1 Volume 24 2025 e253330 Original Research Braz J Oral Sci. 2025;24:e253330http://dx.doi.org/10.20396/bjos.v24i00.8673330 1 Department of Public Health, Yeti Health Science Academy, Purbanchal University, Maharajgunj, Kathmandu, Nepal. 2 Department of Public Health, Peoples Dental College and Hospital, Tribhuvan University, Kathmandu, Nepal. Corresponding author: Rajesh Karki karkirajesh2022@gmail.com Phone No. +977-9842484324 Editor: Dr. Altair A. Del Bel Cury Received: May 05, 2023 Accepted: August 8, 2023 Prevalence of dental caries and oral health habits among school children in Budhanikantha Municipality, Nepal Rajesh Karki1* , Kapila Lamichhane1 , Maheshor Kaphle2 Dental caries is the most common oral health disease among school-aged children worldwide. Aim: This study aims to identify the prevalence of dental caries, oral hygiene practices, and food habits among school children. Methods: A cross-sectional study was conducted at two secondary schools in Budhanikantha Municipality, Ward No. 2 and 12, with a total of 400 students participating. An oral examination was performed by a dentist, and decayed, missing, and filled teeth (DMFT) were used to determine the presence of dental caries. Statistical Package for the Social Sciences version 26 was used for all analyses. Results: Among the participants, the majority (66.3%) were aged 10-14 years, with a mean age of 13.58 years (±1.85), and were male (57.3%). The prevalence of dental caries was 63.0%, with a mean DMFT score of 1.67 (±1.82). Only 38.0% of participants brushed their teeth twice a day, and all used a toothbrush for brushing. Drinking tea with sugar (61%), eating sweets/candy (42%), and biscuits, cakes, and cream cakes (37.8%) were the most frequently consumed items and were consumed on a daily basis. Health-seeking behavior was poor, with the majority (32.8%) of participants not visiting the dentist within 12 months, and 22% never receiving dental care. Conclusion: The study reveals a high prevalence of dental caries among school children, indicating a need for improved oral health practices and healthcare utilization. The low frequency of tooth brushing and high consumption of sugary foods and drinks suggest that oral health education and promotion of healthy habits are essential. Keywords: Dental caries. Oral hygiene. Prevalence. Schools. Nepal. https://orcid.org/0000-0002-8431-2890 https://orcid.org/0009-0007-9301-6704 https://orcid.org/0000-0001-8121-6206 2 Karki et al. Braz J Oral Sci. 2025;24:e253330 Introduction Oral and dental health is an essential component of overall health and well-being and serves as a key indicator of quality of life. Dental caries, periodontal (gum) dis- ease, tooth loss, oral cancer, dental trauma, noma, and birth defects such as cleft lip and palate are some of the conditions included in oral and dental health1,2. Den- tal caries is a common process characterized by localized chemical dissolution of the tooth surface caused by acid production by dental plaque, which is frequently exposed to sugars3. It is a significant public health problem worldwide, affecting important life activities4. Dental caries is the most common oral health disease in school-aged children glob- ally, attributed to excessive sugar consumption, poor oral hygiene, lack of fluoride exposure, and insufficient healthcare utilization5,6. It can cause tooth pain, discomfort, eating difficulties, tooth loss, delayed language development, and financial strain on families, impairing children’s growth and functions, and leading to anxiety and fear, ultimately worsening the severity and incomplete treatment 5. According to the World Health Organization (WHO), 60-90% of schoolchildren world- wide have caries, with the disease being most prevalent in Asian and Latin American countries7. The Global Burden of Disease Study 2019 estimated that oral diseases affect nearly 3.5 billion people worldwide, with caries of permanent teeth being the most common condition2. Although dental caries prevalence has decreased in many developed countries over the last three decades, it remains high in the majority of developing countries8. In eastern Nepal, the prevalence of dental caries is 60.30% and 55.6% in primary and permanent dentition, respectively9. Nepal has a high incidence of dental health problems, with limited resources and manpower being a significant constraint in policy implementation10. The Nepalese people have lower oral health awareness and practice, primarily due to various constraints, including geo-socio-political, economic, and healthcare resources. Dental diseases such as dental caries and periodontal disease are prevalent in Nepal due to a lack of dental awareness. The oral health system in Nepal is currently tran- sitioning Oral hygiene is crucial in the prevention of dental caries and periodontal dis- eases11. Therefore, this study aims to identify the prevalence of dental caries, oral hygiene practices, and food habits among school children. Methods Study design and area For this study, a cross-sectional study design was adopted. The study was con- ducted in two different schools in Budhanilkantha Municipality, Nepal: Little Moon English Academy, located in Ward No. 2, and Shishu Milan English School, located in Ward No. 13. The selection of schools was based on the convenience of the researcher. 