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Oral Health Self-Perception

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Chapter

ORAL HEALTH SELF-PERCEPTION

R. Constance Wiener1, DMD, MA, PhD,

and Alcinda Trickett Shockey2, BSDH, MA, DHSc
1
Department of Dental Practice and Rural Health, School of Dentistry,
West Virginia University, Morgantown, WV, US
2
Department of Dental Hygiene, School of Dentistry,
West Virginia University, Morgantown, WV, US

ABSTRACT

Oral health self-perception is a personal evaluation involving one or

more of the following domains: 1) physical appearance including
psychosocial/cultural concerns; 2) attitudes towards etiological factors
related to lifestyle and oral health (tobacco use, alcohol use, high
carbohydrate diet, brushing, flossing, etc.); 3) role of
genetics/environment; and, 4) oral healthcare needs due to symptoms
(pain, lack of function, disease, etc.). The evaluation of how a person views
himself or herself is subject to change, and each oral health self-perception
evaluation is a snapshot of an individual at a particular time with the
individual focused upon one or several domains when describing his or her
oral health.

Keywords: oral health, perception, aesthetics, self-perception

2 R. Constance Wiener and Alcinda Trickett Shockey

ORAL HEALTH SELF-PERCEPTION:

THE INFLUENCE OF PHYSICAL APPEARANCE
INCLUDING PSYCHOSOCIAL/CULTURAL CONCERNS

The teeth, tongue, and other hard and soft oral tissues influence physical
appearance/beauty (Molina-Frechero, et al., 2017). Oral health self-
perception concerning aesthetics is generally established early in life. At
about age eight years, children have developed oral health self-perceptions
(dos Santos, et al., 2017), particularly concerning physical appearance.
Children use criteria for physical appearance self-perception that are similar
to the criteria used by adults (dos Santos, et al., 2017). Cues include an
appearance of health rather than sickness, and cleanliness rather than poor
hygiene. Teeth, as well as adornment and clothing choices, provide
nonverbal insights into a person’s culture and carry nonverbal messages that
are influential in how people view each other and interact. The focus of this
chapter; however, is limited to oral health self perception.
Adolescents with malformed, discolored teeth, and malocclusion (teeth
that are not properly aligned) often report significant psychological and
emotional problems related to ridicule, insecurity, and feeling negatively
about appearance in Western cultures (Molina-Frechero, et al., 2017);
whereas, attractive people report being evaluated and treated more positively
(Van der Geld, et al., 2007).
Most adults are aware of smile attractiveness. Such awareness of the
beauty of a smile has increased the demand and growth of aesthetic dentistry
in the US (Kokich, et al., 1999). During social engagements, attention is
generally drawn to a speaker’s mouth and eyes; therefore, the mouth has an
important role in social interactions (Thompson, et al., 2004). In considering
smile aesthetics, the dental components include tooth color, size, and shape
(Van der Geld, et al., 2007). Other components are the position and visibility
of the teeth, amount of gingival tissue (tissue around the teeth), and the
position of the upper lip (Van der Geld, et al., 2007). In Western societies,
the emphasis is on white, proportional, aligned teeth (Gonzalez, et al., 2010).
 Oral Health Self-Perception 3

