53 Original ISSN 2413-0516 J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Introduction The World Health Organization (WHO) states that oral health is considered a part of the general well-being and is an essen- tial element for good quality of life.1 Good oral health helps us speak, smile, taste, chew, swallow, and express ourselves confidently.2,3 Besides, it affects appearance, by allowing peo- ple to perform their daily activities without psychological or social limitations (Shah and ElHaddad, 2015)not many peo- ple are aware of the relationship of smoking with potential oral diseases. Therefore, the aims of this study were to ana- lyze oral hygiene behavior, smoking habits, and perceived oral health problems among a sample of university students in Al-Kharj, Saudi Arabia. Materials and Methods: A self-ad- ministered questionnaire about oral hygiene behavior, smok- ing, and perceived oral health problems was developed. The questionnaires were mainly distributed in Medical, Dental, and Pharmacy colleges of the university. Questionnaires com- pleted at other colleges were included under the term “other colleges.” Results: Overall, 380 questionnaires were returned. Majority of the students (92.4%. This depends on several fac- tors, such as personal attitudes, behaviors, and knowledge. In the literature, the focus was mainly on the cure for oral dis- eases rather than prevention.4 Several behavioral models, such as the health belief model and reasoned action theory, established the significant role of knowledge in behavioral changes explanation.5 Parents’ knowledge and attitudes play an essential role in raising the awareness in their children and encouraging them to have a healthy life.6 Additionally, parents’ involvement in health pro- motion programs can improve children’s health, and further, the mothers’ higher education elevated their children’s oral health.7 Moreover, the lack of the mothers’ knowledge about oral hygiene may be one of the contributing factors for the dental caries’ high prevalence among children.8 Therefore, poor parenting may be one of the etiological factors for dental caries.9 It was reported that children of mothers with positive oral attitudes were more likely to brush their teeth twice daily (Z, Virtanen, Ghofranipour, & Murtomaa, 2008). So far, no studies have been conducted in Saudi Arabia to assess the effect of mothers’ education on the oral hygiene of children. The study aimed to evaluate the association between gender and the mothers’ education, and the oral hygiene of their children. Methods This comparative cross-sectional study included 531 children in Jeddah, Saudi Arabia. An electronic database search was performed using Google Scholar and PubMed to gather back- ground information and data related to the research question and to determine the knowledge gap. Arabic was chosen for this survey to avoid possibilities of language barriers, followed by data analysis and segregation from the survey. Students were stratified according to their gender and their mother’s education. Oral health of children in association with gender and mothers’ education: A comparative cross-sectional study Heba Ashi Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia Correspondence to: Heba Ashi (E-mail: hmashi@kau.edu.sa) (Submitted: 12 December 2020 – Revised version received: 28 December 2020 – Accepted: 19 January 2020 – Published online: 26 February 2021) Abstract Objective To evaluate the association between gender and mothers’ education, and the oral hygiene of their children. Methods This comparative cross-sectional study included 531 children in Jeddah, Saudi Arabia. Arabic was chosen for this survey to avoid possibilities of language barriers, followed by data analysis and segregation from the survey. Students were stratified according to gender and their mother’s education. Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 25. Results Brushing twice daily, using the dental floss, using fluoridated toothpaste, using mouthwash regularly, and bruxism were higher among females than males (58% vs. 28%, 28.2% vs. 10.9%, 71% vs. 30%,55% vs. 35% and 16.5% vs. 9.8%, respectively) with a significant difference (p<0.001, <0.001, <0.001, <0.001 and <0.001, respectively). Meanwhile, using toothpick, clenching, and biting on hard objects were higher among males than females (49.3% vs. 34.9%, 21.7% vs. 7.1% and 46.7% vs. 34.9%, respectively) with a significant difference (<0.001 and <0.001, respectively). Going to dentists during the last 3 months was significantly higher among females than males (47% vs. 33%), with a significant difference (p<0.001). On the other hand, going to dentists every 6 months was notably higher among males than females (22% vs.. 17%) (p<0.001). Regular