3 Karki et al. Braz J Oral Sci. 2025;24:e253330 Study population and sample size The study population included students from Grade 5 to Grade 10. A total of 400 students were included in the study, with 100 students from Little Moon English Academy and 300 students from Shishu Milan English School, respectively. Data collection tools and technique The questionnaire utilized in this study was adapted from the WHO Oral Health Sur- veys, 2013. It included sections on dentition status, socio-demographic informa- tion, oral hygiene and food habits practices, and health-seeking behaviors of the participants. Prior to data collection, a list of students was compiled from their daily attendance register. Qualified dentists with a Bachelor of Dental Surgery degree con- ducted the dental examinations. The dentists performed the examinations based on their professional expertise. “Oral health surveys: basic methods: WHO; 2013” ensured standardized evaluation. They assessed the presence of decayed, missing, and filled teeth (DMFT) and determined the dental caries status of the participants12. In a separate room, the students underwent examinations with their class instructor and friends present. The dentist helped the participants feel less anxious by detail- ing what would happen in advance. The demographic information, food habits, oral hygiene practices, and health-seeking behaviors of the students were evaluated by a researcher. Face-to-face interviews were conducted with students from grade 5 to grade 7, while students from grade 8 to grade 10 were provided with the questionnaire. Clear instructions on how to fill the questionnaire were given before distribution. Data collection took place from March 21 to March 27, 2023. Data quality control The collected data were reviewed and organized daily to ensure their completeness and accuracy. Proper coding and cleaning techniques were employed to enhance the accuracy of the results and to reduce the risk of errors and inconsistencies. To ensure the reliability of the questionnaire adopted from the WHO, a pilot test was conducted among 40 students in a similar area. Prior to the pilot test, a lit- erature review was conducted, and subject experts were consulted to ensure the validity of the questionnaire. Clear instructions were provided to the pilot test partic- ipants, who completed the questionnaire in the same format that would be used in the final study. Data analysis The Statistical Package for the Social Sciences (SPSS) Version 26 was utilized to conduct the statistical analysis. Descriptive statistics, such as frequency, percentage, mean, and standard deviation, were employed to measure socio-demographic vari- ables, food habits, oral hygiene practices, health-seeking behaviors, DMFT, and the prevalence of dental caries. The association between dental caries and selected vari- ables was measured using the chi-square test, and a significance level of P < 0.05 was considered statistically significant. 4 Karki et al. Braz J Oral Sci. 2025;24:e253330 Ethical Consideration Ethical clearance was obtained from the Institutional Review Committee of Yeti Health Science Academy (Ref. No.2079-072), and the School granted permission for data collection. All parents of the participating respondents provided written consent, and participants were informed of their right to refuse at any time during data collection, which was guaranteed and accepted. Results Socio-demographic characteristics of the sample Of the 400 participants, majority (66.3%, n=256) were aged 10-14 years, with a mean age of 13.58 years (±1.85). The majority of participants were male (57.3%, n=229), of Janajati ethnicity (64.8%, n=259), and practiced the Hindu religion (75.8%, n=303). Most of the parents had completed basic (31.3%, n=125) or secondary education (42.5%, n=170), and their occupations were predominantly in business (32.3%, n=129) or salaried employment (32.5%, n=130) (Table 1). Table 1. Demographic and Socioeconomic Characteristics of Study Participants Variables Frequency (n) Percentage (%) Age (mean ± SD, years) 13.58±1.85 Age in years 10-14 265 66.3 15-19 135 33.8 Sex Male 229 57.3 Female 171 42.8 Ethnicity Janajati 259 64.8 Brahmin/Chhetri 108 27.0 Others* 33 8.3 Religion Hindu 303 75.8 Bhuddhism 69 17.3 Others** 28 7.0 Grade of the respondent Grade 5 