Attitude, Practice, and Awareness of Oral Hygiene Care among Nursing Professionals of a Tertiary Care Center of Malda in West Bengal: A Cross-sectional Study. (2025)

Author(s): Anjan Jana (corresponding author) [1]; Santanu Mukhopadhyay [1]; Antarip Maji [1]

INTRODUCTION

Mouth is the mirror of our general health, and the oral cavity is the gateway of this. The proper maintenance of oral hygiene not only keeps the teeth and gums healthy, but it also takes a major role to keep our entire body system in a healthy state. We do brush as a regular measure of our oral care, but only brushing is not sufficient to do it properly.[sup.[1]] Apart from teeth, there are so many areas in the oral cavity where bacteria can reside. In the present day, oral hygiene is a big issue in every developing country as it has a direct impact on overall health-care system. Globally, about 3.5 million people are affected by periodontitis, dental caries, and edentulism.[sup.[2]] In 2013, Marcenes et al. first estimated the global oral disease burden from data gathered from the Global Burden of Disease (GBD) study.[sup.[3]] In 2017, Kassebaum et al. studied the global, regional, and national prevalence and incidence of oral diseases and their effects on overall life quality among the people of 195 countries and updated the results of GBD up to the year 2015.[sup.[4]] There are different studies which show oral diseases such as gingivitis and periodontitis, share same common pathophysiologic mechanism of other noncommunicable diseases which aggravates the inflammatory response of the body.[sup.[5]] It is now well approved that there are a lot of systemic diseases which are directly related to poor oral hygiene. Diabetes, cardiovascular diseases, stroke, pneumonia, and premature delivery are foremost. Unfortunately, maintenance of oral hygiene is the most neglected part of our daily life. Although the majority of the oral diseases are curable and easily preventable, only lack of awareness restrains people from practicing good oral hygiene process. Poor oral health is the most common problem among all the developing countries which ultimately increases the burden on the health work system. There are many studies which show the prevalence of dental caries, gingivitis, and periodontitis in different parts of India as well as globally.[sup.[6,7]] It is important to practice good oral hygiene from the very beginning. It is the duty of the dental surgeon, dental health workers, and other health co-workers to provide proper oral care instructions in every patient for betterment of their overall quality of life. In India, most of the people do only brushing as their regular oral hygiene care and most of them are unaware about the importance of tongue cleaning, use of regular interdental cleaning aids, changes of brush in regular interval, and the importance of regular dental checkups.[sup.[8]] Especially in hospital setup in debilitating patients, the oral hygiene has great importance in terms of overall health improvement of the patient. Poor oral hygiene has a direct negative impact on patient quality of life.[sup.[9]] Hence, all the health workers including nursing professionals must have the thorough knowledge about the oral care protocol and its importance in improvement of general health. Nursing professionals and community health workers act as a bridge between our existing health-care system and the common people, so their role cannot be ignored in terms of oral health promotion. They can take a major role to improve overall oral hygiene at the community level which ultimately leads to a reduction of oral disease and improvement of the overall general health.[sup.[10]] In this study, an attempt has been made to evaluate the awareness and current concept of oral hygiene practice among nursing professionals, so that their knowledge can be imparted to the general population in terms of oral hygiene improvement and ultimately the improvement of overall general health of the society.

MATERIALS AND METHODS

The study follows a descriptive cross-sectional design. Initially, the set of 10-item self-administered, closed-ended, prestructured questionnaires assessing the knowledge and awareness of oral hygiene practices was drafted and sent to an expert panel of six for content validation. Subsequently, the reliability was checked by randomly asking thirty participants to fill the survey form twice with a gap of 15 days.

Finally, the self-designed questionnaire, containing total 10 questions, was distributed among the participants in a printed format and was retrieved after 15 days [Appendix 1]. The participants of this study were the nursing professionals enrolled at Malda Medical College, Malda. Inclusion criteria for the study were all the nursing professionals including male and female nursing staffs.

Appendix 1: Oral hygiene awareness survey questionnaires [see PDF for image]

Exclusion criteria

Only nonnursing professionals were excluded.

The questionnaire was designed to assess the awareness, attitude, and practice toward regular oral hygiene care that includes their brushing habits, tongue cleaning, use of any interdental cleaning aids, and the habit of regular dental checkups. The study maintained all the ethical guidelines, ensuring participant's confidentiality and voluntary participation.

The ethical clearance was obtained from the Institutional Ethical Committee of Malda Medical College, Ref. No.: P/MLD-MC/IEC-23/118.

Informed consent was obtained from each participant.

Data were collected from the participants anonymously to maintain participants' confidentiality.

