Closing the gap in oral hygiene: prevalence of twice-daily toothbrushing among adults in Saudi Arabia: a systematic review and meta-analysis

Abstract

Background

Oral diseases are among the most prevalent non-communicable conditions globally, with inadequate toothbrushing contributing to high rates of dental caries and periodontal disease. International guidelines recommend brushing at least twice daily with fluoride toothpaste, yet adherence varies across regions. In Saudi Arabia, where oral disease burden is high, national data on brushing practices remain fragmented. This systematic review and meta-analysis aimed to determine the prevalence of twice-daily toothbrushing among Saudi adults.

Methods

A systematic search of PubMed, Scopus, and Web of Science was conducted up to April 2024, supplemented by manual screening of references. Observational studies reporting toothbrushing frequency among Saudi adults (≥ 18 years) were eligible. Data extraction was performed independently, and risk of bias was assessed using the Joanna Briggs Institute appraisal tool. Pooled prevalence estimates were calculated using random-effects meta-analysis, with subgroup analyses by gender and brushing duration.

Results

Twenty-nine studies (n = 17,734) met inclusion criteria, of which 18 studies (n = 11,865) contributed to the meta-analysis. The pooled prevalence of twice-daily toothbrushing was 44.6% (95% CI: 37.6–51.8%), with high heterogeneity (I² = 98.3%). Subgroup analysis revealed gender disparities, with 25.8% of females brushing twice daily compared to 12.2% of males. Data from two studies indicated that 45.3% of adults adhered to the recommended two-minute brushing duration. Funnel plot and statistical tests indicated no significant publication bias.

Conclusion

Fewer than half of Saudi adults practice twice-daily toothbrushing, with notable gender and regional disparities. These findings highlight the urgent need for targeted oral health promotion, particularly among men, and support the integration of structured awareness and prevention strategies into national health policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-07794-w.

Introduction

Oral diseases remain among the most prevalent noncommunicable conditions worldwide, affecting an estimated 3.7 billion people [1]. Fortunately, these conditions are largely preventable through simple hygiene measures [2]. At the centre of oral disease prevention is regular toothbrushing, a practice that disrupts and removes dental plaque, the biofilm responsible for enamel demineralisation, caries development, and gingival inflammation. International professional guidelines emphasise brushing at least twice daily for two minutes with fluoride toothpaste as the gold standard for maintaining oral health [3]. The American Dental Association, for example, explicitly recommends this regimen as the standard of care [4]. In contrast, inadequate or infrequent brushing allows plaque accumulation, elevating the risk of both dental caries and periodontal disease [2].

Despite such clear recommendations, toothbrushing behaviours vary significantly across populations. Globally, the most common health condition is untreated dental caries in permanent teeth, which indicates there are persistent gaps in preventive care [5]. A study by Yifang Liu and colleagues revealed striking regional differences in brushing frequency: while approximately 83% of individuals in the Americas and Western Pacific report brushing twice daily, only around 41.4% achieve this frequency in the Eastern Mediterranean region, which includes the Kingdom of Saudi Arabia (KSA) [6]. These disparities highlight the uneven adoption of recommended hygiene practices and point to the need for regional data to inform tailored interventions.

In Saudi Arabia, lifestyle transitions over recent decades have intensified the oral health burden. Increased consumption of free sugars, coupled with high rates of tobacco use, has contributed to rising levels of dental caries [7, 8]. Meta-analyses show that between 68% and 75% of Saudi children and adults have caries in their permanent dentition, reflecting one of the highest prevalence rates globally [7]. Contributing to this burden are suboptimal oral hygiene habits; a 2013 national health survey of individuals aged 15 years and older reported that 16.3% had never brushed their teeth, and only 71.5% brushed at least once daily [9]. Similarly, the 2017 Saudi Demographic and Health Survey, which included participants aged 5 years and above, found that on average, the majority brushed less than once per day [10]. Collectively, these findings suggest that only a minority of the Saudi population consistently meets the recommended twice-daily brushing standard, with clear implications for oral health outcomes.