Such teeth are considered characteristic of youth, beauty, strength, health

(Joys, et al., 2016) and wealth.
Psychosocial/cultural factors influence an individual’s perception of
what constitutes attractiveness. Psychosocial/cultural factors change over
time (Van der Geld, et al., 2007). Smile self-perception, therefore, includes
the internalized opinions of others and cultural norms, as well as a personal
level of satisfaction or dissatisfaction with one’s physical appearance (Van
der Geld, et al., 2007, Sheats, et al., 1998). The physical appearance aspect
of self-perception is modulated by education, behavioral factors, and
personality traits as well as culture (Polo and Montero, 2017).
For example, in terms of education, orthodontists often provide opinions
on the aesthetics of a smile to their patients based upon the typically accepted
positioning of teeth and bony landmarks that are considered to represent an
ideal occlusion (biting position) for appearance and function. However, a
patient’s perception may be different from that of an orthodontist or general
dentist and does need to be considered in the provision of dental care (Sheats,
et al., 1998). There was a study in which facial photographs were purposely
altered where the smile in each photograph was changed so that the midline
between the maxillary (upper) incisors deviated by a specified amount
(Kokich, et al., 1999). Orthodontists typically noticed the deviation when
there was a 4 mm change; however, general dentists and lay people did not
notice the deviation until it was beyond 4 mm (Kokich, et al., 1999).
Photographs with a gingival embrasure (space between teeth near the soft
tissue) of 2 mm were noticed by orthodontists; however, general dentists and
lay people did not notice the space until the difference was 3mm (Kokich, et
al., 1999). Physical appearance and psychosocial concerns are also closely
tied to a person’s education, and, as shown in the Kokich et al. 1999 study,
professional culture.
In some cultures in the Amazon Valley, people sharpen their maxillary
central incisors as a sign of beauty (Joys, et al., 2016; Pinchi, et al., 2015).
Some women in cultures in Indonesia sharpen, thin, and place grooves in
anterior (front) teeth for a beautiful appearance (Joys, et al., 2016; Pinchi, et
al., 2015). In some African cultures, anterior teeth are extracted for beauty’s
sake; other cultural groups chip the incisors into a peg shape for beauty;
4 R. Constance Wiener and Alcinda Trickett Shockey

some cultures force the eruption of the maxillary anterior teeth outward to
create an overjet extending beyond the lower lip; and other cultural groups
dye or blacken teeth as a sign of beauty (Joys, et al., 2016; Pinchi, et al.,
2015). The practice of blackening teeth occurs in Borneo, Peru, Ecuador,
Vietnam, Laos, Thailand, Indonesia, and the Philippines (Shameema, et al.,
2016; Pinchi, et al., 2015).
Tooth decoration for beauty is also prevalent worldwide. It is common
in Mexico, Borneo, and Africa. Dental grills, oral jewelry, and anterior gold
crowns are common in the US (Joys, et al., 2016; Pinchi, et al., 2015). Such
ornamentation provides socioeconomic clues in addition to snapshots of a
culture’s perception of beauty (Joys, et al., 2016). In the US, there is a
transition in the perception of body art, in general, and tooth modification,
in particular, from a previous view of body art and tooth modifications as
rebellious expressions to a view that they are expressions of uniqueness,
strength, fitness, and beauty (Joys, et al., 2016).
In some cultures, teeth are not highly valued. Extractions, as options for
dental problems, (with or without prosthetic replacement) are within the
cultural norm. In the US, 14.9% of adults aged 65 years and above have lost
all of their natural teeth due to dental caries (tooth decay) or periodontal
disease (disease to the supporting tissues around a tooth) (CDC, 2014).
However, the range was wide, 27.2%. There were 6.4% in Hawaii and
33.6% in West Virginia of adults aged 65 years and above who had lost all
of their natural teeth due to dental caries or periodontal disease. (CDC,
2014).
In the US, dental health is not considered to include the preemptive
removal of anterior teeth to prevent tetanus as it is in some countries in
Africa (Pinchi, et al., 2015). Dental health is not considered the germectomy
of primary canines in the belief that the primary canines are “mouth worms”
that will cause future disease (Garve, et al., 2016). However, this is the case
in regions of the world. The associated dentition with the removal of the
suspect teeth is therefore considered common, normal, and acceptable in
some cultures. When immigrants arrive in the US with such dentition,
cultural differences concerning oral health perception occur. Assessment
differences of physical appearance and psychosocial/cultural concerns have
 Oral Health Self-Perception 5

to be understood by both the new immigrants and oral healthcare

professionals who may be unaware of oral alterations performed for the
belief that they are preventive or beautiful. The oral health self-perception
based upon physical appearance with psychosocial/cultural factors may
therefore be different depending upon the population being studied.

ORAL HEALTH SELF-PERCEPTION:

