Comparison of Knowledge, Attitude, and Practice of Nursing and Medical Students in Kermanshah, Iran, about Toothbrush Maintenance and Use

Background To promote oral health in society, medical and nursing students are required to have acceptable knowledge, attitude, and practice with respect to correct maintenance and use of a toothbrush. This study explored the knowledge, attitude, and practice of Iranian medical and nursing students about the correct maintenance and use of a toothbrush. Methods A total of 260 nursing students and 320 medical students were randomly recruited. Data were collected by a researcher-made questionnaire on the knowledge, attitude, and practice about toothbrush maintenance and use. Data were analyzed using descriptive and inferential statistics. Results The mean scores of knowledge, attitude, and practice were 54.53 ± 17.18, 49.67 ± 19.17, and 19 ± 51.50 in the nursing students and 54.17 ± 21.42, 51.18 ± 87.28, and 49.87 ± 17.52 out of 100 in the medical students, respectively. There was no significant difference between the medical and nursing students in the mean score of knowledge. The medical and nursing students had a similar attitude and practice in most items of toothbrush maintenance and use. Conclusion The medical and nursing students had average knowledge, attitude, and practice regarding toothbrush maintenance and use, which is not acceptable considering their job nature. Hence, interventional measures should be taken to enhance their knowledge, attitude, and practice.


Introduction
Oral health affects different aspects of life, including physical, mental, and social health [1,2]. Tooth brushing is the most basic and common means of maintaining oral health [3]. Tooth brushing eliminates dental plaques, food residues, and stains on the tooth surface [4,5]. Despite the efficacy of toothbrushes and their role in oral health, incorrect use and maintenance of toothbrushes are dangerous, which is followed by risks such as oral infections [6,7].
Knowledge of correct maintenance and use of toothbrushes plays a pivotal role in oral health [8]. Washing the toothbrush before and after use, replacing the toothbrush every 3-4 months, and regular tooth brushing twice a day for 2-3 minutes are some strategies for the maintenance and use of toothbrushes [8][9][10]. Nowadays, nurses have the most important role in the health education domain [11]. On the other hand, education in medical and nursing disciplines will be practically useless unless it brings about useful changes in the personal health of these students [12]. In this regard, it is highly important that the medical and nursing students, the main healthcare providers, have adequate knowledge about correct maintenance and use of toothbrushes because they are at the center of public interest and are considered role models [13]. Hence, if they have poor knowledge, attitude, and practice, the patients will get the main damage [12]. A study in Kuwait (2003) showed that medical students had little knowledge of oral health [14]. Another study in Hong Kong (2017) reported that nursing students had poor knowledge about oral health, with no significant relationship between their knowledge and practice [15]. As for the effect of education on the knowledge, attitude, and practice of students, a study on Bangladeshi students (2016) showed that teaching the oral health principles promoted their knowledge, attitude, and practice [16]. A study in Iran (2010) on oral health indicated no significant difference between the medical and nonmedical students in terms of the frequency of tooth brushing, but dental flossing was more frequent among the medical students [17].
Since knowledge about the principles of oral health, especially correct use of tooth brushing in medical students, is highly important and that no study has ever investigated the knowledge, attitude, and practice of nursing and medical students about toothbrush maintenance and use, the present study was designed to compare the knowledge, attitude, and practice of nursing and medical students about toothbrush maintenance and use. e results of this study can be helpful to the health authorities and policymakers in adopting necessary interventional measures.

Study Design.
is descriptive-analytical study was performed on the medical and nursing students from February to March 2019. e study was performed according to STROBE instructions.

Study Question.
In this study, we sought to answer the following question: "What levels of knowledge, attitude, and practice do medical and nursing students have about toothbrush maintenance and use?"

Study Hypothesis.
e medical and nursing students have different levels of knowledge, attitude, and practice about toothbrush maintenance and use.

