







































 

Sulistyani et al.                                                                                                                           Asian Journal of Dental and Health Sciences. 2025; 5(1):67-71  

[67]                                                                                                                                                                                                                                              AJDHS.COM 

 

 

Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2025 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided 

the original author and source are credited  

 

 

Oral Health Literacy Level and Biofilm Maturation as Risk Indicators for Dental 
Caries and Gingivitis: A Cross-Sectional Study 

Herastuti Sulistyani * , Quroti A’yun , Dewi Risnawati , Diani Sulistiawati  

Department of Dental Health, Poltekkes Kemenkes Yogyakarta, Indonesia 

Article Info: 
_____________________________________________ 
Article History: 

Received   06 Dec 2024     
Reviewed  14 Jan 2025 
Accepted   07 Feb 2025 
Published 15 March 2025 

_____________________________________________ 
Cite this article as:  

Sulistyani H, A’yun Q, Risnawati D, 
Sulistiawati D, Oral Health Literacy Level and 
Biofilm Maturation as Risk Indicators for 
Dental Caries and Gingivitis: A Cross-
Sectional Study, Asian Journal of Dental and 
Health Sciences. 2025; 5(1):67-71              DOI: 
http://dx.doi.org/10.22270/ajdhs.v5i1.111         
_______________________________________________________ 

*Address for Correspondence:   

Herastuti Sulistyani, Department of Dental 
Health, Poltekkes Kemenkes, Jl. Kyai Mojo 56, 
Yogyakarta, Indonesia  

Abstract 
_________________________________________________________________________________________________________________ 
Background. In Indonesia, dental and oral disorders are prevalent, with dental caries and gingivitis 
being the most common types of tooth decay in elementary school children. Gingivitis affects 90% 
of the world's population, with 80% of those affected being children under 12. Oral health literacy, 
which includes reading, writing, arithmetic, speaking, listening, and making sound decisions, is 
crucial for preventing oral diseases. 

Methods. A study involving 82 primary school students. The study used a modified OHL-AQ 
questionnaire and the GC triPlaque ID Gel™ (TPID) technique to assess biofilm maturation 

Results. The results showed a significant link between oral health literacy and biofilm maturation, 
suggesting that inadequate oral health literacy increases the risk of dental caries.  Conclusions. 
Inadequate oral health literacy increases biofilm maturation and the risk of dental caries. 

Keywords: Health literacy, Biofilm, Dental Caries, Gingivitis, Cross-Sectional Study 

 

 

INTRODUCTION 

Oral health plays an important role in supporting 
individual health. Problems with teeth and mouth in 
Indonesia reached 57.6%, while in the Special Region of   
Yogyakarta Province showed a higher percentage than 
the average in Indonesia, which was 65.6%.1 There are 
several types of dental and oral diseases, but dental 
caries is a dental and oral disease that many children 
suffer from. Dental caries is a dental tissue disease 
characterized by tissue damage, starting from the tooth 
surface, namely from enamel, dentin, and extending 
towards the pulp. Dental caries is one of the most 
common forms of tooth decay experienced by school-age 
children, which can interfere with the growth and 
development process.2 

The problem of dental caries in children, if not treated, 
will get worse, making children experience loss of 
chewing power and disrupting digestion.3 In addition, 
dental caries can also cause dental pain, it reduces the 
frequency of children's attendance to school, disrupts 
learning concentration, affects appetite and food intake, 
it can affect nutritional status and ultimately result in 
impaired physical growth of children. This will affect the 
nutritional status and health of children.4 

Apart from dental caries, the oral cavity disease that 
many people suffer from is gingivitis. The World Health 
Organization survey results show that 90% of the 
world's population suffers from gingivitis and 80% of 
them are children under 12 years of age. Gingivitis is the 
initial stage of periodontal disease in the form of 
inflammation of the gingiva caused by poor oral hygiene 
resulting in the accumulation of biofilm along the 
gingival margin.5 Research conducted by Karim, et al, 
showed a high incidence of gingivitis in children aged 9-
12 years, namely 63.83% had mild inflammation and 
27.66% had moderate inflammation.6  Lossu, et al state 
that gingival tissue that experiences inflammation is 
called gingivitis.7 One of the causes of gingivitis is biofilm 
that sticks to the teeth. Untreated gingivitis will continue 
and cause damage to the supporting tissues of the teeth 
(periodontitis), the teeth become loose and must be 
removed. 