THE INFLUENCE OF ATTITUDES TOWARDS
ETIOLOGICAL FACTORS RELATED TO
LIFESTYLE BEHAVIOR

Brushing/Flossing

Self-perception of oral health is influenced by attitudes toward lifestyle

behaviors. Most people in the US are aware of the American Dental
Association’s (ADA) recommendations concerning oral infection control.
These recommendations include: 1) brushing one’s teeth for two minutes at
least twice daily with a toothpaste that has fluoride; 2) cleaning at least once
daily between one’s teeth with an interdental cleaner/floss; and, 3) keeping
regular dental visits (ADA, 2016). People who are not practicing daily oral
infection control procedures while aware of the recommendations often
report poor self-perception of oral health. However, the skill or motivation
to practice the recommended lifestyle behaviors are often lacking.
Additionally, not all dental associations agree with the ADA guidance.
For example, in an analysis of tooth brushing recommendations from dental
associations in Australia, Brazil, Canada, Denmark, Finland, Japan,
Norway, Sweden, the United Kingdom, and the US, there were differences
in the suggested technique, duration, and frequency of tooth brushing
(Wainwright and Seiham, 2014). In the review of the twelve dental
associations by Wainwright and Seiham (2014), six dental associations
recommended the Modified Bass technique for tooth brushing. The
Modified Bass technique involves placing the toothbrush into the sulcus
6 R. Constance Wiener and Alcinda Trickett Shockey

(tissue collar) around the tooth at a 45-degree angle and making small
circular motions to clean that area, then rolling the toothbrush to the occlusal
(biting) surface of the tooth. Three dental associations recommended the
Fones technique of tooth brushing. The Fones technique involves cleaning
the buccal (cheek side) surfaces of the teeth (while the teeth are touching),
by using large circular motions with the toothbrush and using the same large
motions on the lingual (tongue side) surfaces of the teeth with the mouth
open. The anterior teeth are cleaned with short horizontal movements in the
Fones technique. Three dental associations recommended the Scrub
technique of tooth brushing. The teeth are brushed in short horizontal
motions in the Scrub technique.
A limited amount of research indicates that the Modified Bass technique
is the best technique, although it is a complex technique to learn
(Wainwright and Seiham, 2014). As a result, research is needed to determine
if the technique should be taught early in life, when the complexity may be
a hindrance, or if it should be taught later in life, when the complexity is less
of a concern. The complication is that there is a tendency for people to
maintain the techniques and behaviors learned in childhood and it is
unknown at what point in time the technique should be introduced
(Wainwright and Seiham, 2014).
In practice, many people are not brushing twice daily nor cleaning
interproximally (between their teeth) on a daily basis. In a study of Mexican
Americans, the respondents recognized that brushing and flossing were
important; however, many reported uncertainty as to how to floss (Aguierre-
Zero, et al., 2016). Therefore, the uncertainty was one of the barriers that
they had to flossing routinely (Aguierre-Zero, et al., 2016). In a study of
Pennsylvania National Guard soldiers, 63% reported brushing twice or more
daily and about half flossed daily (Eliasson, et al., 2014). Residents in
Detroit were queried about their brushing and flossing habits and 96.3%
reported brushing at least daily and 30.1% reported flossing daily (Ronis, et
al., 1993). In a sample of US male healthcare professionals, and female
nurses, 73% of the dentists, 74% of the nurses, and 57% of the other
healthcare professionals brushed at least twice daily (Merchant, et al., 2002).
In terms of flossing, 57% of dentists reported flossing daily, 66% of nurses
 Oral Health Self-Perception 7

reported flossing daily, and 37% of other healthcare professionals reported

flossing daily (Merchant, et al., 2002).
From data reported in the National Health and Nutrition Examination
Survey (NHANES), 2013-2014, there were 67.3% of people reporting that
they brushed their teeth two or more times per day (NHANES, 2014). With
a lifestyle standard of brushing twice a day and cleaning teeth
interproximally on a daily basis, self-perception of oral health based upon
daily oral infection control would possibility be different from self-
perception using a metric of aesthetics.

Dietary Choices and Nutrition

Dietary lifestyle choices also influence oral health self-perception. An

individual’s nutrition and diet influences the growth, development, and
function of the tissues in the oral cavity and also have influences on oral
disease (Touger-Decker and Mobley, 2013). Dental caries is a complex
process involving biopsychosocial factors. On the biological level, bacteria
in a biofilm on teeth utilize fermentable carbohydrates. The bacteria
produce acids that demineralize tooth surfaces (Touger-Decker and Mobley,
2013). The demineralization (loss of the minerals in the outer surface of
teeth, particularly calcium) is limited by remineralization (replacement of
the lost minerals) through salivary buffers, oral hygiene, topical fluoride and
other factors. If the dynamic processes are consistently involving more
demineralization thatn remineralization, then teeth erode and dental caries is
more likely. A diet of ad libitum use of highly refined carbohydrates, sugar-
sweetened beverages, sticky foods, sugary/starchy foods, and sugars is a diet
in which there is a likely increase in demineralization and therefore an
increase in the risk of dental caries (Touger-Decker and Mobley, 2013). In
a systematic review of the effect of restricting sugar intake on caries, there
was moderate evidence that caries was lower when free-sugars were less
than 10% of the energy intake (Moynihan and Kelly, 2014).
Mindfulness-Based Eating Awareness is a psychological construct by
which one is to be aware of healthful food choices, satiety cues, and hunger
8 R. Constance Wiener and Alcinda Trickett Shockey

