Assessment of Levels of Oral Hygiene Awareness, Knowledge, Attitude and Practice among the Students of a Government School in Karachi

Aims: The object of this study was to assess the levels of oral hygiene awareness, knowledge, and practice of the children of a Govt. school belonging to low socioeconomic class in Karachi, and to attract more of the health promotion programs and campaigns towards these less privileged areas so version 15 and results were accumulated by frequency distribution. Results: It was observed that 97% of children (n= 446) demonstrated regular oral hygiene practice, results regarding knowledge were also good but bad eating habits were also found prevailing amongst them that need to be addressed. Conclusion: Overall it can be said that the results relating to oral hygiene practice and knowledge were good but only 31% of the students visited the dentist and the concept of regular dental checkup was almost nil. Hence the need for continuing dental education through promotion programs is emphasized with justification.


INTRODUCTION
Health is a fundamental human right and a worldwide social goal which is essential for the improvement of the quality of life of people [1].
According to the WORLD HEALTH ORGANIZATION (1946) "Health is the state of complete physical, mental and social wellbeing of a person and not merely the absence of disease and infirmity" [2].
Health and hygiene go hand-in-hand with each other. Maintaining hygiene of one's own self and also of the surrounding, enables participating in creating a healthy environment and body for the individual and for the whole society.
Attainment of health is impossible if the basic principles of hygiene are not implemented in our day to day life. Poor oral health has proven to have unfavorable effects on general health [3] hence hygiene practice should be initiated from the oral cavity.
It is said that mouth is the mirror of the body and the gateway to good health [4]. It not only performs the special role of mastication but also forms an integral part of a person's beauty and personality. People normally refrain from interacting and socializing with individuals who ignore their oral health care. Unsightly appearance of decayed, discolored teeth and the obnoxious odor completely destroys one's personality, leaving the person socially deprived. Dental problems also adversely deteriorate an individual's routine activities at school and work place causing ample loss of productive working hours throughout the year [5]. Dental problems may affect systemic health, too [6,7]. Young children suffering from oral/dental problems are 12 times more probable to have confined activity days [8]. Literature also reveals that more than 50 million school hours per year are lost due to dental problems affecting the overall health and school performance of the child [9].
Oral hygiene maintenance may be a totally ignored practice in people of low socio-economic class of developing countries and the load is higher significantly in poor and deprived population [10]. A general misconception also prevails amongst them considering oral health being necessary only for esthetic reasons rather than recognizing its functional significance. Illiteracy, poverty and sparse availability of dental hospitals in their vicinity also adds to strengthen this concept. Whilst its importance is often underrated, the need for regular dental care cannot be overlooked [11]. Oral health knowledge and behavior is a prerequisite for enforcing health related behaviors [12].
Children and youth collectively form a large number of population of an area [13]. Assessing the levels of oral hygiene/ health awareness and knowledge amongst them gives us an idea about the status of our current dental service provisions.
Schools serve as a valuable platform and provide a supporting environment for promoting oral health among school children and reach over one billion children universally [14].
In Pakistan, the total Government expenditure on public sector education is only 12% of its federal budget. Overall, there are 256,088 educational institutions in our country out of which 71% are in public sector. The total student enrollment is 37,462,884 out of which 25,213,894 students are enrolled in public institutes [15]. This, along with scarce literature on dental health awareness, attitude, & oral health related behaviors prompt us to assess and proceed towards addressing this particular group of population.
Dentistry not only focuses on eradicating dental diseases, but also endeavors to render services towards the general public especially younger generation, to impart a positive oral health knowledge and attitude in them through education, instructions and self-motivation [16].
Research studies have also established an association between knowledge & better oral health [17,18].
Keeping this in view, many developing countries have introduced school based oral health education program in order to control the growing burden of dental diseases [19].
Oral health promotion through schools is recommended by WHO for improving younger generations' knowledge, attitude and behavior related to oral health education so that it may not only be the duty of the dental professional to recognize health problems but the community as a whole should strive to achieve and practice hygiene to attain a healthy mouth (oral cavity) [20].
It has been observed from previous studies that infrastructure concerning school education already exists in our country, but work needs to be done in order to develop it into "Health Promoting Schools"; it is necessary to reorganize and restructure it in terms of faculty training (teachers) and educational lectures [21]. The community will certainly benefit when such an awareness campaign is directed towards improving the education level of our school going children.

