142142

Dental Journal
(Majalah Kedokteran Gigi)
2022 September; 55(3): 142–147

Original article

INTRODUCTION

Oral health problems have a high rate of occurrence in 
many countries worldwide and affect various aspects of 
an individual’s life, often causing pain and discomfort.1 
According to the Data and Information Center of the 
Indonesia Ministry (2007 and 2013) and Baseline Health 
Research (2018), oral health problems in Indonesia continue 
to increase every year.2 However, most people with oral 
health problems have minimal knowledge, and are not 
concerned, about their situations.3 People who should 
understand and care about dental and oral problems are 
dental students.

Dental students are future dentists responsible for 
maintaining the oral health and hygiene of the community. 
Consequently, they are expected to maintain their oral 
hygiene to be good examples for the community.4 Research 
on dental students’ oral hygiene levels conducted in several 
countries showed varying results. A study in Sudan showed 
a low score on dental hygiene behaviour, and another 

study in Saudi Arabia showed a high level in oral health 
attitudes, but this was not reflected in the oral hygiene 
and gingival statuses. Research conducted on Trisakti 
University dental students using the HU-DBI (Hiroshima 
University Dental Behavioural Inventory) questionnaire, 
which describes oral health perception and behaviour, 
showed good results. Thus, further studies using intraoral 
assessments are needed to confirm the findings of the prior 
studies.5–8 Oral hygiene assessments are usually carried 
out in dental practices with various oral hygiene indexes, 
but these assessments are not possible to perform during 
the COVID-19 pandemic.9

The COVID-19 pandemic began in early 2020 and 
caused a lockdown condition that impacted dental practices, 
mainly routine dental check-ups.10 Research conducted on 
the Brazilian population during the pandemic reported that 
oral hygiene behaviour decreased, and the anxiety level 
associated with visiting dental clinics increased because of 
the risk of virus transmission, meaning that oral hygiene 
could not be monitored appropriately, and eventually, this 

Oral hygiene assessment of dental students using the Oral Rating 
Index (ORI)
Tirza Oktarina Setiabudi1, Fajar Hamonangan Nasution2
1Dental Student, Faculty of Dentistry, Trisakti University, Jakarta, Indonesia
2Department of Orthodontics, Faculty of Dentistry, Trisakti University, Jakarta, Indonesia

ABSTRACT
Background: Oral hygiene screening should be done on a regular basis, notably during the COVID-19 outbreak, during which lifestyle 
changes and government lockdown policies lower the oral hygiene level. The Oral Rating Index (ORI), established by Kawamura, is the 
suitable oral hygiene screening index during the COVID-19 pandemic. Dental students are supposed to be role models for the community 
by maintaining good dental hygiene. Purpose: To study the use of online oral hygiene screening using the ORI and to determine the oral 
hygiene of dentistry students at Trisakti University. Methods: This research is a cross-sectional descriptive observational study. A total 
of 100 preclinical dental students from Trisakti University took part in the study. Intraoral photos were taken and sent to the researcher 
via the internet. The ORI was used to evaluate the data. The reliability of the results was determined using a per cent agreement test 
and Cohen’s kappa coefficient. Results: The average oral hygiene score of dental students at Trisakti University was 0.58±0.88. The 
per cent agreement was 88%, and Cohen’s kappa coefficient was κ = 0.79, indicating excellent reliability. Conclusion: Based on their 
ORI score, it can be stated that dentistry students at Trisakti University have good oral hygiene and that online evaluation using the 
ORI is a useful tool for routine oral hygiene screening.

Keywords: dental students; Kawamura; oral hygiene; Oral Rating Index (ORI)

Correspondence: Fajar Hamonangan Nasution, Department of Orthodontics, Faculty of Dentistry, Trisakti University. Jl. Kyai Tapa, 
No. 260, Jakarta, 11440, Indonesia. Email: fajar@yahoo.co.jp