(Kristeller and Wolever, 2010) rather than eating mindlessly and unaware of
calorie consumption. In a randomized control trial, mindful eating was
associated with eating fewer sweets and was associated with a decreased
fasting glucose level (Mason, et al., 2016). Trait mindfulness was associated
with preference for healthful foods, less impulse eating, and fewer consumed
calories (Jordan, et al., 2014). Impulse eating of sugary foods is a major
concern for oral health as well as overall health. Snacking, which increases
the potential sugar exposure frequency, is influenced by many factors.
Researchers determined that men who used a work beverage station closer
to the snack station increased the likelihood of snacking from 12% to 23%;
and for women, the increase was from 13% to 17% (Baskin, et al., 2016).
Simply moving the snacks may reduce snack consumption (Baskin, et al.,
2016).
Food choices are closely associated with reward, emotion (Weltens, et
al., 2014), culture, and convenience. Although most people are aware of
what constitutes a healthful diet, food preference is determined early in life.
Researchers have shown that parents who ate fruits and vegetables were
more likely to have children who met their daily fruit and vegetable
requirements (Draxten, et al., 2014). There have been many changes in food
composition, availability, and choices over the past several decades (Morris,
et al., 2014) which have influenced diets in the US as well as globally.
Increased consumption of carbohydrates was one such change.
Sucrose consumption (as compared with aspartame) was associated with
a reduction in chronic stress-induced cortisol and an increase in activity in
the left hippocampus (Tryon, et al., 2015). The hippocampus is responsible
for processing short-term memory into long-term memory. In a study by
Dallman, et al. (2003), the researchers proposed that in chronic stress,
glucocorticoids enable a chronic stress-response network. In humans, high
stress and high glucocorticoids induce comfort food intake (resulting in
weight gain) or, alternatively, decrease food intake (resulting in weight loss).
The proposed metabolic-brain-negative feedback pathway may be affected
by sugar and may be a factor in sugar cravings during stress (Tryon, et al.,
2015). High stress individuals who underwent functional magnetic
resonance imaging had exaggerated activity in areas of the brain involved
 Oral Health Self-Perception 9

with reward, motivation, and habitual decision-making when presented with

photographs of high calorie food (ice cream, cupcakes, fatty meats, nachos,
etc.) (Tyron, et al., 2013).
Nutritional intake is a factor in oral health self-perception. Nutritional
intake is lower in older adults with ill-fitting dentures, or with compromised
dentition (Iwasaki, et al., 2014). Quality, conventional prostheses for
individuals with missing teeth improved their quality of life, chewing ability,
smile aesthetics, and satisfaction in a cohort follow-up study (Montero, et
al., 2013). Similar results upon quality of life and dental prosthesis use
and/or need were determined in another study of older adults (Azevendo, et
al., 2015). Lifestyle dietary choices, nutrition and their effects influence self-
perception of oral health.

Tobacco Use

Tobacco use also is a lifestyle choice that not only affects overall health,
but also affects oral tissues. Many people initiate tobacco use at a young age.
Researchers evaluating adolescents in the Dartmouth Media, Advertising,
and Health Study reported that of the adolescents who smoked, 34% first
tried tobacco (primarily as cigarettes) between ages 10-14 years (Soneji, et
al., 2016). The smokers in the study were more likely to be sensation-
seeking, male, and had friends and/or parents who smoked (Soneji, et al.,
2016). Adolescents who used smokeless tobacco had similar characteristics
(Wiener, 2013).
In the US, there are at least 600,000 middle school students and 3 million
high school students who smoke (US Health and Human Services [USHHS],
2017). Few US adults (over age 25 years) initiate tobacco use as a lifestyle
choice, whereas approximately 90% of current smokers began smoking
before age 18 years (USHHS, 2017). Adolescents choose to use tobacco due
to peer/cultural influences, appealing tobacco marketing, price-reduction
programs, and presence of tobacco use in movies, videogames, and websites
(USHHS, 2017). Over a million dollars is spent in marketing tobacco
products every hour (USHHS, 2017). As nicotine is highly addictive,
10 R. Constance Wiener and Alcinda Trickett Shockey

