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Effect of motivation on oral hygiene and caries status among young adults in
Hyderabad City

Article  in  Indian journal of dental research: official publication of Indian Society for Dental Research · January 2019
DOI: 10.4103/ijdr.IJDR-220-17

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Original Research

Effect of Motivation on Oral Hygiene and Caries Status among Young

Adults in Hyderabad City

Abstract Patanapu Shiva

Background: Motivation is a theoretical construct used to explain behavior, it gives the reasons Kumar, Dolar Doshi,
for people’s action, desires, and needs, and it drives an individual to a certain action and Suhas Kulkarni,
determines human behavior. Aim: To determine the effect of motivation on oral hygiene and
caries status among young adults in Hyderabad city. Settings and Design: A  cross‑sectional Padma Reddy,
study was carried out among 18–20‑year‑old engineering college students of Nagole Institute of Srikanth Reddy,
Technology and Sciences. Materials and Methods: Intrinsic motivation was evaluated using a Adepu Srilatha
self‑reported 12‑item dental intrinsic motivation scale  (DIM‑S). The oral examination included Department of Public Health
simplified oral hygiene index  (OHI‑S) and decayed, missing, filled teeth index  (DMFT index). Dentistry, Panineeya Institute of
Statistical Analysis Used: Mann–Whitney U‑test and ANOVA test were used for comparison among Dental Sciences and Research
the variables included in the study. Spearman’s correlation was used to correlate DIM‑S with oral Centre, Hyderabad, Telangana,
parameters. Results: A  total of 393 students participated in the study with majority of them being India
male (61.8%). It was observed that 69% of the students were extrinsically motivated and only 31% of
them were intrinsically motivated. However, intrinsically motivated females had a higher significant
score for calculus index–simplified and OHI‑S scores. All oral parameters showed a negative
correlation, except decayed component and the overall DMFT. However, no statistical significance
was noticed among the variables. Conclusion: The present study revealed that to motivate people
successfully, one not only has to give them information but also has to pay attention to the individual
reasons which restrict their behavior.

Keywords: Behavior, caries status, motivation, oral hygiene

Introduction purpose of preventing or detecting disease

Behavioral dentistry is an interdisciplinary
science which needs to be learned,
practiced, and reinforced in the context
of clinical care and within the community
oral health‑care delivery systems. It helps
understand inter‑  and intra‑personal social
forces that influence the patient’s health
behavior and activities undertaken to avoid
disease.[1] This behavior is primarily due to
physical and mental factors interacting in
complicated ways, and it can be analyzed
by various cognitive theories.[2‑5] The
social learning theory emphasizes that the
interaction between a person and his/her
environment and psychosocial variables has
been found reliably related to dental health
behavior. It also measures the extent to
which individual believes that their health
is influenced by their own behavior or by
external cause.[6]
Conner and Norman defined health
behavior as “any activity undertaken for the
This is an open access journal, and articles are distributed under
the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 4.0 License, which allows others to remix, tweak, and
build upon the work non-commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
or for improving health and well‑being.”[7]
These behaviors were affected by factors
such as motivation, beliefs, intentions, and
attitudes. Motivation is regarded as one of
the most important determinants of health
behavior and has been included in many
health behavior theories.[8‑10]
Etymologically rooted in Latin word
motive  (to move), motivation is one of Address for correspondence:
the most powerful elements in mobilizing Dr. Patanapu Shiva Kumar,
Department of Public Health
individuals to action. Health education, in Dentistry, Panineeya Institute of
particular, relies on motivation to foster Dental Sciences and Research
healthy behavior. Indeed, behavioral change Centre, Road No 5,
Kamala Nagar, Dilsukhnagar,
programs that target motivation as a mediating
Hyderabad ‑ 500 060,
factor are not only successful in accomplishing Telangana, India. 
behavior goals but also remain consistent with E‑mail: shivakumarkittu@
the principle of individual autonomy.[11] gmail.com
Motivation is a theoretical construct used to
explain behavior, and it gives the reasons Access this article online
for people’s action, desires, and needs. The Website: www.ijdr.in
motivation to fulfill basic psychological
DOI: 10.4103/ijdr.IJDR_220_17
needs is held to lie at some point between Quick Response Code:
perceived intrinsic and extrinsic motivation.
How to cite this article: Kumar PS, Doshi D,
Kulkarni S, Reddy P, Reddy S, Srilatha A. Effect of
motivation on oral hygiene and caries status among
young adults in Hyderabad City. Indian J Dent Res
2019;30:15-20.

