KNOWLEDGE, ATTITUDE AND PRACTICE OF

DENTAL FLOSSING AMONG DENTAL AND

MEDICAL STUDENTS OF THE UNIVERSITY OF
NAIROBI

INVESTIGATOR:

NYAMAI JEMIMAH MALINDA

V28 ) 2\)4\) ) 2\)\)1

BDS LEVEL III

A COMMUNITY DENTISTRY RESEARCH PROJECT

PRESENTED IN PARTIAL FULFILLMENT OF THE
BACHELOR OF DENTAL SURGERY DEGREE,
UNIVERSITY OF NAIROBI

0CTOBER 2010
DECLARATION

I, NY AMAI JEMIMAH MALINDA, BDS III, do solemnly swear that this is my original work

Signature
---
and that it has not been submitted for any purpose in any other institution.

~ .
11.,\\_
:.r.
a.OIO-
.
D ate

ii
SUPERVISORS APPRO V AL

This report has been submitted for examination with the approval of the following
supervisors:

DR. MUT AVE R. 1. BDS (NBI), MRES (UK)

LECTURER

DEPARTMENT OF PERIODONTOLOGY, COMMUNITY AND PREVENTIVE

DENTISTRY

SCHOOL OF DENTAL SCIENCES

UNIVERSITY OF NAIROBI

Signature........

Date 4tt ~-
.

~.t../~.(p. .
.

DR.KISUMBI B. K. BDS (NBI), MPhil (UK)

SENIOR LECTURER

DEPARTMENT OF CONSERVATIVE AND PROSTHETIC DENTISTRY

SCHOOL OF DENTAL SCIENCES

UNIVERSITY OF NAIROBI

Signature ¥ ..
~ .
Date ~.l.~.l.~.r~ .

iii
DEDICATION

To my dear family who gave me emotional and financial support.

iv
ACKNOWLEDGEMENT

To the University of Nairobi, School of Dental Sciences, for giving me the chance to indulge my
research interest and develop them.

Dr. Mutave, who worked tirelessly, provided guidance and followed up the progression of my
work.

Dr. Kisumbi for her constant support and guidance.

To my dear parents: Mr and Mrs Benard Nyamai for their financial support.

To all students who took their time to fill my questionnaires.

Above all, thanks to the almighty God for seeing me through my academic life.

v
TABLE OF CONTENTS

TITLE PAGE

Cover page i

Declaration ii

Supervisors' approval .iii

Dedication iv

Acknowledgement v

Table of contents vi

List of figures viii

Abbreviations ix

Abstract. x

CHAPTER 1

Introduction 1

Literature review 3

Problem statement 5

Justification of the study 5

Objectives 6

Hypothesis 6

Variables 7

CHAPTER 2

Materials and methods 8

CHAPTER 3

Results 11

CHAPTER 4

Discussion 23

vi
Conclusion 25

Recommendations 26

References 27

Appendix I (questionnaire) 29

Appendix l1(consent form) 33

vii
LIST OF FIGURES
Figure Title Page

Figure 1 Sex distribution by school 11

Figure 2 Number of times of brushing by school 12

Figure 3 Teeth cleaning aids used by the students 12

Figure 4 Distribution of respondents on the meaning of dental floss 13

Figure 5 Knowledge on dental disease by school 13

Figure 6 Types of diseases by school 14

Figure 7 Dental floss recommendation by school 14

Figure 8 The recommender of dental floss by school 15

Figure 9 Reasons for recommendation to use dental floss 16

Figure 10 The response as to whether use of dental floss is harmful to teeth and gum 16

Figure 11 Effects of dental floss 17

Figure 12 The practice of dental flossing by school 17

Figure 13 Type of dental floss used 18

Figure 14 Time of use of dental floss 18

Figure 15 Frequency of use of dental floss 19

Figure 16 The response as to why the students do not use dental floss by school 20

Figure 17 Places to obtain dental floss 21

Figure 18 Response as to advise or not to advise other students by school 21

Figure 19 Reason for advice of use of dental floss 22

viii
 ABBREVIATIONS
UO - University of Nairobi

BDS - Bachelor of Dental Sciences

ADA - American Dental Association

KNH - Kenyatta National Hospital

SPSS - Statistical Package for the Social Sciences

MRES - Masters in research

MPhil - Master of Philosophy

NBI - Nairobi

I
I.
ix
ABSTRACT

Background: Dental floss is used as an adjunct to other oral hygiene practices such as tooth
brushing and use of mouthwashes in prevention of dental diseases like periodontal diseases and
dental caries. It is used to remove plaque from the inter-dental areas where tooth brushes cannot
access. There is paucity in the information regarding dental floss among college students in
Kenya. With this gap in knowledge and the fact that dental and medical students will play an
important role as future educators on oral health, this study was carried out.

Objective: The aim of this study was to determine knowledge, attitude and practice of dental
flossing among medical and dental students of the University of Nairobi.

Study design: A descriptive cross-sectional study was carried out.

Study area: The study was conducted in the School of Medicine and the School of Dental
Sciences of the University of Nairobi.

Study participants: Undergraduate students from both the School of Medicine and the School
of Dental sciences.

Methodology: Stratified random sampling method was used to select subjects from the school of
medicine and school of dental sciences. The sample size for school of dental sciences was 32 and
125 for school of medicine. Self administered questionnaires were used to collect data.

Results

Of the 157 respondents, 32 (100%) dental students and 117 (94%) students from the medical
school knew dental floss as a special thread used to clean in between the teeth. Only 5 (4%) of
the medical students said that it was a drug while 3 (2%) said it was an oral hygiene aid used to
whiten the teeth. Most students agreed that they would advise other students to use dental floss.
Among these, there were 32 (100%) dental students and 95 (76%) medical students. Only 39.5%
of the students said that they brushed once per day while 53.5% said that they brushed twice in a
day. From medical school, 36% brushed once daily while 56% brushed twice per day. From
dental school, tooth brushing at least twice daily was claimed by 43.8% while 53.1 % brushed
once in a day. Only 25% of the dental students and 16.8% of the medical students practiced
dental flossing while 83.2% medical and 75% dental students never used dental floss.