76 19.0 Grade 6 55 13.8 Grade 7 66 16.5 Grade 8 78 19.5 Continue 5 Karki et al. Braz J Oral Sci. 2025;24:e253330 Continuation Grade 9 63 15.8 Grade 10 62 15.5 Parent’s education Cannot read and write 12 3.0 Informal Education 48 12.0 Basic (grades 1-8) 125 31.3 Secondary (grades 9-12) 170 42.5 University Education 45 11.3 Family occupation of the respondent Farmers 55 13.8 Business 129 32.3 Daily wage workers 86 21.5 Salaried employee 130 32.5 *Dalit, Madhesi, Muslim, **Christian and Islam Oral hygiene practices of the sample More than half of the participants reported cleaning their teeth once a day (57.3%, n=229), followed by twice a day (38.0%) and 2-6 times a week (4.8%). All participants used a toothbrush to clean their teeth (100.0%). The majority of participants reported using toothpaste containing fluoride (56.3%, n=225), while 20.8% did not use fluoride toothpaste and 23.0% were unsure. Additionally, most participants reported that their parents encouraged them to brush their teeth (90.5%, n=362). Food and beverage consumption Table 2 presents the frequency of participants’ consumption of various foods and beverages. The findings show that fresh fruits are the most frequently con- sumed, with 32.5% (n=130) of respondents consuming them several times a week. Biscuits, cakes, and cream cakes are also quite popular, with 37.8% (n=151) of respondents consuming them every day. Sweet pies and buns are consumed less frequently, with only 7.0% of respondents consuming them several times a day. Sweets/candy is consumed every day by 42% (n=168) of respondents. Regard- ing beverages, tea with sugar is consumed most frequently, with 61% (n=244) of respondents drinking it every day. Soft drinks such as lemonade and Coca Cola are consumed moderately, with 24.3% (n=97) of respondents drinking them once a week. Coffee with sugar was consumed by only 18.3% (n=73) of respondents every day. 6 Karki et al. Braz J Oral Sci. 2025;24:e253330 Table 2. Frequency of food and beverage consumption among participants Variables Frequency % (n=400) Several times a day Everyday Several times a week Once a week Several times a month Seldom/ Never How often do you eat fresh fruits? 34 (8.5) 72 (18.0) 130 (32.5) 102 (25.5) 59 (14.8) 3 (0.8) How often do you eat Biscuits, Cakes, and Cream cakes? 35 (8.8) 151 (37.8) 112 (28) 58 (14.5) 36 (9) 8 (2) How often do you eat Sweet pies, Buns? 28 (7.0) 68 (17.0) 95 (23.8) 88 (22) 61 (15.3) 60 (15) How often do you eat Jam or Honey? 16 (4) 36 (9) 73 (18.3) 72 (18) 93 (23.3) 110 (27.5) How often do you eat Chewing gum? 69 (17.3) 138 (34.5) 118 (29.5) 43 (10.8) 14 (3.5) 18 (4.5) How often do you eat Sweets/Candy? 63 (15.8) 168 (42) 95 (23.8) 53 (13.3) 15 (3.8) 6 (1.5) How often do you drink Lemonade, Coca Cola or other soft drinks? 15 (3.8) 33 (8.3) 115 (28.7) 97 (24.3) 110 (27.5) 30 (7.5) How often do you drink Tea with sugar? 44 (11) 244 (61) 37 (9.3) 28 (7) 16 (4) 31 (7.8) How often do you drink Coffee with sugar? 32 (8) 73 (18.3) 58 (14.5) 57 (14.2) 48 (12) 132 (33) Health Seeking Behavior The information provided in table 3 includes the frequency of dental visits among respondents over the past 12 months, the reasons for their last dental visit, and their sources of dental health information. According to the table, a considerable propor- tion of respondents had not visited the dentist in the past year (32.8%, n=131) or had never received dental care (22%, n=88). Among those who had visited the dentist, the majority (62.9%, n=88) did so due to pain or trouble with their teeth, gums, or mouth. The table also shows that teachers (22.5%) and textbooks (21%) were the most com- mon sources of dental health information among respondents, followed by parents (19.3%), social media (9%), and health workers (7.5%). Table 3. Dental care utilization and information sources among the respondents Variables Frequency (n) Percentage (%) Frequency of dental visits in the past 12 months Once 70 17.5 Twice 32 8.0 Three times 4 1.0 Four times 13 3.3 More than four times 21 5.3 Continue 7 Karki et al. Braz J Oral Sci. 2025;24:e253330 Continuation No visit in past 12 months 131 32.8 Never received dental care/visited a dentist 88 22.0 Don’t know/Don’t remember 41 10.3 Reason for last visit to the dentist (n=140) Pain or trouble with teeth, gums or mouth 88 62.9 Treatment/follow-up treatment 25 17.9 Routine check-up of teeth/treatment 27 19.3 Sources of dental health information * Siblings 118 6.9 Friends 143 8.3 Parents 331 19.3 Teachers 387 22.5 Social media 154 9.0 Textbooks 360 21.0 Mass media 95 5.5 Health Workers 129 7.5 * Multiple responses Mean DMFT and prevalence of dental caries In Table 4, the prevalence of dental caries in the study participants is presented, with 63% (n=252) indicating “Yes” and 37% (n=148) indicating “No” out of the total 400 participants. The