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v55.i3.p142–147

mailto:fajar@yahoo.co.jp
https://e-journal.unair.ac.id/MKG/index
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143 Setiabudi and Nasution/Dent. J. (Majalah Kedokteran Gigi) 2022 September; 55(3): 142–147

led to dental and oral health problems.11,12 Particularly in 
dental students, the switch in activity to online learning 
may affect their oral health; however, there is no data 
yet about this. Dental health during the pandemic can be 
monitored by using an oral hygiene screening method that 
can be applied under lockdown conditions. Oral hygiene 
screening methods that are suitable during the pandemic 
are assessments that do not require face-to-face contact 
between dentists and patients and can be done online while 
still providing reliable results.13 An example of an oral 
hygiene assessment that can be done during the pandemic 
is the Oral Rating Index (ORI), which was developed by 
Kawamura and will be modified in this research by using 
remote examination through intraoral photos to adapt to 
the pandemic situation.14,15

The urgency of this research is based on the current 
conditions of the pandemic, during which oral hygiene 
cannot be monitored as usual, and there is no data yet 
regarding dental students’ oral hygiene. Therefore, the 
researchers are interested in conducting this study, which 
aims to obtain an overview of oral hygiene among dental 
students in the Faculty of Dentistry, Trisakti University – 
the most accessible population for testing the new screening 
method during the pandemic. This study will contribute to 
current knowledge as it reflects the community oral hygiene 
condition and reveals whether we will have good future 
dentists. Furthermore, the purpose of this research is to 
assess the reliability of online oral hygiene screening using 
the ORI to monitor oral health as an alternative reliable 
option during the pandemic. 

MATERIALS AND METHODS

This research employed a descriptive observational method 
and a cross-sectional method. This research was conducted 
online from September to October 2021 and received 
ethical clearance from the Faculty of Dentistry Ethics 
Commission at Trisakti University on 23 July 2021, with 
letter number 471/S1/KEPK/FKG/7/2021. The population 
in this study comprised preclinical dental students from 
the Faculty of Dentistry, Trisakti University, Jakarta. The 
research sample was taken by consecutive sampling. The 
minimum sample size required was 97, which was obtained 
based on the Lemeshow formula, but 100 samples were 
taken to prevent data shortages.16 The inclusion criteria 
in this study included preclinical students of the Faculty 
of Dentistry, Trisakti University, who were willing to be 
research subjects and use the same brand of smartphone to 
take the intraoral photos according to the instructions given. 
The exclusion criteria for this study were those using fixed 
orthodontic appliances and students who had performed 
scaling after March 2020. Preclinical dental students were 
chosen because they had the same education and knowledge 
background, they were of a similar age range and they were 
the most accessible population on which to conduct the 
research during the pandemic.

The variables in this study were the dental and oral 
hygiene of preclinical students who were assessed based 
on the ORI. The ORI is an index of dental and oral hygiene 
assessment, which is based on gingival condition and 
plaque and calculus accumulation by visual examination 
as mentioned and established by Kawamura. The area 
examined included the labial surfaces of the upper and 
lower anterior teeth and the lingual surfaces of the upper 
and lower right posterior teeth. The ORI rating uses an 
ordinal scale from +2 to –2. A score of +2 (very good) was 
assigned if the gingivae were healthy and no plaque and 
calculus were detected. A score of +1 (good) was given if 
there was a slight gingival inflammation but oral hygiene 
was generally good. A score of 0 (questionable) was given 
if the researcher found it difficult to determine a positive 
or negative score. A score of –1 (poor) was assigned when 
the gingival inflammation was visible and there was a lot of 
plaque and calculus. A score of –2 (very poor) was given if 
the gingival inflammation was severe and the oral hygiene 
was very bad.14

The data collection was carried out online through 
Google Forms, which included examples and instructions 
for taking intraoral photos. There were four intraoral photos 
that should have been taken: the labial surface of the anterior 
upper teeth and lower teeth and the lingual surface of the 
posterior upper and lower right teeth. The instructions for 
taking intraoral photos included using the same brand of 
smartphone with the specification of a 12-megapixel rear 
camera and activating the camera flash. The distance should 
have been adjusted accordingly so that the result would 
be focused and not blurry. The angle and the intraoral 
photo results should have followed the example from the 
researchers (Figure 1).

The data were collected and assessed based on the 
parameters. By use of Microsoft Excel, the mean score of 
the data was measured and analysed based on the gender 
group and the academic year’s group. The differences 
among the gender groups and the academic year groups 
were analysed using the Mann–Whitney U test and the 
Kruskal–Wallis test, respectively, as well as Statistical 
Package for the Social Sciences (SPSS) Statistics 25 
software.