Conclusion: From the findings, it can be concluded that both medical and dental students have
adequate knowledge about dental floss. Dental students have been shown to practice the use of
dental floss more than the medical students. In general, students from both schools were
knowledgeable on what dental floss is with 32 (100%) being dental students and 117 (94%)
being medical students. In addition, they also wanted to positively influence other students to

x
practice the use of dental floss. It can be deduced from this study that though students displayed
adequate knowledge in some areas, there were areas which could be improved.

Recommendations: Dentists should focus on educating the students on the use of dental floss
when they go for preventive programmes. This will increase students' awareness on how to
effectively use dental floss. A research should be done to investigate why students do not use
dental floss despite the fact that they know about its availability in the supermarkets. The prices
at which dental floss is sold should be checked to ensure that they are fair. Educational seminars
should be organized for medical students to increase their awareness on the role that dental floss
plays in oral health.

xi
INTRODUCTION

It is generally accepted that bacterial plaque is an important etiological factor of periodontal

diseases and plays a great role in causation of gingivitis and periodontitis.' Dental floss is used to
remove plaque especially at the interdental areas, thus reducing chances of one getting these
diseases.

Despite recent advances in oral chemotherapeutics, mechanical removal of plaque remains the
primary method for controlling supra-gingival accumulations+r'. The most common method of
mechanical plaque control is tooth brushing. However, tooth brushing alone does not access the
interproximal areas of the dentition, which means that part of the dentition is left unclean. The
interdental areas, especially the posterior, are the least accessible' 4. Moreover, soft and / or hard
deposits accumulate in the space between teeth in almost all patients '. Periodontal and gingival
lesions are predominantly observed at these sites". As the interproximal areas of the dentition are
also frequently affected by caries, interproximal cleaning represents an important aspect of oral
self-care". Patients should therefore resort to additional techniques to tooth brushing.

The most appropriate interdental aid depends on the size and shape of the interdental space, as
well as the morphology of the proximal tooth surface. Also, the level of dexterity and ability of
the patient to use a hygiene aid should be taken into accounts. As a method to remove
interproximal plaque, flossing has received the most attention. However, the difficulty in flossing
probably makes this technique less than universal in its application".

Dental floss is a special type of thread used for cleaning spaces between teeth which cannot be
reached by tooth brushes. It is either a bundle of thin nylon filament or plastic (teflon or
polythene) ribbon. It may be flavored or unflavored, waxed or unwaxed. It is used as an adjunct
to oral hygiene practices as an antiplaque agent. It is inserted gently between the teeth and
scraped along the teeth sides especially close to the gums. to

Flossing, combined with tooth and tongue brushing, significantly reduces the amount of disease-
causing bacteria in the mouth." Both practices have been shown to prevent gum disease,
halitosis and dental caries, and also to reduce incidence of heart disease'.

A wide variety of interdental cleaning devices are available. Although toothpicks and
interproximal brushes are considered easier to use than is floss and are usually preferred by
patients over floss, such devices can be prescribed only for patients with adequate embrasure
space to accommodate their placement. 12

However, use of dental floss does not eliminate need for tooth brushing and use of
mouthwashes. Dental flossing is done before tooth brushing and at least once in a day. This is to
allow toothpaste to reach in between the teeth for proper cleaning and clearance of plaque".

1
Improper flossing has been reported to cause tooth abrasion, gingival recession and gingival
clefting and localized periodontal bone loss 13.

Literature on use of dental floss among college students in Kenya is scanty hence the aim of this
study is to determine the knowledge, attitude and use of dental floss among dental and medical
students. The results may then be used to design programs for increasing the knowledge on
dental floss among the students. This may then spill over to the community as a means of
enhancing the prevention of dental caries and periodontal diseases through the non-
knowledgeable individuals.

2
LITERATURE REVIEW

Suggestions regarding the benefits of flossing date back to the early 19th century, where the
belief was expressed that irritating matter between teeth is the source of dental diseases 14

Over the years, it has been generally accepted that dental floss has a positive effect on removing
plaque 15.The American Dental Association (ADA) reports that up to 80% of plaque may be
removed by this method'".

Bass (1948) described the good characteristics of dental floss'". However, there is a great deal of
evidence to support the concept that there are no differences in the reduction of plaque and
gingivitis which could be attributed to the use of anyone type of flossl8.Bergenholtz & Brithon
(1980) found a slight tendency toward more effective plaque removal interdentally if unwaxed
dental floss is used instead of waxed'", However, they concluded that the motivation and the
instruction of the patient in oral hygiene techniques are more important than the aids used for the
cleaning procedure.

It has been shown that the most severe gingivitis can be seen in the interdental areas8,9, 10where
the toothbrush has a limited effect on plaque removal'LTherefore many tools and devices have
been developed to supplement ordinary brushing in the interdental area. Studies have shown the
addition of flossing to a daily oral hygiene regimen of thorough tooth brushing to have no long
term beneficial effect on interproximal plaque accumulation. These disappointing findings are
usually related to a lack of patient motivation or inadequate manual dexterity for the proper use
offlossl8.