Biofilm is a collection of microorganism cells that are 
irreversibly attached to a surface and encased in a matrix 
of Extracellular Polymeric Substances (EPS) that it 
produces itself, and shows a change in phenotype.8,9 

Biofilms that are still young (immature) and in the oral 
cavity, are a normal condition, considering that biofilms 
are formed continuously. Mature biofilms can cause 

                     Open Access                                                                                                                                                                                                        Research Article                                                                           

http://jddtonline.info/
http://dx.doi.org/10.22270/ajdhs.v5i1.111
https://crossmark.crossref.org/dialog/?doi=10.22270/ajdhs.v5i1.111&amp;domain=pdf
https://orcid.org/0000-0002-6927-7644
https://orcid.org/0000-0002-1698-8004
https://orcid.org/0009-0006-3292-7427
https://orcid.org/0009-0009-8922-3414


 

Sulistyani et al.                                                                                                                           Asian Journal of Dental and Health Sciences. 2025; 5(1):67-71  

[68]                                                                                                                                                                                                                                              AJDHS.COM 

diseases in the oral cavity such as dental caries and 
gingivitis, because they are dominated by cariogenic 
bacteria and periodontic bacteria.10 Based on research by 
Seneviratne, et al., biofilm matures in vitro after 24-72 
hours, while in vivo after 72 hours.11 

Biofilm accumulation can be prevented by good oral 
health self-care behavior. One of the factors that 
influence oral health self-care behavior is health 
literacy, which is the level of a person's capacity to obtain, 
process and understand basic health information and 
services needed to make appropriate health decision.12 
Oral health literacy is a general term that includes the 
skills of reading, writing, counting, speaking, listening, 
and making appropriate decisions, especially in every 
action related to oral health.13 A person who has low oral 
health literacy has a high risk of oral disease and matters 
related to oral disease.14 

Elementary school children are a critical period for the 
occurrence of oral diseases, because at this age the 
ability to prevent biofilm accumulation, as a causative 
factor in the occurrence of oral diseases is not yet 
adequate. The purpose of this study was to investigate 
the level of oral health literacy of elementary school 
students and biofilm maturation as a risk indicator for 
dental caries and gingivitis. 

MATERIALS AND METHODS 

This study was an analytic observational study with a 
cross-sectional design. The sampling technique used was 
purposive sampling, the number of samples in this study 
were 82 respondents. The research location was at the 
elementary school (SD Negeri) Kadipiro 1 Yogyakarta, 
Indonesia. The data collection method in this study used 
a modified OHL-AQ questionnaire, to obtain oral health 
literacy data, and biofilm maturation examination using 
GC triPlaque ID Gel™ (TPID) to determine the risk of 
dental caries and gingivitis. Data analysis used a non- 
parametric statistical test, namely the Kendall-tau test. 

RESULTS AND DISCUSSION 

Result: 

A. Respondent Characteristics 

The characteristics of respondents in this study can be 
seen in Figure 1.                            

Based on Figure 1, it is known that most of the 
respondents 42 (51.2%) were            male and aged 11 
years old 41 (50.0%). 

B. Oral Health Literacy Level of Elementary School 
Students 

Oral Health literacy level of elementary school student 
can be seen at Figure 2 

Based on Figure 2, it is known that out of 82 respondents 
47 (57.3%) respondents with a marginal level of oral 
health literacy.  

C. Biofilm Maturation in Elementary School Students 

This Research about biofilm maturation in elementary 
School Student can be seen at Figure 3. 

Based on Figure 3, out of 82 respondents, 42 (51.2%) 
respondents were found with mature biofilm 
maturation. This indicates the risk of gingivitis.  