Sample and Sampling Method.
e study population comprised all medical and nursing students studying in the second semester of the academic year 2018-2019. Since the study population included 785 and 1859 nursing and medical students, respectively, the sample size was estimated to be 260 nursing and 320 medical students using the following Cochrane's formula with 95% confidence level, the first type error equal to 5%, and p � 0.5%: (1) e samples were selected by the random sampling method. For this purpose, the list of students' names was taken from the education department and numbered. e samples were then selected using a table of random numbers. In the next step, the researcher referred to the samples according to the class schedule and in case of consent to participate in the study, a questionnaire was provided to them. If the person did not want to participate in the study, the person before or after him/her would be replaced according to the list of names. e inclusion criteria consisted of study in the second semester of the 2019-2020 academic year, consent to participate in the study, and studying in the medical and nursing discipline. Incomplete completion of the questionnaires was the exclusion criterion.

Measurement
Instruments. Data were collected by a researcher-made questionnaire adopted from the previous studies [12,16,18]. Content validity method was used to analyze the validity of the questionnaire, which included two methods: qualitative and quantitative. In the qualitative part, the questionnaire was given to 12 medical, dental, and nursing faculty members, and their corrective comments were applied. In the qualitative part, based on the opinions of experts, the content validity indexes (CVI) were calculated for the scales of knowledge, attitude, and practice, which were equal to 0.87, 0.89, and 0.88, respectively. e reliability of the questionnaire was confirmed by the test-retest method. To this end, the questionnaire was first given to 30 medical and nursing students to complete. After two weeks, the same questionnaire was given to them again to complete. e correlation coefficients for the scales of knowledge, attitude, and practice were 0.87, 0.88, and 0.86, respectively. e questionnaire is comprised of four sections. e first section was about the demographic information of the participants, including age, gender, and major. e second section consisted of 10 items on the students' knowledge about toothbrush maintenance and use. Some items of this section included "How often do you brush your teeth in a day?", "What is a proper place for keeping a toothbrush?", and "How much time is good for tooth brushing?". To calculate the total score, the correct and false responses were given scores 1 and 0, respectively. e score range of knowledge was multiplied by 100 and classified as poor knowledge (≤49), average knowledge (50-74), and good knowledge (≥75). e third section included 6 two-option items, including agree and disagree, on the students' attitude toward toothbrush maintenance and use. Some items of this section were " e toothbrush material affects its life," "Rinsing the toothbrush is enough to reduce its contamination," and "It is usually better to keep the toothbrush in water closet." To compute the total score of attitude, with the exception of items 1 and 4, the opposing answers were given a score of 1 and those who agreed were given a score of 0. e score range of attitude was multiplied by 100 and classified as poor attitude (≤49), average attitude (50-74), and good attitude (≥75). e fourth section consisted of 10 items on the students' practice in toothbrush maintenance and use. Some items of this section included "What method do you use for tooth brushing?", "How do you wash your toothbrush?", and "How long do you brush your teeth?" To calculate the total score, the correct and false responses were given scores 1 and 0, respectively. e range of scores was multiplied by 100 and classified as poor practice (≤49), average practice (50-74), and good practice (≥75).

Data Gathering.
Having taken the approval of the ethics committee of the university, the researcher referred to the education departments of the nursing and medical faculties, obtained and coded the students' names, and selected the samples by systematic random sampling. For this purpose, the researcher referred to the students during the breaks between classes and explained the research objectives to them. If they were willing to participate in the study, they were given the questionnaire to complete. To increase the reliability of the data in this study, the questionnaires were anonymous, the participants were visited in proper time, the questionnaires were given to the participants at an appropriate time, and questionnaires with more than 20% missing data were excluded from the study.

Data
Analysis. Data were analyzed by the Statistical Package for Social Sciences (SPSS-16 Inc., Chicago, IL, USA) using the descriptive (mean, standard deviation, median, interquartile range, and percentage) and inferential statistics (Kolmogorov-Smirnov test, Chi-square test, and Mann-Whitney U test). Kolmogorov-Smirnov test was used to determine the distribution of age and total scores of knowledge, attitude, and practice, which indicated the abnormal distribution of the given variables. Further, the chisquare test was used to compare the frequency of the medical and nursing students' responses to the items of different sections of the questionnaire and the percentage of gender in both groups. Mann-Whitney U test was also used to compare age and the scores of knowledge, attitude, and practice in the medical and nursing students. e significance level for all tests was less than 0.05.