In studies done by Wright et al and Gisselsson et al, four trials reported a decreased relative
caries risk, ranging from 19% to 54%, associated with flossing, while two trials reported a
slightly increased relative caries risk associated with flossing 18,20

According to another study by Waerhaug, flossing was reported to be a caries preventive tool.
This is because dental floss disrupts and removes interproximal plaque, which is cariogenic, thus
reducing caries risk21and periodontal diseases. A study showed that those who flossed at least 4
times a week had less plaque, gingivitis, calculus and shallower pocket depth. The same study
revealed that flossing and brushing combined reduced gingival bleeding double compared to
brushing alone(67% and 35% respectivelyj"

In a study by Heikki et al 35% of the students reported using dental floss, but only 2% reported
daily usage. 45 % of the students had been taught how to use dental floss, and 83 % of these had
been taught by dental personnel. Teaching had no effect on the reported frequency of use. There
were no statistically significant differences in the occurrence of dental plaque and gingivitis
between those who used dental floss and those who did not. The subjects were unable to use
dental floss on lout of every 3 filled proximal surfaces of the first molars. No correlation could
be found between dental caries experience and the reported use of dental floss23

3
Another study by Einno et al reports that dental floss was used sporadically by 10% and daily by
1 %. The use of dental floss was not found to be related with age. No influence of socioeconomic
factors was noticed in any sex or age groups on the use of dental floss. Girls used both toothpicks
and dental floss more frequently than boys. 24

A study done in America showed that 10-21% of the Americans practiced daily flossing.25 In
Tanzania, a study was done which revealed that less than 1% of the population used dental floss
while 76% of the population used toothpicks as an alternative interdental cleaning aid.26 A
similar study done in Jordan revealed that only 19% of the population used dental floss while
8.3% used interdental brushes.27 A study done on self reported oral hygiene practices among
adults in Denmark reported daily use of dental floss by 11%.28

Findings obtained by Mohamed A Sheikh in a study done in 2008 on adult patients visiting the
VON dental hospital regarding the knowledge, attitude and practice of interdental cleaning
revealed that 89.3% knew what it is and 60.7% knew what it achieves, 72.3% practiced it, 35.8%
of the patients used dental floss. It revealed that most of the patients had a positive attitude
towards interdental cleaning. A similar study was done by Ang'a et al among medical and dental
students of the VON in 2002. It revealed that over 82% of the students knew what interdental
cleaning was, less than 50% knew the role it plays and only 30010 practiced it. Another similar
study done by Kimani et al on students in the college of health sciences in the VON in 2007
showed that 69.5% of the students knew what interdental cleaning is, 28.5% knew the role it
plays, 51.6% practiced it. Most of the students (65.4%) used dental floss. Over 95% of the
students had positive attitude towards the practice.

Emphasis and awareness of the importance of interdental cleaning is on the rise. Adverts are run
in the media about dental floss and mouth rinses that can handle interdental cleaning needs. This
contributes to the general awareness of the population on the need to clean interproximal areas of
the teeth.

4
PROBLEMSTATEMENT

Tooth brushing is the mainstay of teeth cleaning. However, most tooth brushes do not clean
between the teeth. Therefore, the use of interdental cleaning aids like dental floss can reduce the
incidence of interproximal tooth decay and periodontal diseases. A small percentage of the
population practice dental flossing. This could be due to lack of knowledge and negative attitude
towards the practice. This has lead to high incidence of caries and periodontal diseases. This
trend can be reversed if awareness initiatives are undertaken to enlighten people on the benefits
of interdental cleaning
This can be enhanced through increasing knowledge on disease prevention of the medical and
dental practitioners and in the process change their attitudes.
Dental and medical students are the study population because they are the ones who will be
encountering conditions presenting in the oral cavity.

JUSTIFICATION OF THE STUDY

There is scarcity of information regarding the knowledge, attitude and the use of dental floss in
Kenya. The study aims at determining the knowledge, attitude and practice of dental flossing
among medical and dental students of the University of airobi.

Educating the students will be useful as they will in turn educate the general population. Dental
and medical students are an important group in the prevention of diseases as they encounter
various groups of people with different disease conditions once they become professionals. They
can also educate the community during community health outreach programs.

The information obtained will provide a baseline data which could be used by policy makers to
develop strategies aimed at improving the oral hygiene of the public.

5
OBJECTIVES

MAIN OBJECTIVE

To determine the level of knowledge, attitude and practice of dental flossing among dental Clncl
medical students of the University of Nairobi.

SPECIFIC OBJECTIVES

1. To determine the knowledge on dental flossing among medical and dental students in the
school of medicine and the school of dental sciences.
2. To determine the attitude towards dental flossing among medical and dental students in
the school of medicine and the school of dental sciences.
3. To determine the practice of dental flossing among medical and dental students of the
University of Nairobi.

HYPOTHESIS

Dental students are more knowledgeable in use of dental floss compared to medical students.
Less than 50% of the students use dental floss.

6
VARIABLES

SOCIO DEMOGRAPIDC

Variable Measurement

Gender Male or Female

Age Number of years

Year of study 1,2,3,4,or5

INDEPENDENT

Variable Measurement
Knowledge on dental floss Likert scale
Attitude toward dental flossing Likert scale
Degree course Medicine or Dental surgery

DEPENDENT

Variable Measurement
Practice of dental flossing Frequency of use of dental floss.
Type of dental floss used.
Duration of use of dental floss.

7
MATERIALS AND METHODS

STUDY POPULATION

Undergraduate in the schools of medicine and dental sciences at the University of Nairobi.

STUDY AREA

The study was conducted at the schools of dental sciences and medicine, University of Nairo bi

The school of dental sciences is one of the schools of the UON. It is located within Nairobi city
opposite Nairobi hospital. It has approximately 135 undergraduate students.

The school of medicine is also one of the schools of the UON. It is also within Nairobi city and
is next to Kenyatta National Hospital, approximately two kilometers from the Central Business
District. It has approximately 1500 undergraduate students.

