J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 31 How Much Do They Know? Oral Hygiene Attitude and Periodontal Awareness in Iraqi Adults Basma Fathi Alanbari, B.D.S., M.Sc. (a) ABSTRACT Background: The scarce literature regarding oral hygiene attitude and periodontal awareness in Iraqi adults warranted the conduction of this study in order to provide a public profile and a baseline data for further researches. Aims of the study: assessing the oral hygiene attitude and periodontal awareness in a sample of Iraqi adults. Materials and Methods: Self-administered questionnaires were distributed to 500 adults. Results: Out of the 500 questionnaires distributed, 482 were included in the study.92% of the sample practiced tooth brushing, 69% out of them reported a daily brushing pattern with variable frequency,69% of the sample did not receive oral hygiene education from any source ,more than half of the sample 60 % used the horizontal brushing method, interdental aids was utilized by 42% of the sample with the dental floss being the commonest type 52%, mouthwash used by 37% and tongue cleaning was uncommon as only 22 % of the sample perform it. 78% of the sample did not know what dental plaque is while dental caries were well known by almost the entire sample 98%. 93% reported having gingival bleeding with only 5% out of them referred to the poor oral hygiene as the causative factor. The motive for seeking periodontal therapy for 80% of the sample was restoring the gingival esthetics. Conclusions: The public periodontal awareness and knowledge is still poor in Iraq, the solution requires shared resources and multiple approaches. Key words: Oral hygiene attitude, periodontal awareness, tooth brushing, Iraqi adults. (J Bagh Coll Dentistry 2017; 29(3):31-38) INTRODUCTION Periodontal diseases and dental caries are classified as the most common infectious diseases affecting the human as well as the two globally leading causes of tooth loss (1,2), the quality of everyday life in periodontal diseased individuals was the subject of many researches recently according to those studies the experience of pain, endurance of dental abscess, difficulty in eating and chewing and embarrassment due to mobile or lost teeth have tremendous effect on the general wellbeing (3). Adding to their oral manifestations and consequences, periodontal diseases have a profound impact on the general health according to the 2013 WHO report as the four most prominent NCDs (non-communicable diseases) cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary diseases do share common risk factors with periodontal diseases (4), while the world is obsessed with the aforementioned diseases, oral diseases till the present day is widely neglected (5) and their management is limited to treatment rather than prevention (6). Periodontal awareness is a prerequisite not only for a healthy dentition but for a successful dental treatment as well, since absence or even a declined level of oral hygiene and periodontal awareness may contraindicate treatment and (in case treatment is conducted) can lead to treatment (a)Assistant Lecturer, Department of Dentistry, Al-Rafidain University College. failure, therefore; the first step in treatment of dental patient should focus on building the patient knowledge, enable the patient to process the provided information in order to modify the behavior and commit to an acceptable standard of oral hygiene (7). Regarding this topic, the dental health providers must be aware of great differences between information and education. Individuals who are informed about dental health are aware of the consequences of specific health practice, but they may be involved in an unsound course of action. In contrast educated individuals are not only well informed, but also use this information in their daily life ideally (8). The scant literature on dental health awareness, attitude, oral health-related habits and behavior among the adult population in Iraq prompted us to conduct this study to assess the oral hygiene attitude and periodontal awareness in a sample of Iraqi adults. MATERIALS AND METHODS This was a cross-sectional study of randomly selected 500 participants (325 males