LLL2: an international global level questionnaire on toothbrushing and use of fluoride toothpaste

Abstract

Purpose: To determine the evolution of toothbrushing frequency and use of fluoridetoothpaste in the FDI–Unilever partnership Live.Learn.Laugh. phase 2 programme using a self-reported questionnaire. Methods: The study was conducted in 23 countries. The key focus of this partnership was to educate people about the benefits of twice-daily brushing with fluoride toothpaste and to support people in adopting this important oral health behaviour. The partnership offers a choice of four project options to the local partnership team of the National Dental Association and local Unilever-operating companies. A self-report questionnaire was used in all participating subjects in local projects to evaluate the brushing frequency, the brushing timing and the use of fluoride toothpaste. Results: After implementation of the project interventions, a clear improvement in the reported frequency of brushing twice a day, regardless of the type of project, was observed. Subjects also increased day and night brushing and the use of fluoride toothpaste. Conclusion: The strategy of using mothers to increase healthy behaviours in oral health achieved the greatest increase in twice-daily toothbrushing, followed by the intervention in schools.

INTRODUCTION

The promotion of oral health in children and adolescents has been prioritised by the World Health Organisation (WHO) for the improvement of oral health globally¹. Children and adolescents are in particular need of oral health-promoting programmes². Poor oral hygiene, in terms of increasing accumulation of plaque and calculus with increasing age, has been reported among children and adolescents in both developed and developing countries3., 4.. This situation might lead to dental caries and periodontal problems later in adult life. In addition, socio-economic status has a profound effect on health and health behaviours⁵. Inequality in health and oral health has not been focused on to the same extent in adolescents as in adults6., 7.. Evidently, the lower the material standard of living, as measured by income, social class and social network and support, the worse the level of oral health, whatever the measures used, being clinical or self-reported oral health indicators. There is a recognised need to deliver oral health information to people to enable them to develop personal skills in managing their own oral health. Whilst poor oral health conditions are almost completely preventable, data on the prevalence of disease indicate that preventive approaches are often ineffective. There is little doubt that oral health behaviours are inextricably connected to the other behaviours that people apply to cope with their lives⁸. There is a need to advance this thinking to develop a model for effective oral health promotion⁹.

In a systematic review of oral health promotion, Kay and Locker¹⁰ concluded that oral health promotion is successful in reducing caries if it brings about the use of fluoride-containing agents.

Improvements in oral health have been demonstrated around the world, with decreasing estimates of both caries and periodontal diseases. Regarding dental caries, this decline has occurred in both developed3., 4. and developing¹¹countries. The improvement in the epidemiological picture in terms of oral health has been related to several factors, including water fluoridation, different preventive programmes and especially the widespread consumption of fluoridated dentifrices. WHO has elected the use of fluoride as a priority to achieve oral health, together with healthy dietary habits¹. However, only one preventive approach is common to virtually all countries that have experienced caries decline: the introduction of regular and widespread use of fluoridated dentifrice¹².

Fluoride toothpastes are the most widely used form of fluoride delivery and have been shown, based on several systematic quantitative evaluations, to be effective anti-caries agents13., 14.. The efficacy of fluoride is determined by the toothpaste formulation and the toothbrushing behavioural and biological factors¹⁵. Brushing twice per day or more has a greater preventive effect than brushing once per day¹³ and should be recommended for most individuals. Ideally, brushing should be performed in the morning, after meals and immediately before bed¹⁶.

The aim of the present study was to determine the evolution of toothbrushing frequency and use of fluoride toothpaste using a self-reported questionnaire in national projects that were run as part of the global FDI–Unilever partnership known as Live.Learn.Laugh. (LLL) phase 2.

MATERIALS AND METHODS

Study design

The present study was conducted as part of a larger study on oral health promotion in 23 countries, within the context of a global partnership between FDI World Dental Federation and Unilever plc, known as LLL phase 2. This supported individual partnership projects with National Dental Associations (NDAs) and local Unilever Oral Care partners in the different countries. The key focus of all the national partnership projects was to educate people about the benefits of twice-daily brushing with fluoride toothpaste and to support people in adopting this fundamentally important oral health behaviour. In addition to the promotion of health messages, a project was implemented with the aim of empowering the NDAs and member dentists as agents of oral healthpromotion within their communities. Their health-promotion efforts were supported by health-promotion materials and aids that were produced as part of the partnership. Further details on the global methodologies and coordination of the partnership projects are provided in a companion paper in this supplement.