While these surveys provide valuable insights, the available evidence is fragmented. Many studies only report average brushing frequency, combine children and adults, or use heterogeneous methodologies, making it difficult to establish a reliable picture of toothbrushing practices among Saudi adults [5]. To date, no systematic review or meta-analysis has comprehensively synthesised this evidence to determine the prevalence of recommended brushing behaviours in the Saudi adult population. Such an assessment is necessary, as higher brushing frequency has been consistently associated with reduced risk of caries and periodontal disease in multiple populations worldwide.

Beyond its clinical relevance, understanding toothbrushing behaviours carries important public health and policy implications. Saudi health authorities have already recognised this gap, noting that oral hygiene practices remain uncommon and calling for structured awareness and education programmes through primary healthcare services. A clear synthesis of brushing practices could provide a benchmark for evaluating the success of such interventions and guiding the allocation of resources. Identifying population subgroups with particularly low adherence could also support the design of targeted health promotion campaigns that could be implemented through schools, workplaces, and media platforms.

This paper, therefore, presents a systematic review and meta-analysis that aims to consolidate the existing evidence on toothbrushing frequency and practices among Saudi adults. By quantifying adherence to the recommended twice-daily brushing regimen, this study sought to fill an important evidence gap to inform strategies for oral disease prevention and support the development of effective health promotion and policy initiatives in Saudi Arabia.

Methodology

Protocol and ethical aspect

The systematic review was conceptualised and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria [11]. As the data for this review exclusively drew on previously collected studies and did not involve direct human participation, ethical approval was not required.

Focused question

This study aimed to determine the frequency of toothbrushing practice in Saudi Arabian adults based on CoCoPop (Condition, Context, and Population) criteria [12]. CoCoPop is a widely and commonly accepted framework for determining incidence in systematic reviews. In this review, the condition (Co) is toothbrushing practice, the context (Co) is adults ≥ 18 years, and the population (Po) is Saudi Arabians. Therefore, the formulated research question is “What is the prevalence of twice daily toothbrushing in the adult population of Saudi Arabia?”

Eligibility criteria

Studies were considered eligible if they met the following criteria:

• (i)All types of observational studies (cohort, cross-sectional and national/oral health surveys) reporting data on prevalence.
• (ii)Studies that include adult participants from the general population of Saudi Arabia (e.g. households, university students) to ensure representation of the broader community.
• (iii)Studies that report the frequency of toothbrushing with sufficient information to derive a prevalence in their outcome.
• (iv)Studies published in the English language.
• (v)Studies published up to April 2024.

The exclusion criteria were case reports/series, letters to the editor, abstracts, studies conducted outside Saudi Arabia, studies with a paediatric sample, unpublished work, systematic reviews, meta-analyses, and studies that did not provide enough clear information on oral hygiene practice to compute the prevalence.

Information source and search strategy

A comprehensive search strategy was implemented in three databases (Web of Science, Scopus, PubMed) from inception to April 2024. Searches of the electronic databases were combined using controlled vocabulary and free-text terms such as “Saudi Arabia”, “toothbrushing” and “prevalence”. The searches were tailored according to each database to optimise the retrieval of articles. Complete, database-specific search strings are provided in the Supplementary Materials, Table S1.

The reference lists of included articles were also searched, and relevant reviews were hand-collated, and forward citation tracking was undertaken to look for articles that could have been missed during the electronic search. The authors of the shortlisted articles were contacted by email to retrieve any missing data. In the case of non-respondence, the article was excluded from the review.

Selection process

All the retrieved records were imported into Microsoft Excel, and duplicates were removed. Stage 1 screening involved two reviewers (AB, ZM) independently screening the titles/abstracts against the eligibility criteria. Stage 2 screening involved the two reviewers studying the full texts of potentially relevant articles in detail to examine their quality. Disagreements at any stage were resolved through discussion with a third reviewer (MA). Inter-reviewer agreement was quantified using Cohen’s kappa during both the title/abstract and full-text screening stages. Reasons for exclusion at the full-text stage (Stage 2) were documented. The study selection process is summarised in the PRISMA flowchart in Fig. 1.