and 175 females) selected among individuals attending Periodontics clinic at Al-Rafidain Dental College Teaching Hospital in Baghdad. The sample age range was (16-71) years with a mean age of 33 years. This research was carried out during the academic year 2015-2016. The data were collected by a self-assessment questionnaires (appendix 1) incorporating three domains, first related to J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 32 personal and socio-demographic data like age, gender, level of education, and occupation, second related to periodontal awareness and health knowledge included items on the pattern of brushing, type of the brush, brush replacement frequency, the source of oral hygiene knowledge, interdental aids, tongue brushing and mouth wash utilization, periodontal awareness were assessed by testing the patient information regarding gingival bleeding, the knowledge about causative factors of periodontal diseases and the third was self-reported dental attendance pattern, type of dental treatment received in the last 12 months and the reason for seeking periodontal treatments. Questionnaires included both open and closed ended questions in which the subjects have pre- chosen items to relate to. After patient’s approval to be enrolled in the study was acquired, full explanations of the study and question contents were provided to the patients in a simple language by the investigator. Later, the questionnaires were filled personally by the patients and delivered back to the investigator. Partially filled questionnaires were excluded from the study. Data were collected from the completed questionnaires then entered into Statistical Package for Social Sciences (SPSS) program version 19.0 which was utilized for data analysis in terms of frequencies and percentages. RESULTS Study sample comprised 500 patients attended the Periodontics department at Al-Rafidain Dental Teaching Hospital. A 500 questionnaire was distributed by the researcher to randomly selected patients, after exclusion, a total of 482 questionnaires were included in the study. The average age of the sample was 33 years old with a 16-71 years old age range. Male gender dominated the sample with a percentage of 66% while females comprised 34%. Twenty two percent (22%) of the sample finished the elementary school, 47% reported high school as their educational level, 31% were a college graduates (Table 1). Table1:Gender distribution according to gender and educational level Variables No. % Gender Male 318 66 Female 164 34 Total 482 100 Educational level Elementary 108 22 High school 226 47 College 148 31 Total 482 100 Daily brushing and frequency of brushing Brushing was reported by the majority of the sample (92%). Sixty nine percent (69%) reported a daily brushing pattern with a variable frequency (Table 2). Table 2: Sample distribution according to brushing attitude and frequency Brushin g No. % Brushing No. % Frequency Yes 444 92 Once/day 212 48 Twice/day 88 20 Three times/day 4 1 Occasionall y 140 31 No 38 8 Total 444 100 Total 482 100 Source of oral hygiene education The parents were the source of information regarding oral hygiene for only 23% of the patients with the majority 69% reported that they brushed their teeth without any provided information, only 4%of the sample reported that their dentist advised them about the correct oral hygiene procedures, 3% reported that their school teachers educated them and the remaining 1% reported that rely on the media (television's programs and commercials regarding)and practice tooth brushing in the same manner they saw on media (Fig. 1). Type of dental brush (regarding the bristles hardness) Hard type tooth brush were utilized by 17% of the patients, 39% utilized the medium type, 28 % utilized the soft type while the remaining 16% had never noticed what type of brush they used (Fig. 2). Brushing direction More than half of the sample 60% were brushing horizontally, 32% brushed vertically and 8% used the circular motion (Fig. 3). 