Project options

The LLL phase 2 construct offered local partners (NDAs and local Unilever brands) a choice of four project options:

• •Project Option A, Mother and Child Focus: this option aims to promote oral health by increasing collaborations and contact between dentists and obstetricians, and dentists and pregnant women and mothers of young children (from 12 months to 6 years of age)
• •Project Option B, School Child Focus: NDAs and dentists to promote oral health through school-based toothbrushing programmes
• •Project Option C, Dental Patient Focus: the NDA and its member dentists disseminate the ‘brush twice-daily message’ to their patients and to health-care providers within their community
• •Project Option D, Community Focus: this option provided the opportunity to reach a specific target group in a community to provide oral health education, disseminate the ‘brush twice-daily message’ and demonstrate brushing.

Questionnaire on behavioural indicators

A questionnaire was used to collect self-report data from all subjects participating in the national projects. The common core indicators, questions and possible answers provided by the respondent during the surveys are described below:

Brushing frequency:

• •
  How often do you* brush your teeth?

  • •
    Never
  • •
    Once a day
  • •
    Once a week/rarely
  • •
    Twice or more a day
  • •
    Don’t know/not sure
  • •
    Refused.

Brushing time:

• •
  What time of day do you* brush your teeth?

  • •
    Morning
  • •
    Evening
  • •
    Morning and evening
  • •
    Don’t know/not sure
  • •
    Refused.

Usage of fluoride:

• •
  Do you* use toothpaste containing fluoride?

  • •
    Yes
  • •
    No
  • •
    Don’t know/not sure
  • •
    Refused.

*‘you’ was replaced with ‘your child’ in the questionnaires of Option A projects.

These variables were collected at baseline (T0) and 12 months after the first intervention (T1).

Data analysis

The data collected by each national project were centralised for global analysis at the FDI Head Office in Geneva. Raw data had been obtained and recorded using standardised and harmonised questionnaires and forms across the different projects. This was to facilitate the data recording and processing locally as well as to ensure alignment and quality of the data collection and data archive at the global level. The individual project database went through multiple rounds of quality control to identify missing data and to detect and clean outliers before compilation within a global database, gathering all questionnaire data collected, for all countries. The main outcomes and quantitative results of global level analysis were summarised in tables giving the main statistics (sample size, percentages, average, mode, standard deviation, specifics, etc.). Analyses were performed using SPSS-18.0 (SPSS Inc., Chicago , IL, USA).

RESULTS

Table 1 shows the baseline results for the 24 participating projects from 23 countries. At baseline, reported twice-daily brushing frequency varied from 45.9% (School Child Focus projects) to 77.7% (Dental Patient Focus projects). Reported use of fluoride toothpaste varied from 91.9% to 100%. Table 2 shows the comparisons between baseline and 12 months of follow up for brushing frequency and use of fluoride toothpaste. Of the 6,826 subjects for whom data were available at the time of the global analysis, complete information was obtained for 6,124 (89.7%). After implementation of the project interventions, a clear improvement in the frequency of brushing twice a day, regardless of the type of project, was observed. Subjects also increased day and night brushing and the use of fluoride toothpaste, but only in Project Options B (School Child Focus) and C (Dental Patient Focus). Table 3 shows the influence of gender, age and educational level on brushing habits and use of fluoride toothpaste at baseline and after 12 months. Regarding gender, at baseline 55% of men and 58% of women brushed twice a day (P = 0.01). These differences disappeared after implementation of the programme. No differences were observed in day and night brushing or in the use of fluoridated toothpaste at baseline and after 12 months, according to gender. At both baseline and after 12 months, frequency of brushing was higher in older age groups. At both baseline and after 12 months, the 6–15 years’ age group had the highest use of fluoride toothpaste. Increased use of fluoride toothpaste following intervention was observed in all age groups. At baseline, the level of education was not related to any variable studied. Regardless of the level of education of the subject, all variables improved after implementation of the programme. The frequency of brushing twice a day was found to be higher in subjects with the highest educational levels.

Table 1.

Brushing frequency and fluoride toothpaste use at baseline (T0) according to type of project and country