Study Design
A cross-sectional study was conducted to assess the oral health knowledge, attitude and practice amongst the students of a government school in Karachi.

Place and Duration of Study
The study was conducted in Railway's Boys Secondary school, situated in Railway colony near Kalapul, South district of Karachi city on 17 th February 2015. This study was a questionnaire based study.

Study Sample
A total of 461 students (251 Males + 210 Females) participated in the study. The sample size was calculated using stat Calculator EPI info version 7.1 keeping confidence level of 95%. All the students studying in the school from grade 1 to 10 th grade, were included in the study, irrespective of gender, age, socioeconomic status and ethnicity discrimination. The students who were absent on that particular day were excluded from the study.

Data Collection
All participants were requested to complete a 24-questions closed ended questionnaire encompassing to demographic details and evaluation of oral hygiene practice, knowledge, attitude, habits and parental awareness, adapted from Nitika Jain et al. [11] & Mahmoud K. Al-Omiri, Ahed M. Al-Wahadni, Khaled N. Saeed [22,23].
A prior written application stating the purpose of project was sent to school management and the principal for acquiring permission and facilitation in obtaining negative consent from the students' parents. The questionnaire was distributed amongst the students according to their grades. A minimum time of 15 minutes was allotted to each student to fill in the questionnaire with the assistance of dental professionals.

Data Analysis
The data was analyzed using statistical package for social sciences (SPSS) version 15 and results were accumulated by frequency distribution.

Discussion
This study presented a complete overview of the oral health behavior, knowledge, attitude and practice in the govt. school children of Karachi aged between 5-19 years [23]. When this study was compared to other studies conducted in the neighboring countries it was observed that our school children demonstrated better dental knowledge, attitude & practice [22].

Oral hygiene practice
The results revealed that a high percentage (97%) of children in this study, brushed their teeth regularly. These results were better than the results obtained in a study [22] and concurrent to the study conducted by Ling Zhu et al. [24], 51% brushed at least once daily, and only 23.4% brushed the recommended twice daily protocol. This is lower than the results obtained by Harikiran et al (38.5%) [25] and WHO (49%) [26]. The primary mode of cleaning teeth for 87% of the children was with a tooth brush and tooth paste. 8.5% of the children exercised other less common modes such as use of miswak, finger and salt and neem stick.
Soft tooth brushes were used by 51% of the participants, and the brushing technique adopted by majority of participants i.e 46% were traditional horizontal method, and 16.3% used a combination of movements for brushing.
Tooth brushing time of 2 min was implemented by 34% of the participants whereas 11.7% brushed for even less than a minute. The time of the day chosen by majority of the participants in this study i.e 81.6% was morning which was improved compared to 74% result (including both before & after breakfast) of the study conducted at Sheikhupura. However brushing at night was depressingly practiced by only 4% of our study population compared to 21% results of same study [27].

Oral hygiene knowledge
Results regarding oral health knowledge were good and higher than those obtained from a study [28] with 82.4% showing a positive attitude towards changing their tooth brushes amongst which 42% changing in every 3 months, 33.2% discarded them when they were useless whereas 7.8% replacing it annually (once a year). The ideal practice of changing tooth brushes every 3 months was observed among just 42% children compared to 72% in a comparable study [3].
There was poor awareness relating to interdental aids knowledge & approximately 88% of the children were ignorant about interdental aids. Amongst the 11% informed, 5% used wooden sticks and tooth picks to pick the debris from their teeth. Mouth washes were not use by 90.4% children. Only 28.4% cleansed their tongue during brushing as a routine oral hygiene procedure but it was also noted that 72% did rinse their mouth after meals. Both results were less when compared with the results of another study [3]. Furthermore, 48.2% of the participants reported bleeding from their gums and 30.5% complained of halitosis.
There were 69% participants who had never visited a dentist, results contrary to 30% [29] and 46% [30] where children awareness regarding dental visit was comparatively enhanced. 26% visited the dentist only when they had some dental problem, which is less as observed in a study conducted in Maharashtra [31] where 51% of students did not fear going to the dentist for regular checkups.
Lack of awareness about the other methods of oral hygiene maintenance and the principle benefits of regular dental checkups in preventing the dental ailments is a major flaw that should be addressed via public education and oral health promotion campaigns.