STUDY DESIGN

Descriptive cross-sectional study

SAMPLE SIZE

Available literature from a study done on self reported oral hygiene practices among adults in
Denmark reported daily use of daily floss by 11%. The sample size was computed using the
following formula:

N = Z2 {P (I-P)}

Where: N = sample size

Z = Z-value = 1.962

P = prevalence = 11%

C = confidence level = 0.05

N= 1.96 x 1.96 {0.1 x(I-0.11)}

0.052

=137

8
SAMPLING METHOD

A stratified random sampling method was used to select subjects from the schools of medicine
and dental sciences. Since the school of dental sciences has approximately 135 students and the
school of medicine has about 1500 students, proportionate allocation of subjects from both
schools was done. The number of the students who were picked from each of the two schools
was calculated in the ratio of 135: 1500 as follows;

School of dental sciences

(135/1635) x 137=12

School of medicine

(1500/1635) x 137=125

This was then distributed equally among the different levels of study. Students were randomly
selected as follows:

From the school of medicine, twenty five students were picked from each level of study (level I,
II, III, IV, V)

Since the sample size of the school of dental sciences was small, 20 students were added to
improve the power of the study and allow statistical analysis. This brought the sample size to 32
students. Eight students were picked from each level (I, II, III and IV)

INCLUSION CRITERIA

Undergraduate dental and medical students who consented to participate in the study.

EXCLUSION CRITERIA

Students not admitted in any of the two courses.

Students who did not consent to the study.

DATA COLLECTION INSTRUMENTS AND TECHNIQUES

A self-administered questionnaire (Appendix 1) was used to collect data. The questionnaire was
administered by the investigator and collected back once the students filled the required
information.

9
ETHICAL CONSIDERATIONS

1. This research proposal was submitted to the UON/KNH ethics research and standards
committee for approval.
2. Permission to conduct the study was sought from the UON.
3. Informed consent was sought from all the subjects prior to the study.
4. Confidentiality of all information given was guaranteed.
5. Subjects were free to decline from participating in the study and to withdraw
participation at any given time.

DATA ANALYSIS AND PRESENTATION

The data was analyzed using SPSS version 13.0 and MS EXCEL. The mean percentage
scores, standard deviation and frequency distribution were calculated. The student's t-test
was used as test of significance. Cross tabulation was used to compare different variables.
The data has been presented by use of charts and texts.

PERCEIVED BENEFITS OF THE STUDY

1. Dentists should focus on educating the students on the use of dental floss when they go
for preventive programmes. This will increase students' awareness on how to effectively
use dental floss hence improving their oral health.
2. A research should be done to investigate why students do not use dental floss despite the
fact that they know about its availability in the supermarkets. The prices at which dental
floss is sold should be checked to ensure that they are fair.
3. Educational seminars should be organized for medical students to increase their
awareness on the role that dental floss plays in oral health.
4. This research proposal is in partial fulfillment for the award ofBDS at the UON.

PROBLEMS ENCOUNTERED

1. Financial constraints.
2. Inadequate time to do the study.

10
CHAPTER3
RESULTS

The 157 respondents were involved in the study with 32 (20.4%) being dental students and 125
(79.6%) being medical students. There were 78 (49.7%) males and 79 (50.3%) females). From
the school of dental sciences, 16 (50%) were males and 16 (50%) were females. From the school
of medicine, 62 (49.6%) were males and 63 (50.4%) were females. (Figure 1)

Figure 1: Sex distribution by school

70

60
•..'"c 50
CII
."~
1;; 40
'0
•..
CII 30 • medicine
..a
E
~ 20 • dental sciences
z
10

0
male female

Gender

When the respondents were asked how often they brush their teeth, 4 (2.5%) said that they
brushed less than once per day, 62 (39.5%) brushed once per day, 84 (53.5%) brushed twice per
day and 7 (4.5%) brushed more than twice per day.

From medical school, 4 (3.2%) said that they brush less than once in a day, 45 (36%) brush once
in a day, 70 (56%) brush twice per day while 6 (4.8%) brush more than twice per day. From
dental school, none of the students brush less than once in a day. Those who brush once daily
were 17 (53.1%),14 (43.8%) brush twice daily and 1 (3.1%) more than twice per day. (Figure 2)

11
Figure 2: Number of times of brushing by school

r---------------~.~)------------
70
•..~60
III

-..
~50
III

040
Q/

~30 • medicine
:::I
Z20 • dental sciences

10
O~~~~~~~~~~
less than once per twice per more than
once per day day twice per
day day
Frequency of brushing

On the aids of cleaning, 155 (80%) of the correspondents used conventional toothbrush and
toothpaste. Some students, 25 (13%) used mouthwash and 14 (7%) used dental floss as an
adjunct to tooth brushing. (Figure 3)

Figure 3: Teeth cleaning aids used by the students

25,13%

• brush and toothpaste

• dental floss

mouthwash

Of the 157 students, all the dental students, 32, knew dental floss as a special thread used to
clean in between the teeth while 117 (94%) students from the medical school gave this response.
However,5 (4%) of the medical students said that it was a drug while 3 (2%) said it was an oral
hygiene aid used to whiten the teeth. (Figure 4)

12
Figure 4: Distribution of respondents on the meaning of dental floss by school

~%
120

•..
III

C
100
QI
"1:1 80

-
:::J
1;;
60
•..
0
QI
.a
E 40 • medicine
:::J
Z
20 5(4%) 3(2%) • dental sciences

0
a special thread a drug an oral hygiene
used to clean in aid used to
between the whiten the teeth
teeth

Meaning of dental floss

When asked whether they knew any dental disease that can be prevented by use of dental floss,
29 (90.6%) dental students and 51 (40.8%) medical students knew of a disease. Those who did
not know of any disease comprised 3 (9.4%) dental students and 71 (59.2%) medical students.
(Figure 5)