tobacco cessation is difficult after tobacco use initiation. Adolescents are

curious about tobacco and curiosity was found to be associated with tobacco
advertising (Portnoy, et al., 2014). Curiosity has the potential to be a warning
sign of potential tobacco use in adolescents (Portnoy, et al., 2014).
Tobacco use is also strongly associated with cultural and religious
practices. In the US, Native Americans use traditional tobacco, or sacred
tobacco (as opposed to commercial tobacco) in prayer and religious
ceremonies (Boudreau, et al., 2016); however, the traditional guidance in
religious tobacco use is dissimilar to the encouragement to use tobacco in
the manner marketed by tobacco companies. As tobacco was introduced
from the Americas to colonies around the world, it was promoted as having
medicinal properties. Tobacco smoking became a practice that was accepted
culturally in many areas. However, in many other regions of the world,
tobacco use was considered a masculine activity and if women smoked, it
was considered unfeminine and improper (Killough, et al., 2013). Culture
has a strong influence on lifestyle behaviors.
As the effects of tobacco use and lung cancer became evident, many
people have quit tobacco use. However, the public has less knowledge about
the association of tobacco with stroke, heart disease, cancers other than lung
cancer, periodontal disease, and impaired wound healing. The effects of
tobacco use that are obvious to lay people (discolored teeth, halitosis, etc.)
do impact oral health self-perception.

Illicit Drug Use and Prescription Medications

Another consideration involving lifestyle that affects oral health self-

perception is the use of illicit drugs. Drugs manufactured in crude
laboratories often are contaminated with the unreacted initial ingredients
used in their manufacture. For methamphetamine, the potential contaminates
are pseudoephedrine, ephedrine, ether, paint thinner, anhydrous ammonia,
iodine crystals, red phosphorus, drain cleaner, battery acid, and lithium
(among other ingredients) (Department of Justice, DOJ, nd). The drugs and
their contaminates harm the body and mind. Additionally, they damage
 Oral Health Self-Perception 11

teeth. For methamphetamine, in particular, rampant caries is a typical

presentation. People with fractured teeth, black stains, severe caries and oral
infections due to illicit drug use report low self-perception of oral health.
With some illicit drugs, there is an alteration in diet resulting in poor
nutritional intake, and a thirst for sugar-sweetened beverages. Poor nutrition
impacts the body’s immune system and periodontal health. Clenching and
grinding of teeth are associated with some illicit drugs such as
methylenedioxymethamphetamine (ecstasy). When the clenching and
grinding are extreme, teeth become worn and flattened, or fracture.
Methamphetamine, similar drugs, and some prescription medications
are antisialagogues, that is, they decrease saliva production. Poor diet,
increased sugar consumption and decreased saliva are factors that lead to
dental caries and poor evaluations of oral health self-perception with drug
use.

ORAL HEALTH SELF-PERCEPTION: THE INFLUENCE OF

GENETIC OR ENVIRONMENTAL FACTORS

Genetics as well as environmental factors influence craniofacial

development. It is estimated that 25,000 genes are involved in craniofacial
growth (Nowrin, et al., 2015) and in recent years, many genes have been
associated with specific malocclusions. For example, the gene, RUNX2, is
associated with cliedocranial dysplasia’s supernumerary (extra) teeth and
impacted supernumerary teeth (Singh, et al., 2016). The genes that are
possibly associated with cleft lip and cleft palate are 17q12, also referred to
as RARA, 7p13-15, 2p13, 6p212.3-21.1, 1q22.3-41, 2135-36, 7q22-qter,
and 12q24-qter (Singh, et al., 2016). Causative genes are associated with
many conditions such as Crouzon syndrome’s maxillary hypoplasia; odonto-
onchyo-dermal dysplasia; and Pierre Robin (glossoptossis and
micrognathia), among many others (Sing, et al., 2016). It is estimated that
genetic analysis will be an important aspect in orthodontic treatment and
diagnosis in the near future (Nowrin, et al., 2015; Carlson, 2015). A
12 R. Constance Wiener and Alcinda Trickett Shockey