check-ups were higher among females (27.8% vs. 16.7%), with a significant difference (p=0.007). In accordance with the mothers’ education, brushing more than twice daily, manual toothbrush, electrical toothbrush, dental floss, and using toothpaste were significantly higher among those who received a university and post-graduate education (p<0.001, <0.001, <0.001, and 0.049, respectively). Going to dentists during the previous 3 and 6 months was higher among those who received a university and post-graduate education (p=0.001). Conclusions Girls and children whose mothers had a university and post-graduate education had better attitudes toward oral hygiene. Therefore, we highly recommend more oral hygiene health education programs, especially for mothers with less education. Keywords Oral health, Oral hygiene, Mothers education 54 Original Oral health of children in association with gender and mothers’ education Heba Ashi J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 25. Categorical variables are presented as numbers and percentages. Results were com- pared using the Chi-square test and the Monto Carlo test. All the tests were 2-tailed, and a p-value <0.05 was considered sta- tistically significant. Ethical considerations: The study was approved by the Research Ethics Committee of the Faculty of Dentistry (REC-FD), and consent was approved by the parents before any data collection. Results Out of the 531 students, the mothers of 250 (47.1%) stu- dents had a university and post-graduate education, whereas the number of students with fathers having a university or post-graduate education were 353 (66.5%) (Table 1). According to oral hygiene habits, when comparing both genders, brushing twice daily, using the dental floss, fluori- dated toothpaste, and mouthwash regularly, and bruxism were higher among females than males (58% vs. 28% , 28.2% vs. 10.9%, 71% vs. 30%, 55% vs. 35% and 16.5% vs. 9.8%, respec- tively) with a significant difference (p<.001, <.001, <.001, <.001, and <.001, respectively). However, using toothpick, clenching, and biting on hard objects were higher among males than females (49.3% vs. 34.9%, 21.7% vs. 7.1%, and 46.7% vs. 34.9% respectively) with a significant difference (<.001 and <.001, respectively) (Table 2, Figs 1, 2, 3, 4, and 5). When comparing dental history between both sexes, going to dentists during the last 3 months was higher among females than males (47% vs. 33%), with a significant differ- ence (p<.001). Contrarily, going to dentists every 6 months was significantly higher among males than females (22% vs. 17%) (p<.001). Additionally, regular check-ups were higher among females (27.8% vs. 16.7%), with a significant difference (p=.007) (Table 3, Figs 6 and 7). While evaluating the oral hygiene habits with regard to the mothers’ education, brushing more than twice daily, using a manual/electrical toothbrush, using dental floss, and using toothpaste were significantly higher among those with a uni- versity and post-graduate education (p<.001, <.001, <.001, and <.01, respectively) (Table 4, Figs 8 and 9). When comparing dental history according to the moth- ers’ education, going to the dentist during the previous 3 and 6 months was higher among those with a university and post-graduate education (p=.001) (Table 5). Discussion This comparative cross-sectional study was conducted at King Abdul-Aziz University and included 531 children. It assessed the association between mothers’ education and gender and oral health practices among their children. The outline suggests that females and children of mothers with a university and post-graduate education showed better attitudes toward oral hygiene habits and dentist visits. In the gender-based oral health comparison in our sam- ple, brushing twice daily, using the dental floss, fluoridated toothpaste, and mouthwash regularly, and bruxism was higher among females than males. However, using toothpick, clench- ing, biting on hard objects was higher among males than females. Therefore, we can conclude that females are more committed to oral health and hygiene. This could be due to their aesthetic concerns and the presentation of their smile. This finding is similar to a study by Singh et al10, who found that the male gender was significantly related to dental car- ies. Additionally, a study by Kumar et al11 found that females had better knowledge and oral health practices than males.11 Similarly, a study by Jaber et al found that males had good knowledge but poor practice toward oral health.12 When comparing the dental history and commitment to visits between both genders, females showed more commit- ment than males, which is similar to a study by McDonald,13 who also reported similar results. Regarding the oral hygiene