23% 69% 4% 3% 1% parents no source dentist school tv Fig. 1: Sample distribution according to source of oral hygiene education J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 33 Changing the brush The vast majority of the patients 77% did change their tooth brush while about one third of the patients 33% did not. Regarding the time interval for brush replacement, 41% replaced it each 3 months, 8% each 6 months, 1% once a year, 50% did not report a specific time interval because they do not change the brush periodically. Interdental aids Interdental aids were utilized by 42 % of the sample, 52% out of them used the dental floss, 5% used the interdental brush and 43% used the tooth picks. Fifty eight percent (58%) of the surveyed patients reported that they do not use any type of interdental aids (Table 3). Mouthwash As adjunctive to tooth brushing, mouthwash used by 37% of the patients. Mouthwash advantages as reported by the patients were to prevent halitosis by 95% and additional cleaning by 5% of the sample (Table 3). Tongue cleaning Approximately 22% of the patient clean their tongue, 89% of them used the same brush for tooth brushing & tongue cleaning while only 11% used the tongue scrapper (Table 3). Table 3: Sample distribution according to the utilization of interdental aids, rinsing with mouth wash and tongue cleaning Interdental aids Yes Type No. % No. % Dental floss 105 52 202 42 Interdental brush 11 5 Tooth picks 86 43 No 280 58 Total 482 100 Mouthwash Yes 176 37 No 306 63 Total 482 100 Tongue cleaning Yes Tooth brush 96 89 108 22 Tongue scraper 12 11 No 374 78 Total 482 100 Level of public knowledge regarding dental caries, calculus and plaque Ninety eight percent (98%) of the patients knew what dental caries is when they were asked about it, 47% knew dental calculus while only 22% knew what dental plaque is (Fig. 4). Fig. 4: Sample distribution according to knowledge level regarding dental caries, calculus and dental plaque respectively 98% 2% Caries yes no 17% 39% 28% 16% hard medium soft never noticed 22% 78% Plaque 47% 53% Calculus 60% 32% 8% Horizontal Vertical Circular Fig. 2: Sample distribution according to type of tooth brush Fig. 3: Sample distribution according to direction on tooth brushing J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 34 Bleeding gingiva and the reason Ninety three percent (93%) of the patients reported gingival bleeding, when they asked about the reason behind such bleeding only 5% answered by poor oral hygiene, 26% due to brushing, 6% due to forceful brushing, 2% due to genetically weak gingival tissue, while almost third of the sample 29% believed it was due to microbial infection, 5% due to smoking, 2% due to food debris, 5% reported that dental calculus is the reason and the rest 21% answered by (I don’t know) (Table4). Patterns of dental visits and dental attendance patterns Two percent (2%) visit the dentist on a 6 months interval, 1% once a year, 81% when having problem such as dental pain or broken tooth and 16% reported that had never been in a dental office before. Sixty two percent (62%) of the sample received restorative treatment, 18 % asked for periodontal scaling and polishing,17 % to extract a badly caries or mobile tooth, 1% for orthodontic therapy, 2% for dental checkup (Table 5). Table 4: Distribution of sample's answers regarding the cause of gingival bleeding Cause of gingival bleeding No. % Poor oral hygiene 21 5 Brushing 115 26 Force-full brushing 26 6 Weak gingival tissue 8 2 Infection 130 29 Smoking 21 5 Food debris 8 2 Calculus 23 5 I do not know 94 21 Total 446 100 Table 5: Sample distribution according to pattern of dental attendance and type of treatment received in the last 12 months Pattern of dental attendance No. % Treatment received in the last 12 months No. % Every 6 months 12 2 Dental filling 254 62 Once a year 4 1 Periodontal scaling 72 18 Only in problems 390 81 Tooth extraction 68 17 Never 76 16 Orthodontic 4 1 Total 482 100 Checkup 8 2 Total 406 100 Reason for seeking periodontal treatment According to the patients answers, not surprisingly 80% of the patients asked for periodontal therapy for esthetic reasons only having no awareness at all about the other consequences of periodontal diseases. Five percent (5%) for stopping the gingival bleeding, 4% for calculus removal, 2% to get rid of the halitosis, 2% to treat the gingival infection,6% to save