Fig. 1.

PRISMA flowchart

Study quality assessment (Risk of Bias)

Risk of bias for each included study was assessed independently by two reviewers (AB, ZM) using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies [13]. This checklist consists of eight questions with four response options (yes, no, unclear, and not applicable). In this study, a total percentage score was derived. Each study was categorised under a different level of bias, ranging from low (80–100%), moderate (50–80%), to high (20–50%). The third reviewer (MA) resolved any disagreement between the first two reviewers regarding methodological quality assessment.

Data synthesis and statistical analysis

The reviewers extracted the data into a Microsoft Excel spreadsheet. The required information was obtained in a tabulated form based on formulated research questions: author’s name, study design, funding source(s), sample size, sampling method, and geographic setting (region).

Raw (unadjusted) data of adults who brushed their teeth twice a day, with 95% confidence intervals (CIs), were used for the primary meta-analysis as well as the subgroup analysis. To stabilise the variances across proportions, particularly where values approached 0% or 100%, the study proportions were transformed prior to pooling using the Freeman–Tukey double arcsine method. Random-effects meta-analysis (DerSimonian–Laird) was applied a priori to account for expected between-study heterogeneity, and pooled estimates were back-transformed to proportions for interpretation. Statistical heterogeneity was assessed with Cochran’s Q and quantified using I², with values of ~ 25%, ~ 50%, and > 75% interpreted as low, moderate, and high heterogeneity, respectively. Medcalc version 23.2 statistical software was used to perform meta-analysis.

Results

Study selection

The comprehensive search of the electronic and manual databases identified 471 records. Around 104 articles were excluded during de-duplication. This left 367 articles for title/abstract screening; 284 were then disqualified for not fulfilling the eligibility criteria. The remaining 83 were included for full-text assessment, and ultimately, 30 articles qualified for qualitative assessment, of which 18 articles were suitable for meta-analysis, with a total sample size of 11,865 (Fig. 1).

Study characteristics

Supplementary Materials, Table S2 shows the 30 included studies that reported on toothbrushing behaviour, met the inclusion criteria, and were published between 2001 and 2024, comprising a total of approximately 17,985 participants. The sample sizes ranged from n = 50 [14] to n = 2023 [15], and the studies were from all regions of Saudi Arabia. All included studies were cross-sectional in nature except one [16], which was a randomised controlled trial on the modified fluoride toothpaste technique. Eleven studies were conducted in the central and eastern regions (e.g. Riyadh) [14, 16–25], a further 10 studies were conducted in the in the western region (Jeddah/Makkah/Madina) [26–35], and three studies were conducted in each of the southern region (Aseer) [15, 36, 37], the northern region [38–40], and other parts of Saudi Arabia [41–43]. All but four of the included studies [17, 20, 28, 29], which only recruited male participants, involved both sexes. Five of the 29 studies explicitly reported their funding source, and all were published in indexed journals.

Quality assessment

Figure 2 shows that approximately 73% of the included studies had a moderate risk of bias. Out of the 30 included studies, only two [34, 43] reported on the 2-minute toothbrushing practice, which is the gold standard recommended by dental care professionals. Six studies [16, 30, 32, 33, 37, 40] were deemed as good quality with a low risk of bias. Almost all the included studies clearly mentioned their inclusion/exclusion criteria; however, two studies [15, 38] fell into the high risk of bias category.

Fig. 2.

Quality assessment of studies using the JBI Checklist for cross-sectional studies Moola et al. [13]

Quantitative results

Figure 3 shows that 18 studies reported on the practice of toothbrushing twice and were analysed using dichotomous meta-analysis. Each participant who took part in the study was termed a sample, whereas those who reported brushing twice were called an event. The overall proportion of Saudi Arabian adults adhering to this practice was statistically significant (p < 0.0001), with a corresponding 95% CI (37.6–51.8%). Furthermore, the estimated pooled prevalence was 44.6, and the heterogeneity was also found to be high across studies (I² = 98.3%).