Figure 5: Knowledge on dental disease by school

80
70

• medicine

• dental sciences

10
o
yes response no

13
Among those who said that they knew of a dental disease that can be prevented by use of a
dental floss, 51 (40.8%) and 15 (12%) medical students were aware of dental caries and
periodontal diseases respectively. From dental school, 23 (71.9%) and 11 (34.4%) students knew
dental caries and periodontal diseases respectively. (Figure 6)

Figure 6: Types of diseases by school

•..c
III
60
~8%
CII
~ 50

-
::J
1;;
40
•..
0
CII
.CI 30
E 1---',----'---------- medicine Count
::J
Z _ dental sciences Count
20

10

0
dental caries periodontal
diseases

Name..o.ldiseas

Dental floss had been recommended to 32 (25.6%) medical students and 24 (75%) dental
students. On the other hand, it had not been recommended to 84 (67.2%) medical and 8 (25%)
dental students. (Figure 7)

Figure 7: Dental floss recommendation by school

90 84(6T.2%-r-- ----
~
fii 80 +---------------
~

-
.a 70
III

~ 60
CII
.CI
E50 +-----
::J _ medicine
Z 40 +-__ ~=_=._--------
32(25.6%) _ dental sciences
30 +---

20
10 -j----

0+---
yes no
Response

14
Among those to whom dental floss had been recommended, 14 (36.8%), 15 (39.5%) and 9
(23.7%) medical students were recommended by a dentist, friend and parent respectively. From
dental school, 20 (83.3%), ] (4.2%), 1 (4.2%) and 2 (8.3%) students were recommended by a
dentist, medical doctor, friend and parent respectively. (Figure 8)

Figure 8: The recommender of dental floss by school

20~~>J-----------------
20
18
•..~16
III
15(39.5%)
"C
'=14
III

•..
'012
• medicine Count
Jho
E
• dental sciences Count
~ 8
6
4
2
o ~-=~~~~~~~~~~~.-~~~~
dentist medical doctor friend parent
Recommender

When asked why the dental floss was recommended, 26 (45%), 26 (45%) and 6 (10%) students
reported that it was due to bad breath, dental disease and to improve oral hygiene respectively.
(Figure 9)

15
Figure 9: Reasons for the recommendation to use dental floss

6,10%

26,45%
• bad breath

• dental disease

improve oral hygiene

Concerning whether the use of dental floss is harmful to teeth and gum, 25 (20%), 92 (73.6%)
and 5 (4%) medical students said yes, no and Tdo not know respectively. Among the dental
students, 2 (6.25%) said yes while 29 (90.6%) said that dental floss has no detrimental effect on
the teeth and gum. (Figure 10)

Figure 10: The response as to whether use of dental floss is harmful to teeth and gum by
school

100
!l 90
c
~ 80
.a70
11\

'060
~ • medicine
~ 50
§ 40 • dental sciences
Z
30
20
10
o ~---------r----------r----------f
yes no i don't know
Response

16
On the effects of dental floss to the teeth and gum, 20 (38%) said that it helps improve oral
hygiene, 17 (33%) said that if well adapted it doesn't hurt while 15 (29%) said that it may
ulcerate the gingiva. (Figure 11)

Figure 11: Effects of dental floss

15,29% • if well adapted it doesn't

hurt

• helps improve oral

hygiene

might ulcerate the gingiva

When asked whether they practiced dental flossing, 104 (83.2%) medical students did not
practice it while 21 (16.8%) of them did. From dental school, 24 (75%) students used dental floss
while 8 (25%) didn't. (Figure 12)

Figure 12: The practice of dental flossing by school

120

100

'"
~ 80
GI
"tI
::l • medicine
-:;;60
'0
•.. • dental sciences
.! 40
E
:i 20
o ~------------~------------~
yes no
Response

17
Among those who used dental floss, 24 (53.3%),8 (17.8%), 2 (4.4%) and 1 (2.2%) students used
waxed, flavored, unflavored and unwaxed types of dental floss respectively. Those who didn't
know the type of dental floss that they used constituted 3(6.7%) of the correspondents. (Figure
13)

Figure 13: Type of dental floss used

dont know

III unflavoured type

III
o
;;::
'0 flavoured type
cu
Q.

~
unwaxed type

waxed type ...,...---...,...---....,..---...,...---....,..----- (5'.3%) I

o 5 15 20 25

When asked when they practice flossing, 17(58.6%),9(31 %),2(6.9%), I (3.4%) used dental floss
after brushing, after meals, before brushing and before going to bed respectively. (Figure 14)

Figure 14: Time of use of dental floss

17(58.6%)
18
16
III

t:cu 14
12

-
"0

::::I
1;; 10
~ 8
CIJ
.c 6
E
::::I 4
Z
2
o~ _f

before after brushing after meals before going to

brushing bed
Time of use of dental floss

18
Concerning the frequency of use of dental floss, 10(34%) floss daily, 9(31 %) use it rarely while
8(28%) and 2(7%) floss weekly and more than three times a week respectively. (Figure 15)

Figure 15: Frequency of use of dental floss

• daily

• weekly

more than three times a

week

• rarely

Among the respondents who did not practice dental flossing, 48 (38.4%) medical and 6 (18.8%)
dental students said that they did not know how to use dental floss, 15 (12%) medical and 5
(15.6%) dental students said that they lack time to do so, 22 (17.6%), ] 7 (13.6%) and 2 (1.6%)
medical students said that it was not necessary, it is expensive, and is difficult to use
respectively. Among the dental students, 5 (15.6%),4 (12.5%), 3 (9.4%) and] (3.125%) said
that it is expensive, it was not necessary, it is difficult to use, and use toothpicks instead
respectively. (Figure 16)