© 2019 Indian Journal of Dental Research | Published by Wolters Kluwer - Medknow 15

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Kumar, et al.: Motivation among young adults
Behaviors that are engaged in spontaneously and for
their inherent interest and enjoyment are characterized as
intrinsically motivated, whereas those that are engaged to
please others are categorized as extrinsically motivated.
In addition, intrinsic motivation has been shown to
mediate the relationship between perceived control and
pro‑environment behaviors and contribute to increased
self‑regulatory efforts across behaviors.[12]
Motivation plays a major role in influencing dental health
behavior. Different theories and models such as push–
pull model and self‑determination theory have explained
the various intrinsic and extrinsic influences affecting
the patient’s motivation to dental care.[13] Furthermore,
Deci proposed that individuals with extrinsic motivation
do not have independence in dental care but prefer
“tooth extraction and emergency treatment” and brush
their teeth “because of other people” and have “a diet
with carbohydrates.” On the other hand, individuals with
intrinsic dental motivation have characteristics of their own
responsibility and “interest in taking care of their teeth to
preserve them for as long as possible,” care and satisfaction
“as criteria for brushing” them, and evaluation of the proper
diet necessary for the sake of one’s teeth.[14]  The study by
Pac et al.[15] found that patients with greater motivation had
better oral hygiene.
There has been very little exploration regarding the role of
motivation for adherence to dental care on the oral health
status.[16‑21] Hence, against this background, the effect of
motivation on oral hygiene and caries status among young
adults in Hyderabad city was studied.
Materials and Methods
Approval for the cross‑sectional study was obtained
from the Institutional Review Board of Panineeya
Institute of Dental Sciences and Research Centre. On
agreement and explanation of the study procedures,
students willing to participate signed the consent
form. Anonymity and confidentiality of respondents
were maintained and participation was voluntary.
Permission from the college was obtained before the
oral examination.
A convenience sample of 18–20‑year‑old engineering
students of Nagole Institute of Technology and Science who
were present on the day of examination was included. Four
hundred and fifty students were approached, of which 393
students returned the questionnaire (response rate – 87.3%).
Students who received antibiotic treatment within last
1  month, students with systemic medical conditions  (renal
disease, immunosuppression), students with active
infections  (dental abscess, respiratory infection), and those
not willing to participate were excluded from the study.
Demographic details such as age, gender, education,
and past dental visit of the students were recorded.
A  self‑reported 12‑item dental intrinsic motivation
16 Indian Journal of Dental Research | Volume 30 | Issue 1 | January-February 2019
scale  (DIM‑S) was developed by Syrjälä et al.[6] was
administered to the study students. The students were
instructed to express their opinion on a dichotomous scale
of score 1  (agree) and score 2  (disagree). The total score
ranged from 12 to 24, in which higher scores indicated
that students were intrinsically motivated. A  score of 18
was regarded as cutoff with score  <18 being grouped as
extrinsically motivated.
Clinical oral examination assessed the oral hygiene status
using simplified oral hygiene index  (OHI‑S) by Greene
and Vermillion[22] and caries status using decayed, missing,
filled teeth index (DMFT index) by Klein et al.[23]
Statistical analysis
The collected data were analyzed using the Statistical
Package Social Sciences  (SPSS) package version  21.0
(IBM SPSS Statistics for Windows, Versions 21.0.,
Armonk, NY, USA).  Mann–Whitney U‑test was used for
comparison of the DIM‑S scores with gender. Comparison
of mean scores of oral parameters  (simplified debris
index  [DI‑S], calculus index–simplified  [CI‑S], OHI‑S,
decayed teeth  [DT], missed teeth, filled teeth, and DMFT)
with DIM‑S scores based on gender was done using
ANOVA test. Spearman’s correlation was used to correlate
DIM‑S with oral parameters. Statistical significance was set
at P ≤ 0.05.
Results
The study comprised of 243 (61.8%) males and 150
(38.2%) females, with a majority of them possessing
B. Tech degree (75.1%) and a mean age of 18.67
±  0.08  years. Based on dental visits, more than half of
the study population  (70%) never visited a dentist, and
among those who visited, only 16% of the students
visited in the last 1 year [Table 1].
Based on responses to DIM‑S, majority of the students
agreed to most of the items. However, significant gender
Table 1: Demographic distribution of study population
Variables Number of respondents, n (%)
Gender
Male 243 (61.8)
Female 150 (38.2)
Education
B. Tech 295 (75.1)
Diploma 98 (24.9)
Dental visits
Yes 118 (30)
No 275 (70)
If yes, when
Within a year 63 (16)
Between 1 and 2 years 36 (9.2)
Over 2 years ago 19 (4.8)
Total 393 (100)
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Kumar, et al.: Motivation among young adults