Statistical analysis

The content validation ratio (CVR) and Cohen's kappa (?) were employed to test the validity and the reliability of the study, respectively. CVR was computed as per Lawshe's formula, wherein an expert panel of six members should agree to all the listed items in the questionnaire as "essential" and "clear," i.e., CVR = 0.99. Similarly, kappa values were interpreted using the following criteria: ? =0.81 - almost perfect; 0.61 =< 0.80 - substantial; 0.41 = ? < 0.60 - moderate; 0.21 = ? < 0.40 - fair; and ? < 0.20 - poor.[sup.[11-13]] The collected data were tabulated in a spreadsheet using Microsoft Excel 2019 and then statistical analysis was carried out using IBM SPSS Statistical software for Windows, version 27.0 (Armonk, NY, USA: IBM Corp). Descriptive statistics were used to report (i) categorical variables in terms of frequencies and percentages and (ii) quantitative variables in terms of mean (central tendency) and standard deviation (measures of dispersion). The analysis was performed using the Chi-square. Binary and multinomial logistic regression analysis was carried out. P = 0.05 was considered the level of significance.

RESULTS

Regarding the validation of the questionnaire, all the six expert panelists adjudged all the ten questions to be "essential" to the given study objective. The reliability among the respondents in the pilot testing produced a kappa score of 082 indicating a good agreement. Among the 261 participants, the overall mean age of the subjects included in the study was found to be 33.6 ± 7.29 years and most of the study respondents were below 40 years of age (78.6, n = 205), which was significantly higher than the other age groups involved in the study (P < 0.001) [Table 1 and Figure 1]. It was also observed that the number of female participants (91.95, n = 240) was significantly higher than the number of male participants [Table 1 and Figure 2]. Table 2 and Figures 3-12 depict the distribution of responses to the questions. It was observed that 77.4 (n = 202) of the study respondents brushed their teeth at least twice daily. The most used cleaning aid was a toothbrush with toothpaste (99.2, n = 259). Soft toothbrushes were preferred by most of the study participants (70.9, n = 185). 68.6 (n = 179) of the respondents reported changing their toothbrushes every 3-4 months and 79.3 (n = 207) cleaned their tongue besides brushing. It was evaluated that only 23.8 (n = 62) of the study respondents used interdental cleaning aids, besides a toothbrush, while the rest either did not use any inter-cleaning aid or were not aware of the same (70.1, n = 183, and 6.1, n = 16, respectively). Among those who used interdental cleaning aids, most of them used either dental floss (54.83, n = 34) or toothpick (37.09, n = 23), respectively, while only 8.06 (n = 5) used an interproximal brush.

Table 1: Demographic characteristics of the study respondents [see PDF for image]

Figure 1: Bar graph showing the distribution of study respondents according to age groups [see PDF for image]

Figure 2: Pie chart showing distribution of study respondents according to gender [see PDF for image]

Table 2: Responses to the questions [see PDF for image]

Figure 3: Pie chart showing response to the question "How many times do you brush your teeth" [see PDF for image]

Figure 4: Pie chart showing response to the question "Which aid do you use for brushing" [see PDF for image]

Figure 5: Pie chart showing response to the question "Which type of toothbrush do you prefer for brushing" [see PDF for image]

Figure 6: Pie chart showing response to the question "How frequently do you change your toothbrush" [see PDF for image]

Figure 7: Pie chart showing response to the question "Do you clean your tongue regularly" [see PDF for image]

Figure 8: Pie chart showing response to the question "Other than toothbrush do you use any interdental cleaning aids regularly to clean your teeth" [see PDF for image]

Figure 9: Pie chart showing response to the question "If yes, which type of aid do you prefer" [see PDF for image]

Figure 10: Pie chart showing response to the question "How frequently do you consult your dentist" [see PDF for image]

Figure 11: Pie chart showing response to the question "Do you clean your teeth after having a meal" [see PDF for image]

Figure 12: Pie chart showing response to the question "Do you use any mouthwash on a regular basis" [see PDF for image]

Interestingly, when asked about the frequency of their dental visit, only 8.8 (n = 23) of the participants reported visiting their dentists regularly every 6-12 months, while 76.6 (n = 200) chose to visit whenever they suffered from pain or any dental problem. Moreover, 14.6 (n = 38) of them never visited the dentist till the time of the present survey.

It was also observed that 68.6 (n = 179) of the study respondents cleaned their teeth following a meal, while only 25.3 (n = 66) used mouthwash on a regular basis. A statistically significant difference was found in the proportion of responses for all the survey questions (P < 0.001).

A multivariate logistic regression analysis was carried out to assess the influence of demographic variables, namely age and gender, the results of which are tabulated in Table 3.