Harmful eating habits
Understanding about the dietary habits of the children and their attitude towards different food item such as areca nut, pan, chocolates, candies plus excessive consumption of soft drinks is essential for the oral health [32].
Results obtained from our study regarding eating habits were not satisfactory and almost 53% of children reported consuming pan, chalia (areca nut) tobacco sometimes during the day. This is relevantly better than the 79.6% & 79.9% results obtained in the studies [33,34] and other 47% denied consuming any of these in their lifetime comparable to study [34].
It is generally accepted that the prevalence of caries is related to the form in which sugar is ingested and the frequency of its consumption [35]. Sugars specifically refined sugars, sticky sugars and sugar alcohol have been evidently proven to be associated with an increased risk for caries occurrence [36] and 88% of our respondents showed averse results with frequent consumption of "bad sugars" on a daily basis. Despite the minimal 12% students who reported nil consumption of sweet were still higher than the 6% results in a study in Spain [37].
Acidic beverage (soft drink) consumption was observed in approximately 64% of the children which is less as compared to (77%) in a study [38].
Hence it is vital to spread awareness among our population to adopt healthy dietary habits and avoid the harmful foods which are a causative factors of many dental diseases.

Parental motivation
Role of parents in motivating and guiding their children to practice appropriate oral hygiene procedures is very significant. Parental knowledge and attitudes toward oral health can promote significant oral hygiene behaviors & skills in their children [39]. Our study showed that 78.1% of the parents advised their children to brush regularly, 47.7% personally supervised them while 63% parents adopted practicing oral care in front of their children for their motivation and setting a role model for them to follow which is similar to the results of the studies [40,41].
Frequency of tooth brushing in parents is linked with frequency of tooth brushing in their children. Tooth brushing and oral hygiene practice in parents can affect the frequency and quality of tooth brushing in children, since children learn many of behaviors from their parents [42].

CONCLUSION
The results extracted from the findings of this study are that the oral hygiene practice among the school children is good which is discernible by 97. 6% children demonstrating regular tooth brushing practice. Although this is appreciable yet their knowledge relating to awareness about other recommended methods of oral health care is poor and confined plus the conjunction of harmful eating habits, and lack of regular dental checkups can pose a risk of dental diseases. Hence there is a need to continue improving and promoting oral hygiene knowledge and awareness through education and oral health promotion campaigns. This will require collaboration of National & International authorities, dental colleges and public health departments to organize outreach programs for other govt. schools of the country as the majority of our children studying in govt. schools, belong to low socioeconomic class.

CONSENT
The school management i.e the principal and higher authorities facilitated in getting written informed consent from the participants' parents/ guardians.

ETHICAL APPROVAL
All authors hereby declare that the study was approved by Bahria University's Ethics committee. We assure that while carryout the research, we observed the highest ethical standards. We maintained integrity at all times regarding data gathering. We have only reported information that is in public domain and within the law. We have avoided plagiarism and fully acknowledged the work of others. While acknowledging the rights of all the research participants, we have compiled this research with all the ethical protocols outlined here: I. The permission of the school principal was obtained prior to research study being carried out. II. The permission of parents with written consent was obtained prior to study. III. Strict confidentiality was maintained and no names were included in the final data analysis. IV. No risk of life, or damage to any body part, organ or belonging was posed during the study.