D. The Association between Oral Health Literacy Level 
and Biofilm Maturation 

The Association between Oral Health Literacy Level and 
Biofilm Maturation can be seen at Tabel 1.  

Based on Table 1, it is known that respondents with 
inadequate oral health literacy, 13 (76.5%) had very 
mature biofilms. The results of the Kendall tau-b test 
obtained a p-value of 0.002 <0.05 means that there is a 
correlation between the level of oral health literacy and 
biofilm maturation in elementary school children. Based 
on this, it is known that inadequate oral health literacy 
will increase the level of biofilm maturation.

 

 

Figure 1: Characteristics of Respondents Based on Gender and Age 

Respondents Characteristic 
60 

51.2 50 
50 

48.8 

40 

30 

20 

10 

0 
Male 

GENDER 

Female 10 y.o 11 y.o 

AGE 

12 y.o 



 

Sulistyani et al.                                                                                                                           Asian Journal of Dental and Health Sciences. 2025; 5(1):67-71  

[69]                                                                                                                                                                                                                                              AJDHS.COM 

 

Figure 2: Oral Health Literacy Level of Elementary 
School Students 

 

Figure 3: Distribution of Biofilm Maturation in 
Elementary School Students

 

Tabel 1: The Association between Oral Health Literacy and Biofilm Maturation 

Oral Health Literacy Biofilm Maturation TOTAL P VALUE 

N 
No Biofilm Immature Mature Very Mature SUM   

 

 

 

 

0,002 

N % N % N % N % N % 

Inadequate 0 0 0 0 4 23.5 13 76.51 17  

100 Marginal 0 0 0 0 25 53.2 22 46.84 47 

Adequate 0 0 0 0 13 72.2 5 27.81 18 

Sum 0 0 0 0 42 52.1 40 48.88 82  

 

DISCUSSION  

Oral health literacy is defined as an individual who has 
the capacity to obtain, process or interpret and 
understand basic health information and services needed 
to make informed health decisions in a way that 
improves health.  Oral health literacy has an impact on a 
person's behavior, this is because the higher the oral 
health literacy, the better the person's knowledge. Oral 
health literacy assumes a person's ability to find, 
understand, and use oral health information is important 
to be able to access and benefit from oral health care 
services.15 

Individuals with inadequate oral health literacy are at 
higher risk for oral diseases and disease-related 
problems. Lower reading skills have been associated 
with problems using preventive services, delayed 
diagnosis of medical conditions, poor adherence to 
medical instructions, poor self- management skills, 
increased risk of death, poor health outcomes, and higher 
health care costs. Age affects a person's absorption and 
mindset, the older the age, the more developed the 
absorption and mindset, therefore the knowledge will be 
better.14 

Oral health literacy is one of the important factors that 

influence an individual's understanding of oral health 
care, as well as the individual's ability to make decisions 
regarding health promotion, disease prevention, and 
utilization of oral health care. Oral health literacy is a 
basic or primary care medium for everyone so it is 
considered an effective part of the health care system.12 

The very mature category was found in 40 (48.8%) 
respondents, which is a risk for dental caries. This shows 
that the oral health self-care ability of elementary school 
students is still lacking, therefore the biofilm that forms 
become mature. 

Biofilm that is still young (immature) and is in the oral 
cavity, is a normal condition, considering that biofilm is 
formed continuously. Mature biofilms can cause diseases 
in the oral cavity such as dental caries and gingivitis, 
because they are dominated by cariogenic bacteria and 
periodontic bacteria.10 Based on research by Seneviratne, 
et al., biofilm matures in vitro after 24-72 hours, while in 
vivo after 72 hours.11 

Approximately 65% of human infections result from 
biofilm formation. Biofilms have unique characteristics 
compared to microorganisms in the form of planktonic 
cells, usually more resistant. 16 Biofilm formation consists 
of 4 steps, namely bacterial attachment to the surface 

Oral Health Literacy 

22% 
(18) 

20,7% 
(17) 

57,3% 

(47) 