Table 3: Logistic regression with demographic variables as the independent variables and the questions as the dependent variable [see PDF for image]

Regression results revealed that compared to brushing teeth once daily, female nurses had significantly higher odds of brushing their teeth twice (odds ratio [OR]: 3.605, 95 confidence interval [CI]: 1.419-9.16; P = 0.007) or more than twice (OR: 8133.544, 95 CI: 1650.419-40083.49; P 0.05).

Pertaining to the frequency of changing toothbrushes, compared to the response of changing it every 3-4 months, older patients had lower odds of changing it after 6 months of use and higher odds of changing it after a year of usage. Female nurses preferred changing it after 6 months of usage and had lower odds of using the same toothbrush for more than a year when compared to male nurses. However, all the findings were not statistically significant (P > 0.05).

The tongue-cleaning habit was practiced more by the elderly and the female nurses, although the OR was not statistically significant (P > 0.05).

Pertaining to the usage of interdental cleaning aids, females were found to be less aware of it, and elderly nurses had lesser odds of using it. The results obtained were however not significant (P > 0.05).

It was observed that female nurses had significantly higher odds of cleaning their teeth after a meal (OR: 2.617, 95 CI: 1.064-6.44; P = 0.036). A similar trend was found in the elderly nurses, although the results were not statistically significant (P > 0.05).

DISCUSSION

Oral cavity provides a unique habitat for oral microbes. Saliva further facilitates the growth by providing the ideal environment and nutrient-rich substrates for bacteria.[sup.[14,15]] The nature of bacteria alters with the eruption of the first dentition and with the development of gingival sulcus.[sup.[16]]

With the first eruption of tooth and formation of gingival crevices, periodontal pathogen appears, hence the oral hygiene process should start from this time only.

There are numerous literature which discuss the different aspects of knowledge, attitude, and practice of oral hygiene in different population groups, but in West Bengal, there is no such study conducted which highlights the attitude, awareness, and practice of oral hygiene among nursing professionals.[sup.[17,18]] From the results of the present study, it is established that the basic oral hygiene knowledge is quite high among the participants in Malda. Most of the participants have two times brushing habits (77.4), and 99.2 of them use toothbrush and toothpaste as their regular oral care. 79.3 of participants use tongue cleaning habits which is very promising. The results are very similar to the study findings of Yavagal et al. in 2020[sup.[19]] but differ from the study results of Yadav et al. in Rajasthan where only 58 of participants use two times brushing and only 43.52 of them have tongue cleaning habits.[sup.[20]] The frequency of brush change shows a mixed result, and 68.6 of participants change their brush within 3-4 months and 26.1 after 6 months.

Apart from brushing and tongue cleaning habits, other oral care awareness is not very satisfactory in the present study group. 70.1 of the participants were unaware of the use of interdental cleaning aids, with only 23.8 reporting usage. This percentage is higher than the 15 reported by Gufran et al.[sup.[21]] Dental floss and toothpicks are the most preferable form of interdental cleaning aids and percentages are 54.83 and 37.09, respectively.

The tendency of mouthwash use was the same as the study result of Yadav et al.[sup.[20]] that is 25.3 and 28.85, respectively.

The attitude regarding the regular dental checkup varies greatly between different study groups. The present study shows only 8.8 of participants do regular dental visits, 76.6 meet dentists only at the time pain arises, and 14.6 never had a dental checkup, which is quite similar to the findings of Dagnew et al. where 76.7 did not attend any dental checkup[sup.[22]] but differs with the results of Yavagal et al.[sup.[19]] where 72.6 of participants have regular dental checkup.

Limitations of the present study include its small sample size; moreover, subjects were taken from one tertiary care center. Therefore, the results from this study may not be applicable to general population in broader aspect.

CONCLUSION

The result of the present study depicts the limitation of knowledge and practice of oral hygiene care among nursing professionals of a tertiary care center in Malda region. In spite of their health-care background, they have limited knowledge regarding regular oral hygiene care. Most of them practice regular brushing twice a day and tongue cleaning, yet they are unaware of the importance of interdental cleaning aids as well as the need to adjust the frequency of brushing and tongue cleaning habits. Only a few participants have a history of regular dental checkups. Hence, it is an urgent need to arrange regular oral health camps, workshops, and seminars to spread the proper knowledge and awareness toward oral health among all the categories of population in the society.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We would like to thank all the participants of the study and all the supporting staff of Malda Medical College.

References

1. Rasines, G. The use of interdental brushes along with toothbrushing removes most plaque. Evid Based Dent. 2009; 10: 74.

2. Dye, BA. The global burden of oral disease:Research and public health significance. J Dent Res. 2017; 96: 361-3.

3. Marcenes, W, Kassebaum, NJ, Bernabé, E, Flaxman, A, Naghavi, M, Lopez, A, et al. Global burden of oral conditions in 1990-2010:A systematic analysis. J Dent Res. 2013; 92: 592-7.