Project and country	Age, years (mean ± SD)	Total toothbrushing sample number	Brushing twice daily		Brushing day/night		Use of fluoride toothpaste
			n	%	n	%	n	%
Project A		4,617	2,911	63.0	2,900	99.6	4,244	91.9
Croatia	–	3,020	2,059	68.2	2,059	100.0	3,020	100.0
Czech Republic	–	997	767	76.9	756	98.5	993	99.6
Morocco	2.7 ± 1.3	600	85	14.2	85	100.0	231	38.5
Project B		27,952	12,849	45.9	7,952	99.9	18,784	95.7
Bangladesh	6.7 ± 0.4	600	14	2.3	14	100.0	569	94.8
Cambodia	6.0 ± 0.0	1,003	602	60.0	602	100.0	1,003	100.0
Chile CCDC	7.2 ± 0.5	990	645	65.2	645	100.0	970	97.9
Egypt	9.1 ± 0.7	1,326	591	44.6	591	100.0	1,256	94.7
Greece HAD	2.7 ± 0.6	468	112	23.9	112	100.0	449	95.9
Greece SSG	33.2 ± 10.7	352	105	29.8	105	100.0	344	97.7
Hungary	6.8 ± 0.4	911	584	64.1	584	100.0	902	99.0
Indonesia	10.8 ± 0.4	1,617	1,282	79.3	1,282	100.0	1,612	99.7
Kenya	7.4 ± 4.1	3,897	1,001	25.7	1,000	99.9	3,347	85.9
Myanmar	6.5 ± 0.5	592	369	62.3	369	100.0	587	99.1
Nigeria	13.5 ± 0.5	8,323	4,894	58.8	–	–	–	–
Pakistan	–	3,864	618	16.0	616	99.6	3,864	100.0
South Africa	8.8 ± 2.5	1,584	561	35.4	561	100.0	1,506	95.0
Sudan	–	1,197	607	50.7	607	100.0	1,162	97.0
Turkey	36.5 ± 5.2	210	105	50.0	105	100.0	202	96.2
Vietnam	–	1,018	759	74.6	759	100.0	1,011	99.3
Project C		1,366	1,062	77.7	1,062	100.0	1,366	100.0
China	27.8 ± 6.5	704	443	62.9	443	100.0	704	100.0
Germany	11.4 ± 3.8	65	62	95.4	62	100.0	65	100.0
Italy	42.2 ± 16.7	597	557	93.3	557	100.0	597	100.0
Project D		6,361	3,916	61.5	3,915	99.9	6,348	99.7
India	25.6 ± 11.6	5,760	3,375	58.6	3,374	99.9	5,751	99.8
Philippines	4.1 ± 0.8	601	541	90.0	541	100.0	597	99.3

Project A, Mother and Child focus; Project B, Schoolchild focus; Project C, Dental Patient focus; Project D, Community focus. Chile-CCDC, Colegio Cirujanos Dentistas de Chile; Greece HDA, Hellenic Dental Association; Greece SSG, Stomatological Society of Greece.

Table 2.

Comparison of brushing frequency and fluoride toothpaste use between baseline (T0) and 12 months of follow-up (T1), according to type of project and country

Project and country	T0					T1
	n†	Brush twice or more daily		Use fluoride toothpaste		n†	Brush twice or more daily		Use of fluoride toothpaste
		n	%	n	%		n	%	n	%
Project A	600	85	14.2	231	89.6	343	134	39.1*	233	88.4
Morocco	600	85	14.2	231	89.6	343	134	39.1*	233	88.4
Project B	5,373	3,218	59.9	3,725	69.3	4,696	3,415	72.7*	3,844	81.8*
Egypt	1,326	591	44.6	1,079	81.4	1,159	575	49.6*	992	85.6*
Greece HDA	468	112	23.9	211	45.2	277	83	30.0	182	65.9*
Greece SSG	352	105	29.8	196	55.8	132	38	28.8	93	70.6*
Indonesia	1,617	1,282	79.3	1,145	70.8	1,445	1,277	88.4*	1,058	73.2
Myanmar	592	369	62.3	361	61.0	599	470	78.5*	542	90.6*
Vietnam	1,018	759	74.6	733	72.0	1,084	972	89.7*	977	90.1*
Project C	662	619	93.5	388	58.6	673	658	97.8*	497	75.5*
Germany	65	62	95.4	51	78.5	74	62	83.8	57	77.0
Italy	597	557	93.3	337	56.4	599	596	99.5*	440	73.5*

Greece-HDA, Hellenic Dental Association; Greece-SSG, Stomatological Society of Greece.

^*P < 0.05 (comparison between T0 and T1 with McNemar test for paired samples).

^†Valid sample size (for T0 and T1) for brushing frequency.

Table 3.