difference was noted only for Q1  (It is not important
to retain one’s own teeth, because extracted teeth can
be replaced by prosthesis, P =  0.02), Q7  (I brush my
teeth more carefully than usual when I am going to the
dentist, P <  0.001), Q10  (It gives me pleasure to brush
my teeth carefully, P =  0.02), and Q11  (I watch my teeth
spontaneously and contact the dentist when necessary,
P  <  0.001) with females agreed more than males for all
items, except for Q10 [Table 2].
Among the study students, the total mean DIM‑S
scores were comparable among males  (16.51  ±  2.05)
and females (16.19 ± 2.08) (P = 0.29). When item‑wise
comparison of mean scores was done based on gender,
a significant difference was observed for Q 1  (It is not
important to retain one’s own teeth, because extracted
teeth can be replaced by prosthesis, P =  0.02),
(I brush my teeth more carefully than usual when I
am going to the dentist, P <  0.001), Q 10  (It gives me
pleasure to brush my teeth carefully, P =  0.02), and
Q 11  (I watch my teeth spontaneously and contact the
dentist when necessary, P <  0.001) with males showing
a higher mean score for the above items, except for the
item Q 10  [Table  3].
It was observed that a high percentage of students were
extrinsically motivated  (69%) and only 31% of them were
intrinsically motivated. Furthermore, similar trend was
found based on gender and no significant difference was
noticed (P = 0.06) [Table 4].
Based on oral hygiene, it was noted that total CI‑S
and total OHI‑S were significantly influenced by type
of motivation. Intrinsically motivated individuals had
significant high overall mean OHI‑S score  (1.86  ±  0.79,
P  =  0.02) and CI‑S score  (1.11  ±  0.66, P =  0.002).
Furthermore, intrinsically motivated females had a higher
significant score for CI‑S score  (1.39  ±  0.76, P =  0.008)
and OHI‑S score  (2.12  ±  0.93, P =  0.05) compared to
those extrinsically motivated. However, no such significant
difference was seen among males. On the other hand, type
of motivation and gender did not impact DI‑S scores.
Likewise, the DMFT scores and individual component of
DMFT were not affected by type of motivation based on
gender with comparable scores in both categories [Table 5].
When correlation between oral parameters and DIM‑S
was carried out, only DT component and overall DMFT
scores revealed a positive correlation, whereas all other
oral parameters had negative correlation. However,
no statistical significance was noticed among the
variables [Table 6].
Discussion
Dental diseases are highly preventable and largely
dependent on the healthy oral behaviors. Among common

