| Abstract|| |
Background: The behavior of oral health providers toward their own oral health reflects their understanding of the importance of preventive dental procedures and of improving the oral health of their target population.
Aim: This study was done with an aim to assess the relationship between oral health behavior, oral hygiene and gingival status of third and final year dental students from a Dental College in Indore City, India.
Methods: A total of 137 dental students participated in the study. The students were invited to complete the Hiroshima University-Dental Behavioral Inventory (HU-DBI) questionnaire. The HU-DBI questionnaire consisted of twenty polar responses (agree/disagree) regarding oral health-related behavior. In addition, two further questions about the frequency of brushing and flossing were included. Subsequently, oral health examination was conducted to assess plaque and gingival status. Data were analyzed using Chi-square test, Independent sample t-test, and Pearson's correlation. The significance level was set at P ≤ 0.05.
Result: The results showed that about 66.6% of the students checked their teeth in the mirror after brushing. Only 20.1% of the students reported bleeding from gums. The mean oral heath behavior score (HU-DBI) was 6.47 ± 2.0. A negative correlation of HU-DBI scores with plaque (r = −0.501) and gingival scores (r = −0.580) was observed.
Conclusion: Thus, it is concluded that there is a significant relationship between the oral health behavior, oral hygiene, and gingival status of dental students. Dental students with better self-reported oral health behavior had lower plaque and gingival scores indicating a better attitude toward oral health.
Keywords: Dental students, gingival score, Hiroshima University-Dental Behavioral Inventory, oral health behavior, plaque score
|How to cite this article:|
Lalani A, Dasar PL, Sandesh N, Mishra P, Kumar S, Balsaraf S. Assessment of relationship between oral health behavior, oral hygiene and gingival status of dental students. Indian J Dent Res 2015;26:592-7
As future leaders in oral health care, dental students have a major role in patient education and oral health promotion. It is expected that dental students will become exemplars in their own oral health attitudes and behaviors, and these may reflect the manner in which their future roles in oral health promotion and education are fulfilled.  Therefore, acquiring knowledge and attitudes related to dental health and the prevention of oral diseases is very important during the future dentists' training period.  One of the main objectives of dental education are to train students who can motivate patients to adopt good oral hygiene. They are more likely to be able to do this if they themselves are motivated. 
|How to cite this URL:|
Lalani A, Dasar PL, Sandesh N, Mishra P, Kumar S, Balsaraf S. Assessment of relationship between oral health behavior, oral hygiene and gingival status of dental students. Indian J Dent Res [serial online] 2015 [cited 2019 May 24];26:592-7. Available from: http://www.ijdr.in/text.asp?2015/26/6/592/176922
Health behavior is defined as "the activities undertaken by people to protect, promote, or maintain health and to prevent disease."  The term "oral health behavior" describes the complex effect on the individual oral health of oral hygiene habits, nutritional preferences and the pattern of a person's utilization of dental services. Dental students, in general, have been found to have a positive behavior and attitude toward oral health. There are controversies among researchers reporting on the impact of education on the attitude, behavior, and oral hygiene of dental students. 
Positive attitudes toward health promotion need to be developed during student days rather than afterward. The FDI has recommended that substantial change in the dental curriculum be implemented to give dentists, the knowledge, skills, and attitudes they will need in future practice.  Calls for such curricular changes dates back to 1960s, although they have not been well heeded, relatively little curricular change seems to have taken place over the years. 
After going through an undergraduate dental curriculum, it is logical for students in the field of dentistry to develop and modify their behavior toward their own oral health and is expected to be a role model for oral health behavior. An important task of oral health professionals is to instill in their patients correct oral habits to prevent oral diseases. 
Dentists' attitudes toward their oral health have been proposed to affect the quality of care delivered to patients. To equip the general population with a proper knowledge of oral health, general dental practitioners must take positive approaches to their own oral health so that they can effectively teach what they believe. 
Oral health is an essential component of general health and quality of life. The relevance of oral health lies in the relationship between the effective oral health knowledge and the behavior.  Oral health status is significantly related to oral health behavior. Dental health is affected by a person's oral health behaviors and oral habits, including tooth brushing, use of dental floss, and regular dental visits.  Behavior modification, therefore, may have a positive effect and produce improvement in oral health.