Influence of gender, age and educational level in brushing habits and use of fluoride toothpaste at baseline (T0) and at 12 months of follow-up (T1)^*

Variable	T0						T1
	Brushing habit		Brushing day and night		Use of fluoride toothpaste		Brushing habit		Brushing day and night		Use of fluoride toothpaste
	n†	%‡	n	%	N	%	n†	%‡	n	%	n	%
All	6,635	7; 10; 24; 59	3,922	76.3	6,152	68.9	5,712	3; 5; 19; 74	4,207	81.7	5,563	79.7
Sex
1 (Man)	2,711	9; 11; 25; 55	1,485	72.3	2,458	69.0	2,238	4; 6; 22; 69	1,541	78.6	2,158	78.0
2 (Woman)	2,893	8; 10; 24; 58	1,674	72.1	2,670	67.8	2,379	3; 6; 20; 71	1,690	76.2	2,310	76.7
P-value§		0.011		0.955		0.353		0.105		0.108		0.308
Age (years)
0 to <6 years	1,108	35; 13; 32; 20	219	90.9	720	60.4	597	18; 4; 44; 34	206	95.6	490	73.5
6 to <15 years	3,594	2; 11; 23; 64	2,299	71.2	3,514	73.1	3,307	1; 6; 20; 73	2,400	74.6	3,265	81.0
≥ 15 years	895	1; 7; 20; 71	639	68.7	887	56.3	714	0; 4; 9; 87	625	81.8	714	63.2
P-value		<0.001		<0.001		<0.001		<0.001		<0.001		<0.001
Education level
1 (basic or primary school)	90	0; 2; 4; 93	84	65.5	90	67.8	94	0; 2; 4; 94	88	71.6	94	75.5
2 (secondary school)	217	0; 0; 5; 95	207	70.0	217	58.5	221	0; 0; 1; 99	218	83.9	221	74.7
3–4 (university or still studying)	349	0; 0; 7; 93	323	61.9	349	56.2	351	0; 0; 1; 99	347	80.1	351	73.2
¶P-value		0.404		0.159		0.137		0.003		0.049		0.871

^*Morocco, Egypt, Greece-HDA, Hellenic Dental Association; Greece-SSG, Stomatological Society of Greece; Indonesia, Myanmar, Vietnam, Germany and Italy.

^†Valid sample for each item of questionnaire.

^‡Never; Sometimes; 1/day; ≥2/day. Data are given as whole-number percentage values (i.e. no decimals).

^§P-values were calculated using the Mann–Whitney U-test (toothbrushing habit) and corrected chi-square test (brushing day/night and use of fluoride toothpaste).

^¶P-values were calculated using the Kruskal–Wallis test (toothbrushing habit) and the chi-square test (brushing day/night and use of fluoride toothpaste).

DISCUSSION

In this study, there were two major limitations. The first refers to the representativeness of the sample. The present study, in various national contexts, has not sought, at any time, to be representative of the different participating countries. The intention was to test different strategies in order to analyse their impact on oral health habits. All samples in the study should be considered as samples of convenience as a result of their participation in a national project carried out as part of the global LLL partnership, and not as representative samples of the different countries. The second major limitation concerns the self-reported questionnaire. The main problem arising from the self-reported questionnaire is called the Hawthorne effect or the observer effect: individuals may change their behaviour as a result of the attention they are receiving from researchers rather than because of any manipulation of independent variables. In the particular case of partnership projects asking subjects about their oral hygiene and use of fluoride toothpaste, a trend occurs as a positive response in the sense of satisfying the interviewer with affirmative answers (healthy behaviours).

Clearly, the coordination of different projects in 23 countries was no easy task. In order to facilitate this coordination, national leaders were appointed for each project, as well as three regional coordinators from FDI who provided guidance on adaptation of questionnaires to suit the local situation, whilst maintaining the alignment needed for global level analysis.

The overarching aim of the global partnership between FDI and Unilever Oral Care (LLL phase 2) was to increase healthy oral care behaviours. For this purpose, four different options were offered to the national partners (NDAs and Unilever brands) to implement their projects, all with the common objectives of promoting the message of ‘brushing twice a day with a fluoride toothpaste’ and educating people in adopting this good oral health behaviour. Health education focused on four main actors/environments: mother; school; dentist; and community. Globally, only one in two subjects brushed their teeth with fluoride toothpaste twice a day at the beginning of the programme. At the end of the programme, regardless of the project, there had been a significant increase in the percentage of people brushing twice a day: 14.2% versus 39.1% in the prenatal/infant option; 59.9% versus 72.7% in the school option; and 93.5% versus 97.8% in the patient focus option. The strategy of using mothers to increase healthy behaviours in oral health is one that has achieved the greatest increase, with a gain of 25% in brushing twice a day, followed by the school’s strategy (with a gain of 12.8%). In the option of patient focus, the gain was only 4.3%. However, bearing in mind that at baseline the value for brushing twice daily was already very high (93.5%), the scope for improvement was very low.