the rest of the teeth from falling (Table 6). Table 6: Sample answers' distribution regarding the reason of seeking periodontal therapy DISCUSSION The vast majority of the sample (92%)reported a daily pattern of tooth brushing, a result close to those obtained in similar studies in Saudi Arabia, Kuwait and China (9-11) but less than those obtained from Iran and India (12,13). While twice-a-day tooth brushing which is the recommended brushing frequency by ADA became an established practice in industrialized countries (14), in the present study it was reported by only 20% of the sample in accordance with results obtained from other studies in India and China (11,13,15) but far less than the percentage in Kuwait that reached up to 62% (10). Sixty percent (60%) of the sample used the traditional horizontal method in tooth brushing which has detrimental consequences such as dental abrasion and gingival recession and this is in accordance with other studies' results (11,13). Reason for seeking periodontal therapy No. % Calculus removal 20 4 Stopping the gingival bleeding 23 5 Esthetics 368 80 Treating the gingival inflammation 12 2 Halitosis 12 2 Saving the rest of teeth from falling 29 6 Total 482 100 J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 35 Only 23% of the patient received instructions on tooth brushing from their parents with the mother being the main educator. Such low percentage reflects the neglection and the lack of the parental guidance that result in relatively large number of children presenting clinical signs of gingivitis in Iraq and worldwide (4,16-17). These findings highlights the impact of parents and the mother specifically on building the growing child perception of oral hygiene and the importance of the females continuous education about general and oral health during different stages of her life (child, teenager, pregnant and mother) in order to pass correct information and practices to their children (18). Twenty eight percent (28%) of the sample used the soft type tooth brush similar to Zhu et al.'s subjects (11) where 27% of the sample chose the soft type brush and explained the reason that this type would not hurt their gingival tissue during brushing. Sixteen percent (16 %) of the sample did not have any idea about the types and specifications of the tooth brush , a proportion less than Jain et al.’s sample where 50 % did the same. Nearly two third of the sample (77%) did replace their tooth brush, less than the half (41%) replaced it each 3 months which is the recommended period for tooth brushing replacement as the bristles become frayed and worn with use and cleaning effectiveness will decrease according to the ADA's recommendations (19). It is proved evidence that periodontal diseases are preventable by the means of self-performed good oral hygiene but first the population must be well informed in order to translate the acquired knowledge into actions. Surprisingly 84% of the sample visited the dentist in the last 12 months out of them only 4% reported receiving information about the oral hygiene measures from their dentist, such finding reveals that a large proportion of the dentists pay little or no attention to the importance of patient education and motivation and neglect the right of the patients in devoting adequate time by the dentist to provide information regarding periodontal diseases etiology, signs, treatment options and preventive procedures. Many dentist reported that it’s the time factor that prevents them from educating their patients, to overcome such obstacle it’s advisable to utilize the variety of educational and motivational tools available in the dental office such as the before and after treatment pictures, educational video on a TV screen, dental illustration posters, a take home instruction brochures and recently with the communication facilities provided by the social media, the dental office's page or online site can be used for the dental education purpose a facility saving the dentist time and providing the patients with adequate knowledge and updates. Brushing alone is not sufficient for adequate plaque removal as clinical trials revealed that brushing alone would leave up to 40% dental