Table 2: Item‑wise comparison of the dental intrinsic motivation scale based on gender
Items Response Gender P Total, n (%)
Male, n (%) Female, n (%)
Q1 Disagree 102 (42) 40 (26.7) 0.002* 142 (36.1)
Agree 141 (58) 110 (73.3) 251 (63.9)
Q2 Disagree 62 (25.5) 34 (22.7) 0.52 96 (24.4)
Agree 181 (74.5) 116 (77.3) 297 (75.6)
Q3 Disagree 111 (45.7) 80 (53.3) 0.14 191 (48.6)
Agree 132 (54.3) 70 (46.7) 202 (51.4)
Q4 Disagree 158 (65.0) 83 (55.3) 0.06 241 (61.3)
Agree 85 (35.0) 67 (44.7) 152 (38.7)
Q5 Disagree 115 (47.3) 84 (56) 0.09 199 (50.6)
Agree 128 (52.7) 66 (44) 194 (49.4)
Q6 Disagree 66 (27.2) 36 (24) 0.49 102 (26)
Agree 177 (72.8) 114 (76) 291 (74)
Q7 Disagree 112 (46.1) 41 (27.3) <0.001* 153 (38.9)
Agree 131 (53.9) 109 (72.7) 240 (61.1)
Q8 Disagree 127 (52.3) 85 (56.7) 0.40 212 (53.9)
Agree 116 (47.7) 65 (43.3) 181 (46.1)
Q9 Disagree 132 (54.3) 85 (56.7) 0.65 217 (55.2)
Agree 111 (45.7) 65 (43.3) 176 (44.8)
Q10 Disagree 26 (10.7) 29 (19.3) 0.02* 55 (14)
Agree 217 (89.3) 121 (80.7) 338 (86)
Q11 Disagree 63 (25.9) 17 (11.3) <0.001* 80 (20.4)
Agree 180 (74.1) 133 (88.7) 313 (79.6)
Q12 Disagree 23 (9.5) 15 (10) 0.86 38 (9.7)
Agree 220 (90.5) 135 (90) 355 (90.3)
*P≤0.05 statistically significant

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Kumar, et al.: Motivation among young adults

Table 3: Comparison of mean scores for each item and the total mean score for the items based on gender
Items Gender P
Males Females Total
Q1 1.42±0.50 1.27±0.44 1.36±0.48 0.002*
Q2 1.26±0.44 1.23±0.42 1.24±0.43 0.52
Q3 1.45±0.50 1.53±0.50 1.48±0.50 0.13
Q4 1.65±0.48 1.55±0.50 1.61±0.48 0.06
Q5 1.47±0.50 1.56±0.50 1.51±0.50 0.09
Q6 1.27±0.45 1.24±0.43 1.26±0.43 0.49
Q7 1.46±0.50 1.27±0.45 1.39±0.48 <0.001*
Q8 1.52±0.50 1.57±0.50 1.54±0.49 0.39
Q9 1.54±0.50 1.57±0.50 1.55±0.49 0.65
Q10 1.11±0.31 1.19±0.40 1.14±0.34 0.02*
Q11 1.26±0.44 1.11±0.32 1.20±0.40 <0.001*
Q12 1.09±0.29 1.1±0.30 1.10±0.29 0.86
Total 16.51±2.05 16.19±2.08 16.3±92.06 0.29
*P≤0.05 statistically significant