Little is known about the oral health behaviors and attitudes of Indian dental students and the influence of educational training on the development of their oral behaviors and attitudes. Since today's students of dentistry will provide dental services in the future and will be responsible for public oral health education, it is important to study their oral health knowledge, attitude, and behavior and also its impact on their own dental health status.
Hence, this study was carried out with an aim - "To assess the relationship between oral health behavior, oral hygiene, and gingival status of third and final year dental students."
| Methods|| |
The present study was carried out in a Private Dental College in Indore City for a period of 3 months (January-March 2014).
Ethical clearance and informed consent
Permissions and Ethical clearance were obtained from the institutional review board. Written consent was obtained from the students. Participation in the study was voluntary, and the answers were anonymous. Students were given the option of discontinuing at any time.
Sampling and data collection
The study population consisted of third and final year BDS students (n = 137). All the third and final year dental students, willing to participate in the study were included. Students who did not provide consent for clinical examination and those undergoing orthodontic treatment were excluded. These students as part of curriculum start learning about preventive aspects of oral health. From a total number of 137 students, 132 volunteered to participate in the study. Three students were excluded as they were undergoing orthodontic treatment. Hence, the final sample size was of 129 dental students (response rate of 94.16%).
The students were invited to complete the English version of a questionnaire entitled "Hiroshima University-Dental Behavioral Inventory" (HU-DBI). This questionnaire was developed by Kawamura and has good translated validity as well as good test-retest reliability as reported by previous studied conducted in different parts of the world.  The questionnaire has been used to compare oral health attitudes and behaviors among dental and dental hygiene students in different countries. 
The HU-DBI questionnaire consisted of twenty dichotomous responses (agree/disagree) regarding oral health-related behavior. One point is given for each "agree" response to items 4, 9, 11, 12, 16, and 19, and one point is given for each "disagree" response to items 2, 6, 8, 10, 14, and 15. In addition, two further questions about the frequency of brushing and flossing were included. A total score was calculated based on the response to each item. Higher scores on the HU-DBI indicated better oral health attitudes/behavior. The possible maximum score is 12, and the minimum score is 0.
A structured proforma was developed consisting of 22 questions to assess attitude and behavior of dental students toward oral health. It also included the formats for plaque index and gingival index to record the oral hygiene status and gingival status, respectively.
Third and final year students were approached in their respective classroom at the end of lecture. All participants were provided with a full explanation of the study and the used questionnaire. Students were asked to fill in the questionnaire and completed questionnaires were collected. Any doubts occurring during the filling of the questionnaire was solved by the principal investigator herself. A total score was calculated based on the response to each item.
Training and calibration
Training and calibration of the investigator (dentist) were carried out in the Department of Public Health Dentistry of the institute under the guidance of an expert. A total of 10 subjects were examined and re-examined for plaque and gingival index until the desired intra- and inter- examiner reliability was obtained (Cohen Kappa value = 0.96).
To compare the self-reported oral health behavior with the actual clinical situation of participants, a calibrated dentist measured plaque scores (plaque index, 1964) and gingival scores (gingival index, 1963) of the participants.
To measure the plaque scores the plaque index (1964),  given by Sillness and Loe was used. The six index teeth were evaluated using a mouth mirror, light source, dental explorer, and air drying of the teeth and gingival. If the index tooth was missing, the plaque index was recorded for the whole dentition. The surfaces examined were the four cervical areas of the tooth, i.e., the distal - facial, facial, mesial - facial and lingual surfaces. Unlike the buccal (facial) surface, the lingual surface was considered as 1 unit.
To measure the gingival scores, the gingival index (1963),  given by Loe and Sillness was used. The mouth mirror, a light source, William's periodontal probe and air drying of the teeth and gingiva were used in the scoring of this index. The six index teeth examined are same as that of the plaque index. If the index tooth was missing, the gingival index was recorded for the whole dentition. The tissues surrounding each tooth were divided into four gingival scoring units: Distal - facial papilla, facial margin, mesial - facial papilla, and entire lingual gingival margin.