plaque in the interdental spaces which is a clear indication for including the interdental aids in the daily oral hygiene routine (1,20). Interdental aids usage by the patients was reported by 42% exceeding the 11.8 % in Kuwait (10), regarding the type the majority used the dental floss 52% followed by the tooth picks with a percentage of 43% while only 5% used interdental brush. Tongue coating is one of the local causes for halitosis due to the volatile sulphur compounds produced by microbial film residing between the filliforms papillae. Coating removal is achieved by tongue scrapping with a scrapper or dental brush. In this study, only 22% of the sample cleaned their tongue similar a close proportion to Jain's et al. result (13). Mouthwash as adjunctive oral hygiene aids was used by only 37% of the patients exceeding Jain's result (13). Mouthwash advantage as reported by the patients was to prevent halitosis by 95% and provision of additional cleaning as reported by 5% of the sample. The knowledge level of respondents in regards to dental caries, dental plaque and calculus was assessed. 98% of the sample were familiar with dental caries and identifying it by the black cavity formed in the teeth which may cause severe pain if left untreated, 47% identified the dental calculus as the harmless whitish-yellow hard deposit on the tooth surfaces, while only 22% knew what is the dental plaque which is the primary causative factor of periodontal diseases (1). Such low level of knowledge regarding dental plaque was also observed by Taani in Jordanians adults (21). The huge gap between the knowledge level of dental caries and that of calculus and plaque is explained by multiple reasons first, most of the dental education is directed towards dental caries, its consequences such as (severe pain, swelling, abscess and tooth loss) and its prevention by proper tooth brushing and dietary modification, second, patients are aware that the tooth is )carious( once a visible black cavity is formed while most of them are unaware of the early signs of gingivitis and periodontitis such as bleeding on provocation. Third and last is the symptomatic nature of dental caries versus the silent nature of periodontal diseases . The gap between the dental calculus and dental plaque is mainly due to the visibility of the calculus and its rough surface , its affect the esthetic while the dental plaque which is a soft J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 36 layer with whitish to yellowish color is wrongly identified by the patients as a food remnants rather than a microbial community forming on the teeth surfaces. Despite the fact that no clinical examinations were performed in this study and therefore no direct verification of clinical signs reported by the sample was done, self-reported oral health complaints can reflect the magnitude of certain oral health treatment and prevention needs, therefore; self-assessment still valuable in epidemiological studies of oral health (22). Although 69% of the sample reported a daily pattern of tooth brushing, self-reported gingival bleeding was reported by 93% of the sample exceeding the 34.4% in Kuwait (10) and the 40% in India (13). Such high results are in agreement with studies of Gilbert et al. (23), this can be explained by either the sample reported a false positive answers, a common problem in questionnaire based survey, or the ineffectiveness of the brushing technique performed by the sample. The patients' explanations for gingival bleeding reflected clearly the misperception of periodontal diseases and lack of awareness as only 5% reported poor oral hygiene as a causative factor, 29% though it’s a microbial infection and tried to treat it by antibiotics, 26% believed it is due to brushing itself since their gingiva bled upon brushing,6% due to forceful brushing, those are the patients with already inflamed gingiva that bled upon contact with the tooth brush. Two percent (2%) thought it is due to remaining food debris after meals and similar proportion though it is due to genetically weak gingival tissue, 5% due to smoking, 5% due to the dental calculus and that what make them seek periodontal treatment, the remaining 