mean DMFT score, reflecting the severity of dental caries, was 1.67 (SD=1.83). Table 4. Dental caries prevalence and severity in study participants: analysis of yes/no responses and mean DMFT Score Variables Frequency (n) Percentage (%) Dentition status (Mean, SD) Caries (D) 1.62(±1.79) Missing due to caries (M) 0.01(±0.11) Missing for any other reason (M) 0.01(0.13) Filled with caries (F) 0.01 (±0.11) Prevalence of dental caries Yes 252 63.0 No 148 37.0 Index Mean ±SD DMFT Index 1.67 (±1.82) 8 Karki et al. Braz J Oral Sci. 2025;24:e253330 Frequency and risk factors for dental caries among different variables Table 5 presents the frequency and percentage distributions of dental caries accord- ing to different variables and the results of the Pearson chi-square test. Regarding age, it appears that those aged 10-12 have a higher percentage (71.3%, n=87) of dental caries compared to those aged 13-15 (59.5%) and 16-18 (58.8%). Males have a slightly higher percentage (64.2%, n=147) of dental caries compared to females (61.4%). Concerning ethnicity, others (75.8%) have the highest percentage of den- tal caries compared to Brahmin/Chhetri (64.8%) and Janajati (60.6%). Respondents with educated parents had slightly higher dental caries (66.7%), while daily wage workers (66.3%), respondents who brushed their teeth once a day (65.5%) and respondents whose teeth lacked fluoride (65.1%) had a higher prevalence of dental caries. However, there is no statistically significant relationship between dental car- ies and oral hygiene practices, including the frequency of teeth cleaning and the use of fluoride toothpaste. Table 5. Association between dental caries and various factors among the respondents Variables Dental Caries Chi-Square P Yes No n (%) n (%) Age 10-14 172 (64.9) 93 (35.1) 15-19 80 (59.3) 55 (40.7) 1.223 0.269 Sex Male 147(64.2) 82 (35.8) 0.327 0.568 Female 105 (61.4) 66 (38.6) Ethnicity Janajati 157(60.6) 102(39.4) Brahmin/Chhetri 70(64.8) 38(35.2) 3.087 0.214 Others 25 (75.8) 8(24.2) Religion Hindu 187(61.7) 116(38.3) Buddhism 45(65.2) 24(34.8) 1.213 0.545 Others 20(71.4) 8(28.6) Parent’s education of the respondent Cannot read and write 7(58.3) 5(41.7) Informal Education 32(66.7) 16(33.3) Basic (grades 1-8) 80 (64.0) 45(36.0) Secondary (grades 9-12) 104(61.2) 66(38.8) 0.785* 0.950 University Education 29(64.4) 16 (35.6) Continue 9 Karki et al. Braz J Oral Sci. 2025;24:e253330 Continuation Family Occupation of the respondent Farmer 33(60.0) 22 (40.0) 0.746 0.862 Business 82(63.6) 47 (36.4) Daily wage worker 57(66.3) 29(33.7) Professional 80(61.5) 50(38.5) Oral hygiene practices Frequency of tooth cleaning Once a day 150 (65.5) 79(34.5) Twice a day 91(59.9) 61(40.1) 1.467 0.480 2-6 times a week 11 (57.9) 8 (42.1) Use toothpaste that contains fluoride Yes 140 (62.2) 85(37.8) No 54 (65.1) 29(34.9) 0.210 0.901 Don’t Know 58(63.0) 34(37.0) *Fisher’s Exact Test Discussion To the best of our knowledge, this is the first study conducted among school children in Budhanilkantha Municipality. Our findings showed that 63% of the participants had dental caries, with a mean DMFT score of 1.67 (±1.83). This result was compa- rable to previous studies9,13, but higher than the findings reported by Suttagul et al.14, Ingle et al.15, and Shitie et al.6. However, a study conducted among male Saudi pri- mary school children reported a prevalence of dental caries of 83%16, while a study conducted on primary schoolchildren in Yasuj Township, Iran reported dental caries in 75.3%, 41.1%, and 89.8% of children’s primary, permanent, and whole dentitions, respectively[5], and a study conducted in three schools in Turkey reported dental caries in 70.9% of participants1. In our study, all the participants reported brushing their teeth. This is similar to a cross-sectional survey conducted among Lahore school students, where only one respondent did not brush their teeth at all17. However, school-aged children in Niger State, Nigeria reported not brushing their teeth at all in 42.3% of cases13. A cross-sectional study carried out among Chepang females of Nepal reported that 85.6% brushed regularly and 76% brushed twice a day18. This result was compara- tively higher than that of our study, which may be due to differences in the age range of participants and sample size. In both studies, however, these results were self-re- ported by the participants and were not verified during the study. A study carried out in five government primary schools in Chitwan’s remote Chandibhanjyang Village Development Committee reported that 24% of children reported brushing their teeth twice daily, and 56% reported cleaning their teeth daily7, which is somewhat similar to our findings. 