Ethical Considerations.
e present study was approved by the Ethics Committee of KUMS, with the reference no. IR.KUMS.REC.1397.798. All participants were assured their demographic information would be kept confidential. Informed written consent was taken from all of the participants.

Results
e study sample included a total of 580 students, 260 nursing students, and 380 medical students. Most of the nursing students (n � 142, 54.6%) were female and most of the medical students (n � 170, 53.1%) were male. e medical and nursing students were homogenous in terms of gender. e results of the KS test showed an abnormal distribution of age (p < 0.001), so the median and interquartile range (IQR) were used to compare the medical and nursing students concerning age. e median and IRR of age in the nursing and medical students were 21 and 3, respectively, indicating no statistically significant difference between them (Table 1). e median and IQR of the total score of medical and nursing students on toothbrush maintenance and use were equal, 60 (out of 100) and 30, respectively. e results of the Mann-Whitney U test showed no statistically significant difference between the medical and nursing students regarding toothbrush maintenance and use ( Table 2). e frequency and percentage of responses to different questions of knowledge section of the questionnaire were compared between the medical and nursing students by Chi-square test, which indicated no significant difference between them. For instance, 47.5% of medical students and 53.1% of nursing students selected the "three times" option of the question "How often do you brush your teeth in a day?". Further, 47.5% of medical students and 55% of nursing students selected the option "2-3 minutes" in response to the item "How long do you brush your teeth?". Moreover, 61.9% of medical students and 67.7% of nursing students chose the option "vertical-rotary" option in response to the item "What is the best tooth brushing technique?" (Table 3).
Regarding the attitude of the medical and nursing students toward toothbrush maintenance and use, the findings showed the median and IQR of each group were 50 (out of 100) and 33.33, respectively. e results of the Mann-Whitney U test indicated no significant difference between the medical and nursing students' total scores of attitude toward toothbrush maintenance and use (Table 2). e comparison of the frequency of responses to different questions of attitude section showed the medical and nursing students had a similar attitude toward toothbrush maintenance and use in all items except the effect of material on the life of toothbrush (p � 0.012). Moreover, 91.5% of nursing students (238 out of 260 students) and 84.7% of medical students (271 out of 320 students) agreed on the effect of material on the life of toothbrushes ( Table 4).
As for the practice of the nursing and medical students in toothbrush maintenance and use, the findings showed the median and IQR of 50 (out of 100) and 30, respectively. e mean total scores of the medical and nursing students' practice in toothbrush maintenance and use indicated no significant difference between them (Table 2). e results indicated the nursing and medical students had similar practice in all items except for the time of using toothbrush cap (p � 0.02) so that 58.5% of nursing students (152 out of 260 students) used toothbrush cap after the toothbrush dried, but 51.2% of medical students (164 out of 320 students) used toothbrush cap immediately after washing the toothbrush. Most of the medical and nursing students (64.4% vs. 63.1%) used medium bristle toothbrushes and kept their toothbrushes out of the bathroom (70.6% vs. 68.8%). Further, 58.1% of medical students and 59.6% of