Inadequate Marginal Adequate 

Immature 
0% (0) 

Very mature 
48.8% (40) 

Mature 
51,2% (42) 



 

Sulistyani et al.                                                                                                                           Asian Journal of Dental and Health Sciences. 2025; 5(1):67-71  

[70]                                                                                                                                                                                                                                              AJDHS.COM 

(initial phase), proliferation and formation of 
extracellular matrix (intermediate phase), increase of 
extracellular matrix material to form a 3- dimensional 
biofilm structure (maturation phase) and after entering 
the maturation phase, some planktonic cells detach and 
attach to the surface to form a new biofilm cycle.9 

According to research conducted by Flemming and 
Wuertz in 2019, biofilm maturation involves complex 
interactions between microorganisms, substrate 
surfaces, and the surrounding environment. The biofilm 
maturation process involves a number of complex stages, 
starting from the attachment of microorganisms on the 
surface to the formation of a mature and complex biofilm 
structure.23 

Once the initial attachment occurs, the microorganisms 
begin to produce an extracellular matrix that protects 
and sustains the biofilm structure. This extracellular 
matrix production is a key stage in biofilm maturation 
that enables the formation of strong and durable 
structures (Bridier et al. 2019).22 At advanced stages of 
maturation, biofilms can become highly resistant to 
external perturbations, including physical stress, 
temperature changes, and antimicrobial therapy 
(Stewart and Franklin, 2020). 

Oral health literacy plays an important role in 
maintaining optimal oral hygiene and preventing various 
dental conditions. One important aspect of oral health is 
the formation and maturation of dental biofilms. This 
discussion explores the correlation between oral health 
literacy and biofilm maturation, especially the impact of 
individual knowledge and practices on oral health 
outcomes. 

Oral health literacy encompasses an individual's ability 
to acquire, process and understand basic oral health 
information to make informed decisions regarding 
their oral care. Limited oral health knowledge has been 
associated with poor oral hygiene practices, increased 
risk of dental disease, and delayed treatment-seeking 
behavior (Jones et al., 2013).22 Understanding the basic 
principles of oral health, including the importance of 
regular brushing, flossing, and professional dental check-
ups, is essential to prevent the accumulation and 
maturation of dental biofilms. 

The presence of highly mature biofilms indicates that 
oral health self-care behavior in elementary school 
children is still lacking. This self-care behavior is 
influenced by oral health literacy. The better the oral 
health literacy, the better the understanding of 
elementary school students in maintaining oral hygiene, 
therefore the biofilm that forms do not become mature. 
This statement is in accordance with the opinion of 
Divaris, et al. (2013), which states that the interaction 
between oral health literacy and biofilm maturation is 
evident in individual oral care practices.21 Individuals 
with higher levels of oral health literacy tend to perform 
effective oral hygiene behaviors, thus disrupting the 
early stages of biofilm formation. Conversely, individuals 
with limited oral health knowledge may neglect 
proper oral care, thus providing a conducive 
environment for biofilm maturation and subsequent oral 

health problems. 

Mature biofilm is an indicator for gingivitis. In this study, 
51.2% of elementary school students were found to be at 
risk of gingivitis. Poor oral health literacy is a significant 
risk indicator for poor oral health. Oral health literacy 
consistently emerged as a predictor of oral hygiene and 
gingival health status among respondents implying that 
low levels of oral health literacy directly affect oral health 
status including gingival index (Baskaradoss, 2018).22 
This study is in line with research conducted by Ineg 
benosun & Azodo, (2020) which shows there is a 
relationship between oral health literacy and gingival 
health status with a p-value of 0.000. Respondents who 
have low health literacy have a risk of 7.054 times to 
experience gum inflammation (gingivitis).21 

Addressing oral health literacy is a key component in 
preventing biofilm maturation and its associated 
consequences. Public health initiatives and educational 
programs should focus on improving oral health literacy 
to empower individuals to make decisions regarding 
their oral care. Simple and clear communication about 
the impact of daily oral hygiene practices on biofilm 
formation can contribute significantly to improved oral 
health outcomes (Guzman- Armstrong et al., 2016).21 

CONCLUSION 

According to this study, oral health literacy level is 
associated with biofilm maturation in elementary school 
students. Inadequate oral health literacy increases 
biofilm maturation and dental caries risk. 