10 Karki et al. Braz J Oral Sci. 2025;24:e253330 In our study, 100% of participants reported using a toothbrush, which is higher than in a previous study19. Our findings also showed that fruits, biscuits, cakes, cream cakes, and sweets/candy were the most commonly consumed foods, which is higher than in a study of preschool children in Abu Dhabi20. We found that regular dental checkups were low (35%), and among those who had visited the dentist, the majority (62.9%) did so due to pain or trouble with their teeth, gums, or mouth. Similar results were reported in previous studies7,21. Our study found that the prevalence of dental caries was higher in children aged 10-12 (71.3%), which is similar to the finding of a study conducted in Chennai, India8. We also found that males had higher dental caries than females, but the difference was not statistically significant, which is similar to a previous study14. Additionally, we found that caries prevalence was not significantly associated with the frequency of brushing or type of toothpaste used, which is similar to a previous study22. The study was conducted in only two schools located in Budhanikantha Municipality, Nepal, due to resource constraints and limited time for conducting the study. The selection of these schools was based on the permission granted by the school author- ities and their willingness to participate, which may limit the generalizability of the findings to a broader population of school children. Furthermore, the convenience sampling method used in selecting the schools may introduce bias and restrict the representativeness of the sample. Moreover, data on food habits, oral hygiene prac- tices, and health-seeking behavior were self-reported. This reliance on self-reporting may result in social desirability bias or recall bias, potentially affecting the accuracy and reliability of the obtained information. In conclusion, the majority had dental caries, with slightly over one-third reporting brushing their teeth twice a day. Drinking tea with sugar, consuming sweets/candy, biscuits, cakes, and cream cakes were frequently reported dietary habits. Further- more, the majority did not regularly visit the dentist for check-ups. Based on our findings, we conclude that dental caries had a high prevalence in the study area, highlighting a significant oral health concern. Oral hygiene practices, dietary habits, and health-seeking behaviors were found to be unsatisfactory. We rec- ommend that school authorities and parents encourage students to improve their oral hygiene, avoid consuming junk foods, and maintain regular dental visits. Additionally, we suggest incorporating oral hygiene topics into the school curriculum and organiz- ing routine dental examinations at schools. Interestingly, none of the factors showed a significant association with dental caries. This suggests the need to increase the sample size to enhance statistical power and improve generalizability. Conducting longitudinal studies can help explore the tempo- ral relationship between dental caries, oral hygiene practices, and food habits. Fur- thermore, we recommend the inclusion of objective measures, such as biomarkers, to assess oral hygiene and dietary habits, reducing reliance on self-reporting alone. Acknowledgement The authors would like to acknowledge the principals of Little Moon English Acad- emy and Shishu Milan English School for granting us permission to collect data. 11 Karki et al. Braz J Oral Sci. 2025;24:e253330 We would like to express our gratitude to Dr. Kripa Lamichhane and her team for helping with the oral examination. We also acknowledge all the guardians who gave their consent and thank all the participants for their valuable time and patience. Financial support None. Conflicts of interest There are no conflicts of interest. Author Contribution Rajesh Karki (Principal investigator): conceived the study design and procedure, per- formed data and statistical analysis, reviewed the manuscript, and participated in all stages of the study. Kapila Lamichhane and Maheshor Kaphle: supervised and par- ticipated in data collection, acquired permission from the concerned school, and pre- pared the first draft of the manuscript. All the authors reviewed the final manuscript and gave their approval. Data availability The data used in this study are available from the corresponding author upon reason- able request. References 1. Aslan Ceylan J, Aslan Y, Ozcelik AO. The effects of socioeconomic status, oral and dental health practices, and nutritional status on dental health in 12-year-old school children. Egyptian Pediatr Assoc Gaz. 2022;70(1):1-10. doi: 10.1186/s43054-022-00104-3. 2. World Health Organization. Oral health. Genebra: WHO [cited 2023 Apr 9]. Available from: https://www.who.int/health-topics/oral-health#tab=tab_1. 3. Machiulskiene V, Campus G, Carvalho JC, Dige I, Ekstrand KR, Jablonski-Momeni A, et al. 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