4. Kassebaum, NJ, Smith, AG, Bernabé, E, Fleming, TD, Reynolds, AE, Vos, T, et al. Global, regional, and national prevalence, incidence, and disability-adjusted life years for oral conditions for 195 countries, 1990-2015:A systematic analysis for the global burden of diseases, injuries, and risk factors. J Dent Res. 2017; 96: 380-7.

5. Babu, NC and Gomes, AJ. Systemic manifestations of oral diseases. J Oral Maxillofac Pathol. 2011; 15: 144-7.

6. Chandra, A, Yadav, OP, Narula, S and Dutta, A. Epidemiology of periodontal diseases in Indian population since last decade. J Int Soc Prev Community Dent. 2016; 6: 91-6.

7. Peres, MA, Macpherson, LM, Weyant, RJ, Daly, B, Venturelli, R, Mathur, MR, et al. Oral diseases:A global public health challenge. Lancet. 2019; 394: 249-60.

8. Choi, HN, Cho, YS and Koo, JW. The effect of mechanical tongue cleaning on oral malodor and tongue coating. Int J Environ Res Public Health. 2021; 19: 108.

9. Baiju, RM, Peter, E, Varghese, NO and Sivaram, R. Oral health and quality of life:Current concepts. J Clin Diagn Res. 2017; 11: E21-6.

10. Al, Agili DE and Khalaf, ZI. The role of oral and prenatal healthcare providers in the promotion of oral health for pregnant women. BMC Pregnancy Childbirth. 2023; 23: 313.

11. Lawshe, CH. A quantitative approachto content validity. J Pers Soc Psychol. 1975; 28: 563-75.

12. McHugh, ML. Interrater reliability:The kappa statistic. Biochem Med (Zagreb). 2012; 22: 276-82.

13. Das, S, Majumder, G, Tudu, SN and Bhattacharya, S. Recent praxis in endodontic irrigation:A region-based cross-sectional survey assessing the knowledge, attitude, and practices among general dental practitioners. J West Bengal Univ Health Sci. 2022; 3: 40-50.

14. Dewhirst, FE, Chen, T, Izard, J, Paster, BJ, Tanner, AC, Yu, WH, et al. The human oral microbiome. J Bacteriol. 2010; 192: 5002-17.

15. Zhao, H, Chu, M, Huang, Z, Yang, X, Ran, S, Hu, B, et al. Variations in oral microbiota associated with oral cancer. Sci Rep. 2017; 7: 11773.

16. Patil, S, Rao, RS, Sanketh, DS and Amrutha, N. Microbial flora in oral diseases. J Contemp Dent Pract. 2013; 14: 1202-8.

17. Tsui, PK, Chau, PH, Wong, JY, Wang, MP, Gao, X, Lam, OL, et al. Oral care knowledge, attitude and practice among nursing staff in acute hospital settings in Hong Kong. PLoS One. 2023; 18: e0289953.

18. Iqbal, MZ, Rathi, R, Prajapati, SK, Omar, K, Bahari, MB, Rajan, S, et al. Knowledge, attitude, and practice of oral hygiene among students of a private university. J Pharm Bioallied Sci. 2021; 13: 123-8.

19. Yavagal, PC, Dalvi, TM, Benson, T, Lakshmi, S, Yann, TH and Gowda, T. Knowledge, attitude and practices related to oral health among nursing students in Davangere city:A cross-sectional survey. Oral Health Prev Dent. 2020; 18: 493-8.

20. Yadav, OP, Khan, A, Khan, S, Gupta, S, Gupta, R and Gupta, R. Oral health knowledge, attitude, and practice among nursing students in the North-Eastern part of Rajasthan, India. Iran J Nurs Midwifery Res. 2019; 24: 394-6.

21. Gufran, K, Alanazi, KM, Alanazi, AK, Alqwiri, AS, Alsubaie, FM and Alotaibi, NM. Self-reported knowledge and practice of interdental aids among people of Riyadh, Saudi Arabia -A cross-sectional study. J Pharm Bioallied Sci. 2021; 13: S280-3.

22. Dagnew, ZA, Abraham, IA, Beraki, GG, Tesfamariam, EH, Mittler, S and Tesfamichael, YZ. Nursesattitude towards oral care and their practicing level for hospitalized patients in Orotta national referral hospital, Asmara-Eritrea:A cross-sectional study. BMC Nurs. 2020; 19: 63.

Author Affiliation(s):

[1] Department of Dentistry, Malda Medical College and Hospital, Malda, West Bengal, India

Author(s) Email: Anjan Jana - [emailprotected]

DOI: 10.4103/jphpc.jphpc_54_23