19
Figure 16: The response as to why the students do not use dental floss by school

--- ---
60

.•..C
III

QI
SO
••
~ 40
.•..::s
III

'0
•..
QI 30
~ • medicine
E
::s
Z • dental sciences
20

10

2 3
0 1
0
it is difficult i do not i lack time it is not it is use a
to use know how to necessary expensive toothpick
use it Reason instead

When asked where they could get dental floss, 94 (59.9%) said from a supermarket, 38 (24.2%)
said from a pharmacy, 38 (24.2%) said that they do not know, 29 (18.5%) said from a dental
clinic and 7 (4.5%) said from a hospital. (Figure 17)

20
Figure 17: Places to obtain dental floss

i don't know

pharmacy
GI
~ hospital
0::
dental clinic

supermarket

o 20 40 60 80 100
Number of students

Concerning whether they would advise other students to use dental floss, 32 (100%) dental
students and 95 (77.9%) medical students said that they would while 27 (22.1 %) medical
students would not. (Figure 18)

Figure 18: Response as to advise or not to advise other students by school

~oo
c
cu
't:J
~ 80
1;;
'0
~ 60
.0
• medicine
E
~ 40
Z • dental sciences

20
dental sciences
o
yes
no

Response

Among those who said that they would advise other students to use dental floss, 46 (58.2%)
thought that it improves oral hygiene and 27 (34.2%) thought that it prevents dental diseases. As

21
to those who could not advise others to use dental floss, 6 (7.6%) said that it is time consuming.
(Figure 19)

Figure 19: Reason for advice of use of dental floss

----- ---

46{58.2%)
50

..'"
c
0.1
40

30
"tJ
::::II
~ 20
10
0

improve oral
hygiene time consuming
prevent dental
diseases
Reason for advice of use of dental floss

22
CHAPTER 4

DISCUSSION

There were slightly more females (50.3%) than males (49.7%) recruited in the study. This could
be attributed to the fact that there are more female students admitted in the school of medicine
and the school of dental sciences.

Majority of the respondents thought dental floss is a special type of thread used to clean In
between the teeth, 100% being dental students and 94% being medical students.

Concerning the knowledge on dental diseases that can be prevented by use of dental floss, 40.8%
and 12% medical students knew dental caries and periodontal diseases respectively. From dental
school, 71.9% and 34.4% of the students knew dental caries and periodontal diseases
respectively. Thus, more dental students knew of dental diseases that could be prevented by use
of dental floss as compared to medical students. This can be attributed to the fact that dental
students spend most of their time learning diseases that affect the oral region than the medical
students. This compares to studies done by Wright et al and Gisselsson et aI, where four trials
reported a decreased relative caries risk, ranging from 19% to 54%, associated with flossingI8,20.
It also compares to another study done by Waerhaug, in which flossing was reported to be a
caries preventive tool" and that those who flossed at least 4 times a week had less plaque,
gingivitis, calculus and shallower pocket depth.

Responses concerning advice of use of dental floss to other students confirmed positive attitude
towards dental flossing, 100% being dental students as compared to medical students (76%).
This compares to a study done by Kimani et al where over 95% of the students had a positive
attitude towards the practice.

Regarding the practice of dental flossing, 18.5% of the students practiced it. Only 25% of the
dental students and 16.8% medical students used dental floss while 83.2% medical and 75%
dental students had never used dental floss. This compares to a study done in America which
showed that 10-21% of the Americans practiced daily flossing and to another study done in
Jordan revealed that only 19% of the population used dental flOSS25,27. However, this is in
contrast to a study done in Tanzania which revealed that less than I% of the population used
dental floss while 76% of the population used toothpicks as an alternative interdental cleaning
aid.

Concerning the types of dental floss they used, 15.3% used waxed type, 5.1% used flavored type,
and 1.3% and 0.6% use unflavored and unwaxed types respectively.

Only 39.5% of the students brushed once in a day, 53.5% brushed twice per day while 4.5%
brushed more than twice in a day.

23
Among the medical students, 36% brushed once in a day and 56% brushed twice per day. From
dental school, 53.1 % and 43.8% brushed once and twice in a day respectively. Only 4.8% of the
medical students and 3.1 % dental students brushed more than twice in a day. Therefore medical
students practiced tooth brushing more often than dental students. Only 64.6% of the females
brushed their teeth twice in a day compared to 42.3% of the males. From these findings, it can be
noted that the practice of tooth brushing is better in female subjects than males because ladies
care more about their oral hygiene and practice good oral hygiene maintenance than men. This is
in agreement with Einno et al study where girls were observed to use both toothpicks and dental
floss more frequently than boys, and thus were able to maintain a better oral hygiene".

Majority of the students, 80%, used tooth brush and toothpaste to clean their teeth, 7% used
dental floss and 13% used mouthwashes as an adjunct to tooth brushing. Only 25% of the dental
students and 16.8% medical students used dental floss.

Dental floss had been recommended to 35.7% of the students. When asked who recommended it
to them, 60.7% were recommended by a dentist, 28.6% by a friend and 19.6% by a parent.
Therefore, dentists are more involved in encouraging the use of dental floss. This is because they
have a better understanding of the role that a dental floss plays in promoting oral health. This
compares to a study done by Heikki et al where dental floss had been recommended to 45 % of
the students who had also been taught how to use it, and 83 % of these had been taught by dental
personnel='.

When asked where they could get dental floss, 56% medical and 75% dental students said from a
supermarket, 16% medical and 28.1 % dental students said from a dental clinic, 22.4% medical
and 31.3% dental students said from a pharmacy while 3.2% and 9.4% medical and dental
students respectively, said from a hospital. The school did not matter neither the gender.