The intra-rater reliability test was carried out by one 
researcher who reassessed the data within two weeks of 
the first assessment by blinding the respondent's identity to 
prove that the assessment carried out had reliable results. 
Reliability analysis was carried out using Cohen’s kappa 
coefficients and SPSS Statistics 25 software. The results of 
the Cohen’s kappa assessment can be categorised as poor 
agreement (κ < 0.40), good agreement (0.40 < κ < 0.75) or 
excellent agreement (κ > 0.75). The data obtained in this 
study were then calculated using Microsoft Excel software 
to find the mean of oral hygiene and per cent agreement. 
The results of per cent agreement can be categorised as 
none (0%–4%), minimal (4%–15%), weak (15%–35%), 
moderate (35%–63%), strong (64%–81%) and almost 
perfect (82%–100%).

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v55.i3.p142–147

https://e-journal.unair.ac.id/MKG/index
https://doi.org/10.20473/j.djmkg.v55.i3.p142-147


144Setiabudi and Nasution/Dent. J. (Majalah Kedokteran Gigi) 2022 September; 55(3): 142–147

Figure 1. Example for taking intraoral photos and the desired results.

 

+2 (very good) 
Normal gingival condition 
and no detectable plaque 
or calculus 

 

+1 (good) 
Normal gingival 
condition; small amount 
of plaque and calculus 
accumulation detected; 
fairly good oral hygiene 

 

0 (questionable) 
Localised gingival 
inflammation but small 
amount of plaque and 
calculus accumulation 
detected; questionable 
appearance 

 

–1 (poor) 
Gingival inflammation; 
notable amount of plaque 
and calculus accumulation 
detected; poor oral 
hygiene 

–2 (very poor) 
Gingival inflammation; 
large amount of plaque 
and calculus accumulation 
detected; very poor oral 
hygiene 

Figure 2. Examples of data collected and Oral Rating Index (ORI) assessment, in order from top to bottom: +2 to –2.

Table 1. Respondents’ characteristics distribution (n = 100)

Year Male Female Total
First 6 21 27
Second 13 21 34
Third 3 15 18
Fourth 2 19 21

Table 2. Results distribution of Oral Rating Index (ORI) 
examination based on gender (n = 100)

Gender
ORI score

(+2) (+1) (0) (–1) (–2)
Male 2 7 10 2 3
Female 5 53 11 6 1
(n = 100, Mann–Whitney Test = 0.003 (p < 0.05))

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v55.i3.p142–147

https://e-journal.unair.ac.id/MKG/index
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145 Setiabudi and Nasution/Dent. J. (Majalah Kedokteran Gigi) 2022 September; 55(3): 142–147

RESULTS

Data were collected online via Google Forms from 100 
preclinical dental students attending Trisakti University. 
Of the 100 respondents, 76 were female and 24 were 
male; they were distributed from first year to fourth year 
(Table 1).

The collected intraoral photos were then compiled and 
assessed for each ORI score based on the gingival condition 
and the plaque and calculus that were visible in the intraoral 
photos. The acceptable intraoral photos were those that 
showed the examination parameters clearly. The researcher 
marked the inflammation signs of the gingivae and the 
accumulation of plaque and calculus (Figure 2).

The majority of the students (60%) got a +1 score, which 
indicates good oral hygiene and good gingival healthcare 
levels, while only 4% of the total respondents registered 
the lowest score of –2 (very poor) (Table 2). The data were 
then analysed using Microsoft Excel, and the average ORI 
score was 0.58 ± 0.88, which could be categorised as good 
oral hygiene. The average ORI score can be reviewed based 
on gender; the oral hygiene in female dental students was 
0.72 ± 0.76, while in the male students, it was lower, at 0.13 
± 1.12. There is a significant difference between the oral 
hygiene scores of males and females (p < 0.05).

In addition to the gender distribution, the results of the 
ORI examinations can be assessed by year of study. The 
average ORI score of third-year students is the highest, at 
0.72 ± 0.57, followed by first-year students at 0.55 ± 0.89, 
second-year students at 0.55 ± 1.49, and lastly, fourth-year 
students, whose average was 0.52 ± 0.87 (Table 3). There 
is no significant difference between oral hygiene scores 
among students in different academic years (p < 0.05).