The data collected were entered into a Microsoft Excel data sheet and analyzed using Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). The data were analyzed for frequency distributions. Data were analyzed using Chi-square test, Independent sample t-test, and Pearson's correlation. The significance level was set at P ≤ 0.05.
| Results|| |
A total of 129 dental students participated in the study. Among the study subjects, 46.51% belonged to 3 rd year, and 53.48% belonged final year. Nearly, one-third (31%) of the study subjects were males and two-third (68.99%) were females [Table 1].
|Table 1: Distribution of subjects according to year of study and gender |
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As assessed by HU-DBI questionnaire, bleeding gums were reported in 20.1% of the participants. More than two-thirds (70.5%) of the study population were worried about the color of their teeth. Ten percent reported that they used a child sized toothbrush for oral hygiene maintenance. While 70.5% reported that they brushed their teeth carefully. Nearly, two-third (62.7%) was not in agreement that they would have false teeth when they grew older. A small fraction of the study population (17.1%) used a dye to assess the cleanliness of their teeth. Related to dental health behavior, nearly two-third of the participants checked their teeth in mirror after brushing and reported brushing twice daily or more. The dental floss practice was reported to be used by 21.7% of the study population.
No significant differences were found in dichotomous response in 17 out of 22 questions between the third and final year students. There were statistically significant differences (P < 0.05) between third and final year students for item 4 (I have noticed some white sticky deposits on my teeth), item 5 (I use a child-sized toothbrush), item 10 (I have never been taught professionally how to brush), item 12 (I often check my teeth in a mirror after brushing), and item 19 (I feel I sometimes take too much time to brush my teeth) [Table 2].
|Table 2: Hiroshima University-Dental Behavioral Inventory questionnaire items and percentage of agree/disagree response |
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The distribution of the plaque score according to gender showed that nearly two-third of the males and females had good plaque score. None of the study population showed either excellent or poor plaque scores. The distribution of gingival score according to gender showed that majority of the males and females had mild gingivitis. None of them showed severe gingivitis [Table 3].
|Table 3: Distribution of plaque and gingival scores according to gender |
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When plaque scores and gingival scores were related to the HU-DBI responses, a statistically significant (P < 0.05) value relation was found between nineteen items. There was a statistically significant relation observed between the agreement of item 2 with high plaque, gingival scores, and low HU-DBI score. Furthermore, a relation was observed between agreement of item 4 and item 5 with high plaque scores. A statistically significant relation was observed between the agreement of item 9, 12, and 21 with low plaque, gingival scores, and high HU-DBI score. A statistically significant relation was also observed between disagreements of item 10 with low plaque; gingival scores and high HU-DBI score [Table 4].
|Table 4: Mean Hiroshima University-Dental Behavioral Inventory scores in relation to plaque/gingival scores and the agreement/disagreement to the Hiroshima University-Dental Behavioral Inventory items |
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No significant differences were observed in the mean gingival score, plaque score, and HU-DBI score between gender and year of study [Table 5] and [Table 6].
|Table 5: Mean Hiroshima University-Dental Behavioral Inventory, plaque and gingival scores based on gender |
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|Table 6: Mean Hiroshima University-Dental Behavioral Inventory, plaque and gingival scores based on year of study |
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The mean oral heath behavior score (HU-DBI) was 6.47 ± 2.0. Pearson's correlation coefficient test was performed to see any correlation between the oral health behavior and oral health status. We found a significant negative correlation of HU-DBI scores with plaque (r = −0.501, P < 0.0001) and gingival scores (r = −0.580, P < 0.0001).
| Discussion|| |
The present study was carried out to assess the relationship between oral health behavior, plaque, and gingival status of third and final year dental students in a private dental institution in India. The study throws light about the dental health of dental students during their academic training and the extent to which the knowledge acquired was reflected in their own dental care. The third and final year dental students were selected to understand the immediate effects of the knowledge that they acquired in preventive dentistry during their professional training and its effects on their oral health behavior, oral hygiene, and gingival status. A mean HU-DBI score of 6.47 ± 2.0 was obtained, which indicates average dental health behavior in the cohort of dental students. Similar findings were reported by Yildiz and Dogan,  who found that dental education experiences appeared to have had a clear influence on oral health behavior.