habits, in association with the mothers’ education, brushing twice daily, using the manual toothbrush and electrical toothbrush, was higher among those with a university and post-graduate education. This is on par with a study by Hallas et al8, who found that lack of knowledge of mothers regarding oral hygiene might be one of the con- tributing factors for the high dental caries prevalence in chil- dren. Additionally, a study by Z, Virtanen, Ghofranipour, and Murtomaa (2008) found that children of mothers with posi- tive attitudes were more likely to brush their teeth twice daily. This study showed the difference in oral health and atti- tudes among girls and boys, children of mothers with a uni- versity or post-graduate education, and with secondary or primary education. Thus, we highly recommend more oral hygiene health education programs, especially for mothers with less education. Data were collected via an online survey that had some restrictions, such as the likelihood of inaccurate information, as the survey is in the form of multiple-choice questions. Respondents may not feel comfortable providing answers that present themselves in an unfavorable manner. Conclusion Females had a better attitude toward oral hygiene than males. Moreover, children whose mothers had a university and post-graduate education also had better attitudes toward oral hygiene habits and dentist visits. Thus, we highly recommend more oral hygiene health education programs, especially for mothers with less education. The literature review suggests that no studies have been conducted in Saudi Arabia to assess the effects of the mothers’ education on oral hygiene of chil- dren. Further research is needed to determine oral health problems based on clinical examination and comprehensive Table 1. Family education of the sample (n=531). N Percent 1. What education does your mother have? University and postgraduate 250 47.1 Secondary and preparatory 75 14.1 Others 206 38.8 2. What education does your father have? University and postgraduate 353 66.5 Secondary and preparatory 31 5.8 Others 147 27.7 Note. All variables are summarized as percentage 55 Original Oral health of children in association with gender and mothers’ educationHeba Ashi J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Table 2. Oral hygiene habits according to gender. boys girls P-value N % N % 1. How often do you brush your teeth? Never 2 1% 0 0% <0.001* Once or a few times a week 43 16% 4 2% Once a day 119 43% 30 12% Twice a day 78 28% 149 58% More than twice a day 23 8% 61 24% Other 11 4% 11 4% 2. What do you use to brush your teeth? Manual toothbrush 233 84.4% 217 85.1% 0.003* Manual and electrical toothbrush 6 2.2% 2 0.8% Manual toothbrush and miswak 12 4.3% 2 0.8% Electrical toothbrush 20 7.2% 26 10.2% Miswak 0 0.0% 5 2.0% None 2 0.7% 3 1.2% Other 3 1.1% 0 0.0% 3. Which of the following product do you use to clean between your teeth? Dental floss 30 10.9% 72 28.2% <0.001* Dental floss and Interdental brush 5 1.8% 7 2.7% Dental floss and Toothpick 5 1.8% 2 0.8% Interdental brush 26 9.4% 21 8.2% Interdental brush and Toothpick 6 2.2% 0 0.0% Toothpick 136 49.3% 89 34.9% None 65 23.6% 60 23.5% Other 3 1.1% 4 1.6% 4. Do you use any toothpaste while brushing? Yes 269 97% 236 93% 0.009** No 7 3% 19 7% 5. What kind of toothpaste do you use? Fluoridated 82 30% 182 71% <0.001* Non-fluoridated 8 3% 0 0% Do not know 184 67% 73 29% 6.Do you use any mouthwash regularly? Yes 96 35% 141 55% <0.001** No 178 65% 114 45% 7. Do you have any of the following oral habits? Bruxism 27 9.8% 42 16.5% <0.001** Clenching 60 21.7% 18 7.1% Biting on a hard object 129 46.7% 89 34.9% Other 60 21.7% 106 41.6% Note. All variables are summarized as percentage. The test of significance was carried out at 0.05 level. *Monto Carlo test was used. **Chi-Square test was used. Significant results are in bold. 56 Original Oral health of children in association with gender and mothers’ education Heba Ashi J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Fig. 3 Toothpaste type according to gender. Fig. 4 Mouthwash use according to gender.Fig. 1 Toothbrushing according to gender.2017 (n=8665). Fig. 2 Cleaning product use according to gender. Fig. 5 Oral habits according to gender. Fig. 6 Dentist last visit according to gender. 