The intra-rater reliability test was then carried out by 
conducting a second examination using the same intraoral 
photos from respondents with a blinding method, which 
uses code numbers to replace respondents’ initials and 
randomises the examination order. The results of the 

first and second examinations were combined in a cross-
tabulation, which was then processed with the per cent 
agreement using Microsoft Excel and Cohen’s kappa 
coefficient through SPSS Statistics (Table 4). In this 
research, the per cent agreement was 88%, which can be 
deemed almost perfect reliability. In this study, the Cohen’s 
kappa results obtained were κ = 0.79, with a significance 
value of 0.00 (0.00 < 0.05), which means the reliability 
was excellent.

DISCUSSION

Oral hygiene screening using the ORI on preclinical dental 
students was conducted online through intraoral photos. 
Instructions were given for standardising the photo results 
for the ORI examination as the respondents took photos of 
their oral cavity by themselves. Hitherto, there had been 
no available reference for the standardisation of intraoral 
photos for ORI assessment. However, the overall results 
of the intraoral photos obtained showed the parameters 
needed for the assessment, so they were considered 
adequate for ORI examination. Therefore, this method can 
be an alternative for conducting similar research remotely 
during the pandemic or after the pandemic ends, as long 
as the participants are able to take the photos according to 
the instructions.

The average score in the oral hygiene of dental 
students at the Faculty of Dentistry at Trisakti University 
was considered good. The research results aligned with 
the dental and oral hygiene behaviour assessment using 
the Hiroshima University Dental Behavioural Inventory 
(HU-DBI) questionnaire, previously conducted in 2020 
with similar respondents.6 The ORI and the HU-DBI are 
complementary tools; data from the two studies conducted 
at Trisakti University showed a direct, unidirectional 
relationship between the ORI and the HU-DBI. Specifically, 
the higher the HU-DBI score, the higher the ORI score. 

Table 4. Intra-rater agreement for Oral Rating Index examination

First examination
Second examination

Total
Very good (+2) Good (+1) Questionable (0) Poor (–1) Very poor (–2)

+2 7 0 0 0 0 7
+1 1 57 2 0 0 60
0 0 4 13 4 0 21
–1 0 1 0 7 0 8
–2 0 0 0 0 4 4
Total 8 62 15 11 4 100
(n = 100, % agreement = 88%, κ = 0.79 (SD = 0.05))

Table 3. Results distribution of Oral Rating Index examination based on year of study (n = 100)

Year
ORI score

(+2) (+1) (0) (–1) (–2)
First 2 15 7 2 1
Second 4 18 8 1 3
Third 0 14 3 1 0
Fourth 1 14 3 4 0
(n = 100, Kruskal–Wallis Test = 0.928 (p < 0.05))

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v55.i3.p142–147

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146Setiabudi and Nasution/Dent. J. (Majalah Kedokteran Gigi) 2022 September; 55(3): 142–147

Good oral and dental hygiene can also be found in dental 
faculty students in Korea who were examined with the ORI 
index and in dental faculty students in India and Romania, 
where other intraoral clinical examinations, such as the 
gingival index, the plaque index and the Oral Hygiene Index 
were used.17–19 Dental students at the Faculty of Dentistry 
at Trisakti University have been learning subjects related to 
oral health and hygiene since the first year; hence, good oral 
hygiene may indicate that the students have implemented 
dental and oral hygiene knowledge, yet further analysis and 
assessment are required to confirm this conclusion.

The ORI examination was given according to the 
condition of the gingivae and the plaque and calculus 
accumulation on a scale of +2 (very good) to –2 (very poor). 
The higher the ORI value, the better the level of dental and 
oral hygiene. The score of +2 (very good) was expected to 
appear the most in the respondents of this research as they 
are dental students. However, from the results data, only 
a few respondents (7%) who met the assessment criteria 
were very good, while the majority of respondents (60%) 
got a score of +1 (good). Healthy gingival conditions 
and the presence of minimal or even no calculus during 
the pandemic are signs that oral hygiene behaviour has 
been applied routinely and adequately considering that 
calculus is formed from mineralised plaque, which can 
only be prevented by daily plaque control, and if calculus 
has formed, it can be cleaned only by scaling at the dental 
clinic.20