Discussion
e present study compared the knowledge, attitude, and practice of nursing and medical students about toothbrush maintenance and use. To promote the oral health of people in society, medical and nursing students are required to have acceptable knowledge, attitude, and practice with respect to toothbrush maintenance and use. e findings showed the medical and nursing students had similar and average knowledge, attitude, and practice regarding toothbrush maintenance and use, which is not acceptable considering their educational role. On the other hand, these students have important responsibilities such as providing personal health principles to society, including oral health. Hence, they are expected to have acceptable knowledge, attitude, and practice with respect to correct toothbrush maintenance and use.
In this study, no statistically significant difference was found between the nursing and medical students in the total scores of knowledge and attitude. A study in India (2018) showed dental students had better knowledge and attitude about toothbrush maintenance and replacement [18]. Another study in Tanzania (2015) indicated the nursing students had acceptable knowledge about oral hygiene [19]. A study in India (2012) showed the nursing students had good knowledge and attitude about oral hygiene [12]. Another study in India (2012) indicated the nursing students had significantly higher knowledge and better attitude regarding oral health than nurses [20].
Moreover, a study in Kuwait (2003) revealed the medical students had little knowledge about oral health [14]. A study in Hong Kong (2015) reported the nursing students had little knowledge about oral hygiene [15]. e results of the current research were in line with those of some of the above-mentioned studies, indicating that the medical and nursing students had insufficient knowledge and unfavorable attitude with regard to toothbrush maintenance and use. e medical and nursing students, as the future healthcare providers of the society, need to have adequate knowledge and a favorable attitude about oral hygiene. e medical and nursing students had similar and average practice in toothbrush maintenance and use in all items. e nursing students had better practice in using the toothbrush cap so that most of them used the cap after the toothbrush dried, but most medical students used the cap before the toothbrush dried. e results of a study in Kuwait (2003) and a study in Hong Kong (2015) showed the nursing students had unacceptable practice in oral hygiene [14,15]. e findings of the present study confirmed the results of the above studies with respect to the poor practice of students in oral hygiene. On the other hand, the studies conducted in India (2012) and Tanzania (2015) reported the nursing students had acceptable practice in oral hygiene [12,19], which is in contrast with the findings of the present study. In the above studies, the nursing students had acceptable knowledge and a favorable attitude, so it is not unexpected that they have a favorable practice. However, the nursing and medical students in the present research had unacceptable knowledge and attitude about toothbrush maintenance and use, which normally affected their practice.
In the present study, most nursing and medical students washed their toothbrushes before and after tooth brushing. Washing the toothbrush before and after tooth brushing is necessary because the toothbrush contains a significant number of microorganisms after tooth brushing [21]. On the other hand, a wet toothbrush can increase bacterial growth and lead to accumulation of microbes in toothbrush [22]. erefore, it is important to dry the toothbrush before using the cap.

Journal of Environmental and Public Health
In the current study, most nursing and medical students kept their toothbrush out of water closet. Keeping the toothbrush in the bathroom can cause toothbrush contamination and oral infections [6,7]. In addition, more than half of the students in the present study replaced their toothbrushes every 2-3 months, which seems to be an appropriate activity. A toothbrush should be replaced every three months [23]. Since oral health is very important and the medical and nursing students had good practice in this regard, it seems necessary to provide them with more training. e use of internet-based methods can be an effective strategy to promote the knowledge, attitude, and practice of nursing and medical students [24]. e present study had several limitations. Since this study was cross-sectional, it was not possible to determine a causal relationship between students' major and their knowledge, attitude, and practice. Moreover, data were collected through self-report, which might have affected the accuracy of the results. However, the researchers made an attempt to minimize this limitation by assuring the participants that the questionnaires would remain anonymous.

Conclusion
Doctors and nurses as healthcare providers are responsible for the health of patients. erefore, they are expected to have acceptable knowledge, attitude, and practice regarding oral health principles. e medical and nursing students in the present research did not have favorable knowledge, attitude, and practice with respect to toothbrush maintenance and use.
ey had similar knowledge about all items of toothbrush maintenance and use. As for most items of toothbrush maintenance and use, the medical and nursing students had similar attitudes and practices. is study was carried out on the medical and nursing students. Future studies are recommended to be performed on other students, especially dental students. Further studies are also advised to explore the effect of educational interventions on the knowledge, attitude, and practice of medical students.

Consent
All participants were assured their demographic information would be kept confidential. Informed written consent was taken from all of the participants.

Conflicts of Interest
e authors declare there are no conflicts of interest.