Fig. 3.

Toothbrushing practice among adults in Saudi Arabia

Subgroup analysis (Fig. 4) revealed notable differences between population groups. The pooled prevalence among male participants was 12.2% (95% CI: 7.5–18.0%), while females showed a higher prevalence of 25.8% (95% CI: 15.8–37.3%). Furthermore, based on two studies, the estimated pooled prevalence for the recommended 2-minute toothbrushing practice was 45.3% (95% CI: 20.5–71.4%). All the subgroup analyses showed statistical significance (p < 0.0001), with high heterogeneity (I² > 98%), reflecting substantial variability between studies. Funnel plot readings suggested no major asymmetry, and the statistical tests for publication bias supported these findings (Egger’s test, p = 0.9539; Begg’s test, p = 0.9698), indicating no significant bias. These results strengthen our confidence in the robustness of the pooled prevalence estimate.

Fig. 4.

Subgroup analysis

Discussion

This present systematic review and meta-analysis revealed that less than half of Saudi Arabian adults adhered to the recommended twice-daily toothbrushing practice. The pooled prevalence of brushing at least twice per day was 44.6%, which indicates that more than half of the adults did not meet optimal oral hygiene frequency. This finding closely aligns with a previously reported prevalence rate of 44.4% from China [44]. In contrast, significant level of reduction in toothbrushing practice have been observed in general population of Ethiopia (12.2%) [44].

This review underscores a substantial gap between current behaviours and professional guidelines, which typically advise brushing twice daily with fluoride toothpaste [3, 4]. Notably, there are pronounced gender disparities. In our meta-analysis, female participants were significantly more likely to brush twice daily than their male counterparts: the prevalence of twice-daily brushing was approximately 25.8% among females versus only 12.2% among males. This trend supports observations from previous studies in Saudi Arabia. For example, Abogazalah et al. [5] reported that more than half of women brushed twice daily, while a large proportion of men brushed only once daily or not at all. These findings highlight a clear gender gap in oral hygiene, whereby women generally exhibit better brushing habits than men, a pattern that mirrors global trends [5]. The high male deficit in twice-daily brushing is a critical insight from this review and suggests that men in Saudi Arabia may require targeted interventions to improve their oral hygiene practices.

Beyond gender, the included studies hinted at other subgroup differences. Several reports indicated that younger adults tend to brush more frequently than older adults. In one multi-regional Saudi survey, individuals under 40 years old had significantly higher odds of brushing twice daily than those over 60 [5, 33]. Socioeconomic and educational factors also appear influential; participants with higher education levels and better oral health knowledge showed more frequent brushing behaviours [33]. Conversely, smokers and individuals with lower health awareness were less likely to maintain a twice-daily regimen [5, 33]. These findings reinforce that toothbrushing frequency in Saudi Arabia is not uniform across the population but varies with demographic and lifestyle factors such as age, gender, education, and smoking status.

The prevalence of twice-daily brushing ranged widely across studies, methodologies, and settings, reflecting genuine variability among communities. This was evident in our meta-analysis through the high heterogeneity (I² = 98.3%). Similarly, a 2017 nationwide health survey reported that only 15.3% of Saudis brushed twice daily [10], a figure far lower than our pooled estimate. In contrast, local surveys focusing on specific cities or age groups reported rates approaching 45–50% [34]. This suggests that brushing practices differ markedly by region or sample characteristics, and the pooled estimate in this current study should be interpreted cautiously as a national average due to this broad variation.

The included studies also indicated regional and socioeconomic disparities, where residents of large urban centres (particularly in the Western Province) reported better oral hygiene behaviours than those in other regions. The Western region—home to cities such as Jeddah and Makkah—was associated with higher odds of frequent brushing, whereas central or rural areas lagged behind [5]. Economic factors such as income and access to dental care were also associated with better hygiene practices. Individuals with regular dental visits or those who could afford oral care products were more likely to maintain a twice-daily brushing routine. Although detailed socioeconomic analyses were limited in most included studies, our qualitative synthesis suggests that inequities in oral health behaviour exist and should be considered in public health planning.