practical, genetic-based, theoretical model for craniofacial development

involves a continuum from significant craniofacial abnormalities that are
strongly the result of genetics (and to which normal growth assumptions are
not applicable) to normal phenotypic variations (in which normal growth
assumptions do apply) (Carlson, 2015).
Environmental factors are also very important in oral health. Shared
family environments were associated with periodontal status and number of
teeth in middle-aged and older adults (Kurushima, et al., 2015). Similarly,
environmental factors, such as socioeconomic status and social network
were thought to influence subjective oral health outcomes through the
mediation of stress (Gupta, et al., 2015), financial access to care, and access
to necessary nutrition for proper growth and development. Children living
in a socioeconomic environment of low or very low food security had higher
caries prevalence as compared with children who were food-secure (Chi, et
al., 2014). Oral healthcare disparities by poverty and race continue to be
significant environmental factors that require urgent policy solutions (Flores
and Lin, 2013).
Also, the environmental location in which a person grows and develops
can impact oral health. Geography is important, as location impacts access
to oral healthcare even after adjusting for child, family, community, and
state variables (Fisher-Owens, et al, 2016). Geography also matters in terms
of environmental heavy metal exposures (such as lead) which were shown
to be associated with increasing numbers of carious teeth in children ages 24
to 72 months (Wiener, et al., 2014). In a systematic review, exposure to
fluorides, molybdenum, strontium, lithium and vanadium were found to be
associated with the reduction of caries incidence, while selenium, cadmium,
lead, and copper were found to be associated with promoting caries (Pathak,
et al., 2016; Paula et al., 2012).
The interaction of genetics and the environment is a factor affecting the
oral cavity in many chronic diseases. As previously mentioned in the impact
of lifestyles on oral health self-perception, some prescribed medications for
chronic diseases and chemotherapy for cancers are antisialagogues. The
decreased saliva associated with the medications reduces the potential for
remineralization and increases the risk for dental caries. Individuals with
 Oral Health Self-Perception 13

Sjogren’s syndrome, and similar autoimmune diseases have limited salivary

production. Head and neck radiation destroys salivary glandular cells when
the glands cannot be shielded from the radiation. The lack of saliva cells due
to radiation exposure of salivary glands, autoimmune disorders, or
medications reduces the potential for remineralization and increases the risk
for dental caries. Individuals with a dry mouth are at greater risk for caries,
mucosal erosions, and other oral health concerns. These genetic and
environmental factors influence a person’s oral health self-perception.

ORAL HEALTH SELF-PERCEPTION: THE INFLUENCE OF

ORAL HEALTHCARE NEEDS DUE TO SYMPTOMS

Perhaps one of the most significant influence on a person’s self-report

of oral health perception is related to symptomatology. Pain and oral
symptoms (ulcerations, caries, halitosis, etc.) are strong indicators of
dysfunction and are, therefore, intimately associated with poor oral health
self-perception. Dental, periodontal or oral-facial pain is associated with
distress and disturbance in daily activities (Halvari, et al., 2013). Pain and
oral symptoms are also important motivators for addressing oral health
issues.
Acute or severe dental pain and oral symptoms are associated with
accessing urgent care facilities and emergency departments (ED) as well as
seeking immediate care with a dental professional. Although inability to pay
may delay care, denial of care in EDs due to the lack of financial ability to
pay is not permitted in the US.
There was an annual increase in ED visits for young adults (ages 20-29
years) of 6.1% for toothaches during 2001-2010 in the US (Lewis, et al.,
2015). Toothaches were the fifth most common reason for an ED visit during
that time period for young adults (Lewis, et al., 2015). Lack of insurance
was their most commonly cited reason for seeking dental care at an ED
(Lewis, et al., 2015). In 2009-10, there were approximately 1.27 million ED
14 R. Constance Wiener and Alcinda Trickett Shockey

visits by young adults for toothaches in the US (Lewis, et al., 2015). This
was 42% of all ED toothache visits in 2009-2010 (Lewis, et al., 2015).
Dental symptoms and dental pain strongly influence oral health self
perception.

CONCLUSION

Oral health self-perception is more than the absence of dental pain. It is

a holistic reflection of subjective well-being with one’s oral and dental
health (Halvari, et al., 2013). It also includes cultural influences and personal
beliefs about function, beauty, and values.

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