24
CONCLUSIONS

From the findings, it can be concluded that in general, medical and dental students have adequate
knowledge about dental floss. However, knowledge on the types of diseases that can be
prevented by use of dental floss should be given to the students as their response could be seen as
being unsure. Additionally, some of them (9.4%) did not know any of the diseases that can be
prevented by use of a dental floss.

Considering that medical students will be future doctors and have social responsibility to the
community's general health, it is then mandatory that they should have sufficient knowledge,
proper attitude and practice of the use of dental floss. There is need to provide more health
education to male subjects to improve their oral hygiene.

In general, from both schools were knowledgeable on what dental floss is with 100% being
dental students and 94% being medical students.

Students from both schools had varied opinions as to where to get mouthwashes, supermarkets
being the most preferred place by many students (59.9%). In addition, they also wanted to
positively influence other students to practice dental flossing.

It can be deduced from this study that though students displayed adequate knowledge in some
areas, there were areas that could be improved upon as discussed.

2S
RECOMMENDATIONS

1. Dentists should focus on educating the students on the use of dental floss when they go
for preventive programmes. This will increase students' awareness on how to effectively
use dental floss.
2. A research should be done to investigate why students do not use dental floss despite the
fact that they know about its availability in the supermarkets. The prices at which dental
floss is sold should be checked to ensure that they are fair.
3. Educational seminars should be organized for medical students to increase their
awareness on the role that dental floss plays in oral health.

26
REFERENCES

1. Van der Weijden GA, Hioe KP. A systematic review of the effectiveness of self
performed mechanical plaque removal in adults with gingivitis using a manual
toothbrush. J Clin Periodontol2005; 32: 214-228.
2. Christou V, Timmerman MF, Van der Velden U, Van der Weijden GA. Comparison of
different approaches of interdental oral hygiene: interdental brushes versus dental floss. J
Periodontol 1998; 69: 759-764.
3. Asadoorian J. Flossing. Canadian dental hygienists association position statement. CJDH
2006; 40: 1-10.
4. Sjogren K, Lundberg A, Birkhed D, Dudgedon DJ, Johnson MR. Interproximal plaque
mass and fluoride retention after brushing and flossing - a comparative study of powered
toothbrushing, manual toothbrushing and flossing. Oral Health Prev Dent 2004; 69: 759 -
764.
5. Cumming BR, Loe' H. Consistency of plaque distribution in individuals without special
home care instruction. J Periodontal Res 1973; 8: 94-100.
6. Hugoson A, Koch G. Oral health in 1000 individuals aged 3-70 years in the community
of Jonkoping, Sweden. A review. Swed Dent J 1979; 3: 69-87.
7. Galgut PN. The need for interdental cleaning. Dent Health (London) 1991; 30: 8-11.
8. Darby ML, Walsh MM. Dental Hygiene Theory and Practice. ED 2. Saunders, Elsevier
St. Louis, Missouri, USA, 1995.
9. Fischman SL. The history of oral hygiene products: how far have we come in 6000
years? Periodontology 2000; 15: 7-14.
10. Kenney, E. B., Saxe, S. R., Lenox, J. A., Cooper, T. M., Caudill, J. S., Collins, A. R. &
Kaplan, A. The relationship of manual dexterity and knowledge to performance of oral
hygiene. Journal of Periodontal Research 1976; 11, 67-73.
11. Wolffe, G. N. An evaluation of proximal surface cleansing agents. Journal of Clinical
Periodontology 1976; 3, 148-156.
12. Council on Dental Therapeutics. Accepted Dental Therapeutics, 40th edition. Section III.
Chicago, USA, American Dental Association, 1984.
13. Parmly LS. A practical guide to the management of the teeth; comprising a discovery of
the origin of caries, or decay of the teeth. Philadelphia: Collins & Croft, 1819.
14. Wilkins EM. Clinical Practice of the Dental Hygienist, 9th ed. Lippincott Williams &
Wilkins, Philadelphia, USA, 2004.
15. Bass, C. C. The Umuiii characteristics of dental floss for personal hygiene. Dental items
of Interest 1948; 70, 921-934.
16. O'Leary, T.I. Oral hygiene agents and procedures. Journal of periodontology 1970; 41,
625-629.
17. Badersten, A., Egelberg, J. & Koch, G. Effect of monthly prophylaxis on caries and
gingivitis in school children. Community Dentistry and Oral Epidemiology 1975; 3, 1-4

18. Wright GZ, Banting DW, Feasby WHo The Dorchester dental flossing study: final report.
Clin Prev Dent 1979; 1:23-26. [Medline ] [Order article via Infotrieve]

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19. Granath LE, Martinsson T, Matsson L, Nilsson G, Schroder U, Soderholm B.
Intraindividual effect of daily supervised flossing on caries in schoolchildren. Community
Dent Oral Epidemiol1979; 7: 147-150.[Medlinel [Order article via Infotrieve
20. Gisselsson H, Birkhed D, Bjorn AL. Effect of a 3-year professional flossing program
with chlorhexidine gel on approximal caries and cost of treatment in preschool children.
Caries Res 1994; 28:394-399.[Medlinel [Order article via Infotrieve
21. Waerhaug J. Healing of the dento-epithelial junction following the use of dental floss. J
Clin Periodontol1981; 8: 144-150.[Medlinel [Order article via Infotrieve
22. Lang WP, Ronis DL, Farghaly MM. Preventive behaviors as correlates of periodontal
health status. J Public Health Dent 1995; 55(1):10-17.
23. LauriTttjrtola" Heikki Murtomaa'andlinkeriRrvtomaa' Use of dental floss by Finnish
students -"'journal of Clinical Periodontology 1984; 11: 443-447
24. Eino Honkala, Matti Rajala and Matti Rimpela Oral hygiene habits among adolescents in
Finland Behavioral Dental Science 1-9
25. Macgregor ID, Regis D, Balding J: Self concept and dental health behaviours in
adolescents. J clin periodontal 1997; 24:335-339
26. Mumghamba EGS, KP Manji, J Michael: Oral hygiene practices, periodontal conditions,
dentition status and self reported bad mouth breath among young mothers, Tanzania
International Journal of Dental hygiene 2006; 4(4),166-173.
27. Tubaishat RS, MI Darby, DB Bauman, CE Box: use of miswaki versus tooth
brushes:Oral health beliefs and behaviors among a sample of Jordanian adults:
International Journal of Dental hygiene 2005; 3(3) 126-136.
28. Christensen LB, Peterson PE, Krustupu, K jeller M. Self reported oral hygiene practices
among adults in Denmark: Community Dent Health.2003 Dec;20( 4):229-35