This is the first comprehensive systematic review and meta-analysis focusing on toothbrushing practices in Saudi Arabia. Examining 30 included studies from a broad timespan and diverse populations provides a robust overview of oral hygiene behaviours across the country. Quantitatively pooling data from 18 studies and estimating the overall prevalence of twice-daily brushing offers a benchmark figure for Saudi adults that was previously unavailable. Subgroup and qualitative syntheses helped interpret the nuances behind the numbers by identifying consistent patterns, such as the gender gap, and contextual factors from studies that could not be meta-analysed. The review followed PRISMA guidelines [11] and employed a rigorous search strategy, duplicate screening, and quality appraisal using the JBI checklist [13], ensuring methodological soundness and minimised bias.

Another strength of this review lies in its combined quantitative and qualitative approach: it not only pooled prevalence data but also synthesised findings on knowledge, attitudes, and behaviours, producing a richer and more policy-relevant discussion. Moreover, many included studies were recent, reflecting the current oral hygiene landscape in Saudi Arabia. Comparing Saudi data with international findings further situates this review within the global oral health context, strengthening its relevance for regional and global policymakers.

Despite these strengths, several limitations must be acknowledged. Most included studies were cross-sectional surveys with self-reported outcomes and, in some cases, convenience sampling. Self-reported toothbrushing frequency is susceptible to recall and social desirability bias, with participants potentially over-reporting desirable behaviours. Consequently, the true prevalence of twice-daily brushing might be somewhat lower—or occasionally higher if miswakuse was not accounted for. The high heterogeneity (I² > 98%) reflects methodological inconsistencies and population differences among studies.

Another limitation concerns potential publication bias. Although Egger’s and Begg’s tests indicated no significant bias, it remains possible that studies reporting low adherence or conducted in certain communities were not published or accessible. Urban bias in published research may also have skewed national estimates, particularly since the Northern and Southern regions were underrepresented [37–40]. Therefore, our findings may be less generalisable to these understudied populations.

Furthermore, this review focused exclusively on twice-daily brushing, without incorporating other hygiene behaviours such as flossing, mouthrinsing, or professional cleanings. While this focus ensures consistency, it limits conclusions about overall oral hygiene quality. Individuals brushing once daily but also flossing and using fluoride products may still achieve favourable outcomes. Nonetheless, brushing frequency remains a widely accepted indicator and was the most consistently reported metric across studies [5, 10, 33].

Finally, this review highlights the urgent need for standardised, nationally representative research on oral hygiene practices in Saudi Arabia. Future studies should employ unified definitions (e.g., clear criteria for “twice-daily brushing” and inclusion of miswak), validated instruments, and objective measures such as plaque scoring or clinical observation. A nationwide oral health survey with detailed regional, demographic, and behavioural stratification would be invaluable for accurately mapping toothbrushing behaviours and guiding public health interventions.

Conclusion & recommendations

This systematic review underscores the importance of sustained investment in oral health promotion as a public health priority consistent with Saudi Vision 2030 objectives for preventive healthcare transformation. However, by addressing gender and regional disparities and elevating overall adherence to optimal toothbrushing practices, Saudi Arabia can align more closely with global benchmarks in oral hygiene. Over time, this would likely reduce the national burden of dental caries and periodontal disease.

Improving twice-daily toothbrushing among Saudi adults is an achievable and cost-effective strategy that can significantly enhance oral health outcomes. Preventive strategies should prioritise at-risk groups and adopt a multifaceted approach integrating education, community engagement, school-based programmes, and supportive national policies.

Authors’ contributions

AAS, AB, Malik ZUA, MA, FLA, and AAM contributed to the concept of the research, study design, data collection, supervision, statistical analysis, writing the original draft, and reading and editing the final paper.

Funding

No funding.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent participate.

Not applicable.

Consent for publication

“Not Applicable”.

Competing interests

The authors declare no competing interests.