Ethical Approval: The study was approved by the 
DP.04.03/e- KEPK.1/130/2023 Committee. 

Author Contributions:  

Herastuti Sulistyani: Conceptualization, study design, 
methodology, writing—original draft, and supervision. 

Quroti A’yun: Data collection, analysis, and writing—
review & editing. 

Dewi Risnawati: Data curation, statistical analysis, and 
visualization. 

Diani Sulistiawati: Funding acquisition, resources, and 
final manuscript approval. 

Funding: The authors received no financial support for 
the research, authorship, and/or publication of this 
article. 

Conflicts of Interest: The authors declare no conflicts 
of interest. 

Informed Consent Statement: Informed consent was 
obtained from all subjects involved in the study.  

Data Availability Statement: The data presented in 
this study are available on request from the 
corresponding author.   

Acknowledgement: 

The authors would like to express their gratitude to 
Poltekkes Kemenkes Yogyakarta, Indonesia for providing 
the necessary resources and support throughout this 
study.  We appreciate the insightful comments and 



 

Sulistyani et al.                                                                                                                           Asian Journal of Dental and Health Sciences. 2025; 5(1):67-71  

[71]                                                                                                                                                                                                                                              AJDHS.COM 

suggestions from the anonymous reviewers, which have 
helped improve the quality of this manuscript. 

REFERENCES 

1. Kemenkes RI, Hasil Riset Kesehatan Dasar Tahun 2018, Kementrian 
Kesehatan RI, 2019; 53(9), 1689-1699. 

2. Afrinis, N., Indrawati dan Farizah, N, Analisa Faktor yang 
Berhubungan dengan Kejadian karies Gigi Anak Usia Dini, Jurnal 
Obsesi: Jurnal Pendidikan Anak Usia Dini, 2021;5(1) 
https://doi.org/10.31004/obsesi.v5i1.668 

3. Widayati, N., Faktor Yang Berhubungan Dengan Karies Gigi Pada 
Anak Usia 4-6 Tahun (Studi Di Tk Ra Bustanussholihin Desa Balun 
Kecamatan Turi, Jurnal Berkala Epidemiologi, 2014; 2:197. 

4.Fatimatuzzahro, N., Prasetya, R. C., & Amilia, W., Gambaran Perilaku 
Kesehatan Gigi Anak Sekolah Dasar di Desa Bangalsari Kabupaten 
Bantaeng, Jurnal IKESMA, 2016; 12(2):85. 

5. Pontoluli, Z.G, Khoman, J.A, Wowor, V.N.S., Kebersihan Gigi Mulut 
dan Kejadian Gingivitis pada Anak Sekolah Dasar, e-Gigi, 2021; 
9(1):21-28. https://doi.org/10.35790/eg.9.1.2021.32366 

6. Karim CAA, Gunawan P, Wicaksono D., Gambaran status gingiva 
pada anak usia sekolah dasar di SD GMIM Tonsea Lama. e-GiGi, 
2013;1(2):9. https://doi.org/10.35790/eg.1.2.2013.3227 

7. Lossu, F. M., Pangemanan, D. H. C., & Wowor, V. N. S., Hubungan 
Pengetahuan Kesehatan Gigi Dan Mulut Dengan Indeks Gingiva 
Siswa Sd Katolik 03 Frater Don Bosco Manado, E-GIGI, 2015; 3(2). 
https://doi.org/10.35790/eg.3.2.2015.10489 

8. Gunardi, W. D., Peranan Biofilm dalam Kaitannya dengan Penyakit 
Infeksi, Jurnal Kedokteran Meditek, 2007; 15 (39A). 

9. Wibawa, T, Candida albicans biofilm: formation and antifungal 
agents resistance, J Med Sci, 2012; 44(2) 

10. Tugeman, H., Rahman, N.A, Yusoff, A dan Daud, MKM, Oral Health 
Knowledge, Practice and Dental Plaque Maturity Status of 
Hearing-Impaired Children, Sains Malaysiana, 2016; 45(5):761-
768 

11. Seneviratne, C.J., Zhang, C.F. & Samaranayake, L.P., Dental plaque 
biofilm in oral health and disease. The Chinese Journal of Dental 
Research, 2011; 14(2):87-94. 