Scores of –1 (poor) and –2 (very poor) were still found 
in a small proportion of respondents (12%). Although 
only slight, these results were worrying because, as 
prospective dentists who should provide awareness about 
the importance of maintaining oral and dental hygiene, these 
respondents had not yet taken care of their oral hygiene 
properly. Research conducted on students of the dental 
faculty in Denpasar also showed that there was still a small 
proportion of students from the faculty who had poor levels 
of oral and dental hygiene.21

A score of 0 (questionable) is a condition in which 
the researcher finds it difficult to determine a positive 
or negative value in the ORI assessment. In this study, a 
score of 0 was given to respondents who had asynchronous 
conditions, such as gingivae that looked healthy alongside 
quite a lot of plaque and calculus accumulation (or vice 
versa) seen on the photo. Although online assessment of 
the ORI using photographs is recommended, there are 
still limitations that cannot be avoided; in some cases, the 
researchers were hesitant to determine the extent of gingival 
inflammation and plaque and calculus accumulation. 
Therefore, it is necessary to conduct another study by face-
to-face ORI examination with the respondent to confirm 
the results. If necessary, another dental and oral hygiene 
index examination can be added using an instrument to 
confirm and facilitate the determination of the level of 
oral hygiene.

The results obtained in this research had a refractive 
factor because the research was carried out during a 

pandemic and a government-mandated lockdown policy 
under which conditions were not normal, so the existing 
results could not be used as baseline data. After the 
pandemic, oral hygiene examinations can be carried out 
again to obtain baseline data on the oral hygiene level of 
dental students and to be used as a basis of comparison 
between oral hygiene during a pandemic and oral hygiene 
in everyday situations.

ORI assessment can be viewed from the gender 
perspective, where the average score in this study was 
higher among women than it was among men and where 
women got scores of 0.72 ± 0.76 while men got 0.13 ± 
1.12. Consequently, it can be stated that oral hygiene 
among women is better than it is among men. Women 
have better oral and dental hygiene behaviour than men 
in terms of brushing teeth, using dental floss and visiting 
the dentist. Women tend to care more about their bodies 
and their appearance, and they form habits that support 
dental and oral hygiene even before getting lessons about 
dentistry.22

Reliability tests were carried out to prove that the 
assessments that have been conducted have consistent and 
reliable results. The reliability test of this research used 
the intra-rater test-retest method, in which one researcher 
performed two assessments on the same data so that 
agreement was obtained between the results of the first 
and second assessments. The ORI assessment reliability 
test results in this research were processed with per cent 
agreement and Cohen’s kappa coefficient. Excellent results 
were obtained (% agreement = 88%, κ = 0.79), meaning 
that the ORI examination index has a clear definition and is 
understood by researchers so that it gives the same results 
when repeated assessments are carried out.23,24

The limitations of this study are that dental and oral 
hygiene examinations were conducted remotely. Therefore, 
it was very dependent on the respondent because the 
researcher could not observe directly when the respondent 
took the intraoral photos. The accuracy of the intraoral 
photos was influenced by many factors, so it was not easy 
to standardise the results of these photos. Ideally, however, 
the intraoral photos collected in this research can still be 
assessed.25 The blinding that was carried out in this study 
was done by only one researcher, so there could still be an 
examination bias. Efforts that can be taken to standardise 
the photos include using the same smartphone brand, giving 
exact instructions to all respondents and providing examples 
of intraoral photos and how to take the photos. 

Above all the shortcomings and limitations, it can be 
stated that online assessment using the ORI is reliable 
and safe, and it can be used as an initial dental screening 
tool and routine oral hygiene examinations, providing an 
alternative reliable option during the pandemic. From this 
research, it can be concluded that the oral hygiene level of 
dental students from the Faculty of Dentistry at Trisakti 
University is classified as good based on ORI examination 
(0.58 ± 0.88), and online oral hygiene screening using the 
ORI can be implemented well.

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v55.i3.p142–147

https://e-journal.unair.ac.id/MKG/index
https://doi.org/10.20473/j.djmkg.v55.i3.p142-147


147 Setiabudi and Nasution/Dent. J. (Majalah Kedokteran Gigi) 2022 September; 55(3): 142–147

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Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 158/E/KPT/2021. 
Open access under CC-BY-SA license. Available at https://e-journal.unair.ac.id/MKG/index
DOI: 10.20473/j.djmkg.v55.i3.p142–147

https://e-journal.unair.ac.id/MKG/index
https://doi.org/10.20473/j.djmkg.v55.i3.p142-147