The influence of gender on toothbrushing habits has been widely described. Studies performed since the 1960s have found quite consistent differences between the sexes in toothbrushing behaviour in all age groups. Female subjects brush more regularly and more frequently than do male subjects17., 18., 19., 20., 21.. A review on the influence of sex on the frequency of toothbrushing showed that regardless of age, women brush more frequently than do men²². In this study, at baseline, the percentage of subjects toothbrushing twice a day was higher in women (58% vs. 55%; P < 0.001). After implementation of the programme activities, these sex differences in patterns of toothbrushing disappeared (P = 0.10). In contrast, there was no difference, according to gender, in the percentage of those who used fluoride toothpaste, either at baseline or after 12 months.

Regarding the age variable, both at baseline and after 12 months, as age increased so did the percentage of those who brushed their teeth twice daily. In all age groups, the project intervention was capable of increasing the percentage of those who brushed twice daily. Regarding the use of fluoride toothpaste, both at baseline and after 12 months, the frequency was higher in subjects 6–15 years of age.

Most studies have also revealed that toothbrushing frequency increases with education level, occupation (some studies show a better toothbrushing habit in “white-collar occupation” in comparison with “blue-collar”) and income level23., 24., 25.. A few studies, however, found no difference in brushing frequency in children whose mothers had different education levels26., 27.. The differences in brushing behaviour according to level of education were more consistent in adults than in children²⁸. There is fairly strong evidence for an inverse relationship between socio-economic status and the prevalence of caries among children <12 years of age. The evidence for this relationship is weaker for older children and for adults because of the relatively small number of studies²⁹.

In the present study, the level of education had an influence on brushing habits only after 12 months: there was a higher frequency of brushing twice a day in those with higher education level. However, the level of education had no influence on the percentage of users of fluoridated toothpaste, either at baseline or at the end of the programme.

On the basis of a review of the literature, the most striking result was that sex had a significant, independent effect on brushing behaviour: being female led to a greater likelihood of brushing. This finding was consistent for all age groups analysed. In general, the literature has shown that individuals with higher education, occupation (white collar) and education levels are more likely to brush regularly. However, this relationship is only significant for adults. For children, the magnitude of the association did not support the general expectation that those whose fathers had higher occupational (white collar) or educational levels would brush more regularly.

Overall, the national projects ran as part of the global partnership programme LLL phase 2 and succeeded in increasing the percentage of subjects who brush twice a day. In the Option B intervention, at the start of the programme, 60% of the sample analysed brushed twice a day. After 12 months this increased to 73%, which represents an increase of 13% in the frequency of brushing twice a day. Regarding the type of project, the Option A intervention, which focused on the mother/child target, was able to increase, by 25%, the number of subjects who brushed twice daily. Conversely, Option C, which focused on dental patients, resulted in an increase of only 4% in the number of subjects who brushed twice a day. However, it must be borne in mind that the subjects of this group showed a high percentage of brushing twice a day at the beginning of the study (93.5%), so a considerable increase was not expected (Table 2). Overall, the LLL phase 2 partnership projects were also able to increase the percentage of people who used fluoridated toothpaste, with the exception of mother/child subjects who were targeted in project Option A. Some gender differences were identified in relation to the frequency of brushing twice a day. These disappeared following project intervention. Regarding age, the gradient was maintained at the end of the programme: the older subjects brushed more than the younger subjects, but in all age groups there was an increased frequency of brushing following intervention. The use of fluoride toothpaste increased in all age groups. However, a social gradient appeared in relation to the frequency of brushing following intervention. Those with a higher educational level brushed more than did those with a lower educational level.

In summary, the outcomes of this global partnership programme have shown a positive impact on participating subjects’ knowledge and reported behaviours regarding twice-daily toothbrushing with fluoride toothpaste. However, the correlation between lifestyle behaviours and increased risk of dental tooth decay, periodontal disease, oral infections, oral cancer and other oral conditions indicate the need to adopt an integrated approach to the promotion of both oral and general health. Such an integrative approach is likely to be more efficient and effective than programmes targeting a single disease or condition³⁰. The common risk-factor approach provides a valuable opportunity to incorporate oral health promotion, such as that delivered throughout the partnership projects in LLL phase 2, into general health promotion that addresses obesity, diabetes, cancer, heart disease and respiratory diseases, in line with the WHO Global action plan for the prevention and control of non-communicable diseases³¹.

Conflict of interest

Juan Carlos Llodra, Prathip Phantumvanit and Denis Bourgeois have received consultancy payments from FDI World Dental Federation. Virginie Horn is employed by FDI World Dental Federation.