12. Baskaradoss, J. K., Relationship between oral health literacy and 
oral health status. BMC Oral Health, 2018; 18(1):1-6. 

https://doi.org/10.1186/s12903-018-0640-1 PMid:30355347 
PMCid:PMC6201552 

13. Sistani, N M. M., Montazeri, A., Yazdani, R., & Murtomaa, H., New 
oral health literacy instrument for public health: development and 
pilot testing, Journal of Investigative and Clinical Dentistry, 2014; 
5(4):313-321. https://doi.org/10.1111/jicd.12042 
PMid:23559571 

14. Batista MJ, Lawrence HP, Sousa M. Oral health literacy and oral 
health outcomes in an adult population in Brazil. BMC Public 
Health, 2017;18(1):60. https://doi.org/10.1186/s12889-017-
4443-0 PMid:28747157 PMCid:PMC5530456 

15. Robinson, L.A., Oral Health Literacy. J Calif Dent Assoc, 2012; 
40(4): 312-314. PMid:22679670 
https://doi.org/10.1080/19424396.2012.12220899  

16. Weerasekera, M. M. Wijesinghe, G.K., Jayarathna, T.A., Gunasekara, 
C.P., Fernando, N., Kottegoda, N., Samarayanake, L.P., Culture 
media profoundly affect Candida Albicans and Candida tropicalis 
growth, adhesion and biofilm development, Memorias do Instituto 
Oswaldo Cruz. Fundacao Oswaldo Cruz, 2016; 111(11):697-702. 
https://doi.org/10.1590/0074-02760160294 PMid:27706381 
PMCid:PMC5125054 

17. Bridier, A., Briandet, R., Thomas, V., & Dubois-Brissonnet, F., 
Resistance of bacterial biofilms to disinfectants: a review. 
Biofouling, 2019; 27(9):1017-1032  PMid:22011093 
https://doi.org/10.1080/08927014.2011.626899  

18. Stewart, P. S., & Franklin, M. J., Physiological heterogeneity in 
biofilms. Nature Reviews Microbiology, 2020; 18(1):56-67. 

19. Jones K, Parker E, Mills H, Brennan D, Jamieson LM, Development 
and psychometric validation of a Health Literacy in Dentistry scale 
(HeLD). Community Dent Health, 2013; 30(3):133-140. 

20.Divaris K, Lee JY, Baker AD, Vann WF., Caregivers' oral health 
literacy and their young children's oral health-related outcomes. 
Pediatrics, 2013; 132(5):e1274-e1281. 

21. Inegbenosum, H., & Azodo, C.C., Association between oral health 
literacy, gingival health and oral hygiene among dental patients. 
Nig J Dent Res, 2020, 5(1):7-13. 

22. Guzman-Armstrong S, Warren R, Cunningham-Ford MA, Sinclair C., 
Effective communication and oral health literacy: A guide for oral 
health professionals. NSW Public Health Bull, 2016; 27(4):153-
157

 

 

https://doi.org/10.31004/obsesi.v5i1.668
https://doi.org/10.35790/eg.9.1.2021.32366
https://doi.org/10.35790/eg.1.2.2013.3227
https://doi.org/10.35790/eg.3.2.2015.10489
https://doi.org/10.1186/s12903-018-0640-1
https://doi.org/10.1111/jicd.12042
https://doi.org/10.1186/s12889-017-4443-0
https://doi.org/10.1186/s12889-017-4443-0
https://doi.org/10.1080/19424396.2012.12220899
https://doi.org/10.1590/0074-02760160294
https://doi.org/10.1080/08927014.2011.626899