Majority of the students reported good plaque score and mild gingivitis suggesting good oral health status among them. This could be because of a positive attitude toward oral hygiene maintenance and adherence to good oral hygiene practices. Similar findings were reported by Maatouk et al.,  highlighting the importance of dental studies on motivation and attitude toward oral health.
The mean HU-DBI score for male subjects was 6.13 and for the female subjects were 6.63. However, the differences were not significant. Furthermore, the corresponding mean plaque and gingival score to the mean HU-DBI score was found to be similar in both male and female students. Our finding is in agreement with a previous study done by Khami et al.,  on Iranian dental students. This can be attributed to the fact that both male and female dental students had equal exposure to the same academic curriculum in the college. Hence they have similar knowledge regarding oral health and preventive dentistry. On the contrary Rahman and Al Kawas,  Al-Wahadni et al.,  and Petersen et al.,  reported gender to be a major factors influencing the HU-DBI percentage of agree/disagree responses. Female dental students showed a significantly better attitude than their male colleagues. This condition may be explained on the basis that females usually are more esthetically conscious. They would be more interested in visiting the dentist and would tend to be better informed about their oral health even before entering a course related to dentistry.
The mean HU-DBI score for 3 rd year subjects was 6.45 and for the final year subjects were 6.49. No significant difference was observed in oral heath behavior between third and final year students. The corresponding mean plaque and gingival score to the mean HU-DBI score was also found similar in third and final year students. This may be because of sociopsychological factors that may influence the relationship between health behavior and level of education. Similar findings were reported by Dagli et al.  However, in some previous studies, it was found that the level of dental education was related to oral health attitudes and behavior. ,,, Better health attitudes and behavior were reported by the students as they progressed in their studies and education. The authors believed that as a student progresses in their dental education, they may become more aware of their overall health and more attentive toward oral-health-related issues.
Pearson's correlation coefficient test was performed to see correlation between the oral health attitude and oral health status. A negative correlation of HU-DBI scores with plaque (r = −0.501, P < 0.0001) and gingival scores (r = −0.580, P < 0.0001) was obtained. This shows that the students who have greater HU-DBI scores had lower plaque and gingival scores. Thus, this study suggests an association between oral health behavior, oral hygiene, and gingival status. This finding is in agreement with previous studies done by Rahman and Al Kawas,  and Levin and Shenkman. 
The study was limited by its cross-sectional design, which allowed identification of trends but cannot explain causation of changes over time in attitudes and behavior of participants. Self-report may be an imperfect recording of oral health behavior and may be biased by social expectation. This study relied upon students providing honest responses. Because anonymity was assured, the validity of responses was assumed. However, the history of adverse oral habits such as pan chewing, gutkha consumption, and smoking were not evaluated as the dental students were more likely to provide false reporting of these habits which could have caused social desirability bias, hence, adversely affecting the results. Although every attempt was made to include the maximum number of variables which could have affected oral hygiene and gingival status but there are other factors such as stress and emotional conditions which could have affected oral hygiene and gingival status of the dental students and were not evaluated in this study. Furthermore, the study was carried out in a single institution on a small sample size and hence the generalizability of the results can be questioned. Further longitudinal studies with a larger sample size involving participants from different dental institutions are warranted.
| Conclusion|| |
The study found that there is a relationship between the oral health behavior, oral hygiene, and gingival status of dental students. Dental students with better self-reported oral health behavior had lower plaque and gingival scores indicating better behavior toward oral health. This study demonstrates and reaffirms the relationship of dental status (represented by plaque and gingival index) and oral health behavior (as measured using HU-DBI). Comprehensive programs in preventive care, including oral self-care regimens, should be an essential part of undergraduate dental education. Professional education of dental students should create stable health behaviors which will overcome differences in personal characteristics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Afsheen Lalani
Department of Public Health Dentistry, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]