57 Original Oral health of children in association with gender and mothers’ educationHeba Ashi J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Table 3. Dental history according to gender. Boys Girls P-value N % N % 1. Have you ever been to a dentist? Yes 266 96% 250 98% 0.248** No 10 4% 5 2% 2. If yes, how often do you visit a dentist? Every 6 months 61 22% 43 17% 0.001* Every year 5 2% 16 6% Irregularly 61 22% 39 15% Only when in pain 119 43% 109 43% Other 30 11% 45 18% 3. When was the last visit? Previous 1–3 months 90 33% 121 47% <0.001** Previous 4–6 months 39 14% 44 17% Previous 7–12 months 41 15% 19 7% >1 year ago 33 12% 38 15% >2 years ago 31 11% 23 9% >5 years ago 42 15% 10 4% 4. What was the purpose of the visit? Regular check-up (dental examination) 46 16.7% 71 27.8% 0.007** Cleaning the teeth 40 14.5% 35 13.7% Filling 68 24.6% 46 18.0% Extraction 33 12.0% 18 7.1% Orthodontic treatment 63 22.8% 51 20.0% Other 26 9.4% 34 13.3% Note. All variables are summarized as percentage. The test of significance was carried out at 0.05 level. *Monto Carlo test was used. **Chi- Square test was used. Significant results are in bold. Fig. 7 Purpose of the visit according to gender. Fig. 8 Toothbrushing according to mothers’ education. 58 Original Oral health of children in association with gender and mothers’ education Heba Ashi J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Table 4. Oral hygiene habits according to mother’s education. University and postgraduate Secondary and preparatory Others P-value N % N % N % 1. How often do you brush your teeth? Never 0 0% 2 3% 0 0% <0.001* Once or a few times a week 11 4% 11 15% 25 12% Once a day 65 26% 9 12% 75 36% Twice a day 97 39% 41 55% 89 43% More than twice a day 60 24% 10 13% 14 7% Other 17 7% 2 3% 3 1% 2. What do you use to brush your teeth? Manual toothbrush 207 82.8% 66 88.0% 177 85.9% <0.001* Manual and electrical toothbrush 0 0.0% 0 0.0% 8 3.9% Manual toothbrush and miswak 2 0.8% 0 0.0% 12 5.8% Electrical toothbrush 33 13.2% 7 9.3% 6 2.9% Miswak 5 2.0% 0 0.0% 0 0.0% None 0 0.0% 2 2.7% 3 1.5% Other 3 1.2% 0 0.0% 0 0.0% 3. Which of the following product do you use to clean between your teeth? Dental floss 69 27.6% 15 20.0% 18 8.7% <0.001* Dental floss and Interdental brush 9 3.6% 0 0.0% 3 1.5% Dental floss and Toothpick 2 0.8% 2 2.7% 3 1.5% Interdental brush 28 11.2% 4 5.3% 15 7.3% Interdental brush and Toothpick 2 0.8% 0 0.0% 4 1.9% Toothpick 89 35.6% 38 50.7% 98 47.6% None 49 19.6% 14 18.7% 62 30.1% Other 2 0.8% 2 2.7% 3 1.5% 4. Do you use any toothpaste while brushing? Yes 236 94% 68 91% 201 98% 0.049* No 14 6% 7 9% 5 2% 5. What kind of toothpaste do you use? Fluoridated 144 58% 45 60% 75 37% <0.001* Non-fluoridated 5 2% 0 0% 3 1% Do not know 101 40% 30 40% 126 62% 6. Do you use any mouthwash regularly? Yes 121 49% 29 39% 87 42% 0.193** No 127 51% 46 61% 119 58% 7. Do you have any of the following oral habits? Bruxism 42 16.8% 9 12.0% 18 8.7% 0.004** Clenching 21 8.4% 15 20.0% 42 20.4% Biting on a hard object 103 41.2% 29 38.7% 86 41.7% Other 84 33.6% 22 29.3% 60 29.1% Note. All variables are summarized as percentage. The test of significance was carried out at 0.05 level. *Monto Carlo test was used. **Chi- Square test was used. Significant results are in bold. 59 Original Oral health of children in association with gender and mothers’ educationHeba Ashi J Contemp Med Sci | Vol. 7, No. 1, January-February 2021: 53 – 60 Fig. 9 Toothbrushing way according to mothers’ education. Table 5. Dental history according to mother education. University and postgraduate Secondary and preparatory Others P-value N % N % N % 1. Have you ever been to a dentist? Yes 246 98% 72 96% 198 96% 0.275** No 4 2% 3 4% 8 4% 2. If yes, how often do you visit a dentist? Every 6 months 45 18% 19 25% 40 19% 0.001* Every year 7 3% 7 9% 7 3% Irregularly 57 23% 5 7% 38 18% Only when in pain 107 43% 40 53% 81 39% Other 34 14% 4 5% 37 18% 3. When was the last visit? Previous 1–3 months 116 46% 34 45% 61 30% 0.001* Previous 4–6 months 43 17% 11 15% 29 14% Previous 7–12 months 20 8% 14 19% 26 13% >1 year ago 28 11% 7 9% 36 17% >2 years ago 24 10% 6 8% 24 12% >5 years ago 19 8% 3 4% 30 15% 4. What was the purpose of the visit? Regular check-up (dental examination) 57 22.8% 19 25.3% 41 19.9% 0.634** Cleaning the teeth 36 14.4% 10 13.3% 29 14.1% Filling 48 19.2% 20 26.7% 46 22.3% Extraction 23 9.2% 3 4.0% 25 12.1% Orthodontic treatment 56 22.4% 13 17.3% 45 21.8% Other 30 12.0% 10 13.3% 20 9.7% Note. All variables are summarized as percentage. 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Oral hygiene behavior, smoking, and perceived oral health problems among university students. J Int Soc Prev Commun Dent. 2015;5(4):327–33. This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. https://doi.org/10.22317/jcms.v7i1.944 https://doi.org/10.1007/978-0-387-09834-0_51 https://doi.org/10.1016/j.sdentj.2011.12.004 https://doi.org/10.1002/j.0022-0337.2004.68.11.tb03864.x https://doi.org/10.2190/dalp-3f95-gct3-m922 https://doi.org/10.2190/dalp-3f95-gct3-m922 https://doi.org/10.1016/j.socscimed.2003.10.021 https://doi.org/10.1016/j.socscimed.2003.10.021 https://doi.org/10.4103/jispcd.jispcd_30_17 https://doi.org/10.18203/2394-6040.ijcmph20173316