28
APPENDIX I

KNOWLEDGE, ATTITUDE AND PRACTICE OF DENTAL FLOSSING AMONG

DENTAL AND MEDICAL STUDENTS OF THE UNIVERSITY OF NAIROBI.

QUESTIONNAIRE

This questionnaire is for a community dentistry project, please answer the following questions.

School. .

Sex (Male/Female) .

Age .

I.How often do you brush your teeth?

1. less than once per day

2. once per day

3. twice per day

4. More than twice per day.

2. What do you use for cleaning your teeth?

I. Brush + toothpaste

2. Dental floss

3. Mouthwash

4. All the above

5. Others (specify) .

3. What do you understand by the term dental floss?

1. A special type of thread used to clean in between the teeth.

2. A drug.

3. An oral hygiene aid used to whiten the teeth.

29
 4. Other
(specify) .

4. Do you know any dental disease that can be prevented by use of a dental floss?

Yes . No .

If yes, which one(s) .

5 (a) Has use of a dental floss ever been recommended to you?

yes No .

If yes, who recommended?

1. Dentist

2. Medical doctor

3. Friend

4. Parent

5. Other (specify) .

(b) Why was it recommended? Because of:

1. Bad breath

2. Dental disease

3. Cardiac disease

4. Other (specify) .

6. In your opinion, is use of a dental floss harmful to teeth and the gum? (Tick one option)

yes .

No .

Please explain your answer. .....

7. Do you practice dental flossing? .

30
yes . No .

Tfyes, answer the following questions

Tfno, go to question 11

8. Which type(s) of dental floss do you use?

1. Waxed type

2. Unwaxed type

3. Flavored type

4. Unflavored type

5. Other (specify) .

9. At what time(s) do you use the dental floss?

1. Before brushing

2. After brushing

3. After meals

4. Before going to bed

5. Other (specify) .

10. How often do you use the dental floss?

1. Daily

2. Weekly

3. More than three times a week

4. Other (specify) .

Proceed to question 12

11. Why don't you use a dental floss?

1. It is difficult to use

31
 2. I do not know how to use it

3. I lack time

4. It is not necessary

5. It is expensive

6. Other (specify) .

12. Where can you get a dental floss?

1. Supermarket

2. Dental clinic

3. Hospital

4. Pharmacy

5. I don't know

6. Others (specify) .

13. Given the instructions on how to use a dental floss, would you advise other students to
practice dental flossing?

yes .

No .

Please explain your answer .

THANK YOU FOR TAKING TIME TO FILL THIS QUESTIONNAIRE.

32
APPENDIX II

KNOWLEDGE, ATTITUDE AND PRACTICE OF DENTAL FLOSSING AMONG

DENTAL AND MEDICAL STUDENTS OF THE UNIVERSITY OF NAIROBI.

CONSENT FORM

I am an undergraduate student at the University of Nairobi, school of Dental Sciences. I wish to

request for your participation in a study that will form part of my degree course work. The study
involves filling out a questionnaire. Results will be recorded and analyzed for research purposes
only. No invasive procedure will be undertaken on you. Your participation in the study will be
highly appreciated.

Thank you.

JEMlMAH MALINDA

I do hereby freely consent to participate in the mentioned study.

Student has explained the procedure to be carried out. I

understand that no harm will be caused and I can withdraw at any time without any adverse
consequences to me. I am informed and understand that all information I give will be treated
with utmost confidence.

Signed

Participant.

33
 KENYATTA NATIONAL HOSPITAL
Hospital Rd. along, Ngong Rd.
P.O. Box 20723, Nairobi.
Tel:; 726300-9
Fax: 725272
Telegrams: MEDSUP", Nairobi.
Email: KNHplan@Ken.Healthnet.org
Ref: KNH-ERCI UA/213 July 15, 2010

Nyamai J. M.
V28/2040/2007
School of Dental Sciences
University of Nairobi

Dear Ms. Nyamai

Research proposal: Clearance "Knowledge, Attitude and Practice of Dental Flossing among
Dental and Medical Students at the University of Nairobi" (UP219/07/2010)

Your above proposal refers.

This is to inform you that permission has been granted by the KNH/UON-Ethics & Research
Committee to carry out research on "Knowledge, attitude and practice of dental flossing among
dental and medical students at the University of Nairobi".

By a copy of this letter, I am requesting the relevant persons to accord you the professional support
and other materials that may be useful to your research.

-·,)
Yours faithfully,

if
I; " .
",' f{'dL1/L.az-rL~
PR FAN GUANTAI
SECRETARY, KNH/UON·ERC

c.c. Prof. K. M. Bhatt, Chairperson, KNH/UON-ERC

The Deputy Director CS, KNH
The Dean, School of Dental Sciences, UON
The HOD, Records, KNH
Supervisors: Dr. Mutave R. J, Dept.of Period. Community and Preventive DentistrY,UON
Dr. Kisumbi B. K. Dept.of Conservative and Prosthetic Dentistry, UON