] conducted a study on tertiary education students and general public in Singapore, in which 55% of the nonmedical students and 42% of the general public agreed for alcohol to be a risk factor for oral cancer. 82.4% of the respondents knew about sports drink causing erosion to the tooth surface; 78% about physiological tooth loss due to ageing and 62.9% about fluoride having a protective role in the development of dental caries. Similar results were obtained by Jiang et al.[14] in China, where 70.1% had knowledge about the role of fluoride in prevention.

A contradiction to all the questions was the poor knowledge about dental avulsion, which was present only in 37.1% of the respondents counter to 95% knowledge about the use of mouth-guards in the prevention of sports-related injuries. Similar results were concluded by Çalışkan et al.[15] in nurses and emergency physicians.

Only 20.8% of the respondents brushed their teeth twice daily similar to the study of Karaka and Bakir.[12] Contrary to this, 89% nursing students in Denmark brushed twice daily.[16] Various studies have quoted increased plaque removal by electronic brushes as compared to manual by 41%,[17] but in our study, only 2.5% of individuals are using electronic brushes. Use of dental floss, mouthwashes, interdental cleaning aids, and tongue cleaning have been reported to aid in oral hygiene and prevent dental caries and periodontitis.[18] 74–76% nursing staff had rarely or never used dental floss or an interdental brush as adjuncts, but 61.8% showed an ease with the habit of using a mouth rinse. 87.5% respondents cleaned their tongue daily.

Our study reveals that the attitude of the nursing officers toward oral health is inadequate despite good knowledge, as 32% have never visited the dentist while 37% visited only in adverse situations like pain and swelling. The results were in concordance with a study performed by Rambabu and Koneru, who also concluded that people visited a dentist when the severity of their problem increased.[19] Moderate self-assessment scores elucidate a need to educate them to visit the dentist more frequently so that prevention and early detection of oral diseases can be taken care of.

The knowledge score obtained was 84.93% which was good,[20] the attitude score was 42.8% and the practice score was 50.1% which were both moderate. There was a significant difference in the attitude of male vs. female nurses, which can be seen by a P value of 0.001. This difference between the good knowledge score and the moderate scores of attitudes and practice gives us a clear understanding toward the neglect shown toward oral health. There is a need to create motivation toward the implementation of the knowledge present for obtaining a good oral health.

CONCLUSION

Based on the results of the current study, it can be concluded that the knowledge, attitude, and practice about oral health and hygiene need to be improved among the nursing officers. Nursing officers are considered to be the backbone of any hospital setting. Educating and motivating them can help the society at a larger scale, as they have increased chances of spreading awareness among the people around them as well as while taking care of the admitted patients in the wards.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.