21% were completely unaware nor having any explanation on the cause behind the bleeding gingival tissue. Compliance with regular dental visits was extremely low where only 3% of the sample visit the dentist on a regular interval, 81% of the sample visited the dentist only when they had a dental pain similar findings were reported in Lithuania by Petersen et al. (24) but exceeding the 69.7% in Syria (25) and the 54% in India (13). The question regarding the reason for seeking periodontal treatment reflected the low level of the general population education and periodontal awareness regarding the early signs and consequences of the periodontal diseases as 80% answered that the reason for seeking periodontal therapy was to restore the esthetics of their smile. CONCLUSIONS The public periodontal awareness and knowledge is still poor in Iraq, the solution for such problem require shared resources and multiple approaches. Currently, in Iraq in order to implement oral disease prevention programs, multiple factors must be taken into consideration including: the increased urbanization, changing in the demographic and socio-economic status, increased number of illiteracy, increased numbers of orphans, lack or difficulty in delivering health services. 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Eastern Mediterranean Health J 1997; 3(2): 258- 262. الخالصة الدراسة هاجراء هذ استدعى العراقين البالغين ودرجة الوعي بامراض اللثة لدى الفم بصحة العناية ندرة المنشورات بشأن مدى: خلفيةال بصحة ى العنايةمد تقييم هدفت هذه الدراسة الى .األبحاث من لمزيد أجل تقييم مستوى الوعي في المجتمع وتوفير بيانات تكون اللبنة من .ينالعراقي البالغين من عينة والوعي بامراض اللثة في الفم .البالغين من 055 إلى ذاتيا االستبيان توزيع تم :الموادوالطرق من العينة يمارس تنظيف االسنان ٪24. الدراسةاستبيان في 284على العينة, بعد االقصاء تم ادراج استبيان 055تم توزيع :النتائج حول العناية الصحي يحصل على التثقيف لم العينة من ٪62، تباينمنهم انهم يقومون بذلك يوميا و لكن بتكرار م ٪62بالفرشاة ،ذكر بنسبة ألسنانا تنظيف ما بينوسائل واستخدمت األفقي، التنظيف نصف العينة يستخدم طريقة من يقرب مصدر،ما أي بالفم و االسنان من بينما تنظيف اللسان لم يكن ٪73 استخدم بنسبة الفم , غسول ٪04 األكثرشيوعا هوالنوع األسنان تنظيف و كان خيط العينة من 24٪ ناألسنا تسوس أن حين في األسنان الجرثومية لويحة ماهي اليعرفون العينة من ٪38 .مارسه العينة من فقط ٪44 حيث أن مألوفا المتدنية كونها العامل الفم نظافة إلى فقط أشار ٪0 نزف من اللثة مع وجود ٪27 ذكر. ٪28 من جميع العينة يقرب ما قبل معروف من .اللثة جمالية هواستعادة العينة من ٪85 لدى اللثة عالج عن للبحث الدافع. المسبب لجهود و تبني ظافر ات تطلبي المشكلة لهذه والحل العراق، في ضعيفا اليزالوالمعرفة فيما يخص امراض اللثة العام الوعي:االستنتاجات .متعددة مناهج .العراقيين،البالغين الموقف من نظافة الفم و الوعي بامراض اللثة،تنظيف االسنان بالفرشاة :الرئيسية الكلمات J Bagh College Dentistry Vol. 29(3), September 2017 How Much Do Oral and maxillofacial Surgery and Periodontics 38 Appendix (1) ةالوعي بنظافة الفم و امراض اللث استمارة تقييم اسم المريض: العمر: الجنس: المهنة: التحصيل الدراسي: العنوان: الرجاء من المشتركين االجابة على جميع االسئلة و اختيار جواب واحد فقط لكل سؤال و كتابة بقية االجوبة بخط واضح. هل تقوم بتنظيف اسنانك باستعمال الفرشاة ؟ نعم كال مرة يوميا مرتان يوميا ثالث مرات يوميا كم مرة تقوم بتفريش اسنانك ؟ بين الحين و االخر من علمك كيف تعتني بنظافة فمك؟ ما نوع فرشاة اسنانك )ناعمة, متوسطة , خشنة( ؟ دائري باي اتجاه تقوم بتفريش اسنانك ؟ افقي عمودي هل تقوم بتبديل فرشاة اسنانك؟ نعم ال ما هي المدة التي تقوم فيها بتبديل فرشاة اسنانك ؟ عندما تصبح غير صالحة لالستعمال كل ثالثة اشهر كل ستة اشهر مرة سنويا هل تستعمل ادوات تنظيف ما بين االسنان ؟ نعم ال االسنان عيدان االسنان فرشاة ما بين االسنان ما هو النوع الذي تستعمله؟ خيط هل تقوم بتنظيف لسانك؟ نعم ال ماذا تستعمل لتنظيف اللسان ؟ فرشاة االسنان كاشطة اللسان هل تستعمل مضمضة الفم ؟ نعم ال لماذا تستعمل مضمضة الفم؟ هل تعاني من نزيف اللثة ؟ نعم ال برايك ماهو سبب نزيف اللثة ؟ ال هل تعرف ما هو البالك )الصفيحة الجرثومية(؟ نعم هل تعرف ما هي تكلسات االسنان )الجير(؟ نعم ال ال نعم هل تعرف ما هو تسوس االسنان ؟ ب االسنان ؟ لم ازره مسبقا فقط عندما اعاني من مشكلة ماهو معدل زيارتك لطبي مرة كل ستة اشهر مرة سنويا و تغليفها قلع االسنان شهرا الماضية ما هو نوع العالج الذي تلقيته؟ حشوات االسنان 21خالل ال تنظيف االسنان تقويم االسنان الفحص اخرى)يرجى الذكر( ؟ما هو سبب رغبتك في تنظيف اسنانك