Table 4: Distribution of study subjects base on type of
motivation (intrinsically or extrinsically)
Type of motivation Gender Total
Male Female
Extrinsic+ 176 (72.4%) 95 (63.3%) 271 (69.0%)
Intrinsic# 67 (27.6%) 55 (36.7%) 122 (31.0%)
Total 243 150 393
P 0.06
+
Extrinsic motivation <18, #Intrinsic motivation >18
oral diseases, dental caries is one of the most common oral
pathologies, which remains widely prevalent and affects
all population throughout the life. Dental health‑care
professionals recommend regular oral self‑care behaviors for
plaque removal as bacterial plaque plays an important role in
the etiology of caries, gingivitis, and periodontal diseases.[18]
At present, obtaining the patient’s interest, motivation, and
cooperation to practice and maintain good oral hygiene is
one of the most difficult problems because of scheduled
lifestyles, deleterious habits, and hectic workload. An
effective dual‑approach involving periodic professional
teeth cleaning and performing daily dental home care
not only requires effective oral hygiene instructions by
professionals but also patients to be motivated to carry out
these important behaviors.[16] Gao et al.[24] studied the effect
of motivation in improving oral health through a systematic
review and found that oral health outcomes were positively
affected by motivation. A  growing body of evidence[25,26]
showed that the intrinsic motivation is more likely to
predict behavior change than extrinsic motivation. Hence,
to objectively measure motivation, Syrjälä et al. developed
DIM‑S to determine whether or not individuals will take
responsibility for their own health.
In the present study, the population chosen was
engineering students aged 18–20  years. This age is a
crucial period as personal responsibility for preventing
dental disease begins at this age and determines future oral
health. However, with a higher education background, the
concept of prevention and well‑being could be more easily
understood by the students, along with proper utilization
of the dental‑care services.[18] Hence, the assessment of
oral health awareness and dentition status of young adults
becomes more essential.
The only available instrument which measures the
intrinsic motivation in dental care is DIM‑S developed by
Syrjälä et  al.[6] This questionnaire measures the intrinsic
motivation in dental care in a homogeneous manner with
good internal consistency and standardized item alpha
being 0.69.
The present study comprised 393 students, of which
243  (61.8%) males and 150  (38.2%) females aged
18–20 years. Similarly, a study conducted by Anuradha and
Sinha[18] among engineering students on dentition status
and treatment needs in Lucknow, Uttar Pradesh, noted that
71.1% were male and 28.9% were female aged 19–25 years.
In the current study, majority of the students  (70%) never
visited a dentist, and among those, only 16% of the students
visited within the last 1 year. In contrast, a study by Fotedar
et al.[27] et  al. among Shimla population reported that
52.3% visited dentist  >2  years ago and 46% visited dentist
regularly. Likewise, Schuurs et  al.[28] found that regular
attendance gives a higher priority to retention of their teeth
than do irregular attenders. This reflects a need to increase
awareness through oral health education programs and
reinforcement of more positive attitude toward oral health.
The existing study revealed that both males and females
had a comparable mean score with respect to the most
of the items of DIM‑S. However, a significantly high
percentage of females agreed that it is not important to
retain one’s own teeth (Q1), brush their teeth more carefully
when going to dentist than usual (Q7), and I watch my teeth
spontaneously and contact dentist when necessary (Q11) and

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Kumar, et al.: Motivation among young adults

Table 5: Comparison of the total mean score of Oral Parameters with subjects intrinsically and extrinsically motivated
Oral parameters Type of motivation Male P Female P Total P
DI‑S Extrinsic+ 0.76±0.35 0.48 0.77±0.31 0.65 0.76±0.33 0.77
Intrinsic# 0.77±0.28 0.73±0.23 0.75±0.26
CI‑S Extrinsic+ 0.80±0.55 0.09 1.04±0.64 0.008* 0.88±0.59 0.002*
Intrinsic# 0.88±0.46 1.39±0.76 1.11±0.66
OHI‑S Extrinsic+ 1.56±0.76 0.15 1.82±0.81 0.05* 1.65±0.78 0.02*
Intrinsic# 1.65±0.60 2.12±0.93 1.86±0.79
DT Extrinsic+ 1.15±1.63 0.69 1.45±1.76 0.43 1.25±1.68 0.89
Intrinsic# 1.18±1.42 1.29±1.65 1.23±1.53
MT Extrinsic+ 0.05±0.27 0.06 0.12±0.35 0.61 0.07±0.30 0.29
Intrinsic# 0.12±0.37 0.25±0.95 0.18±0.69
FT Extrinsic+ 0.01±0.08 0.48 0.01±0.10 0.45 0.01±0.09 0.93
Intrinsic# 0.01±0.12 0.00±0.00 0.01±0.09
DMFT Extrinsic+ 1.20±1.63 0.71 1.58±1.87 0.47 1.34±1.72 0.92
Intrinsic# 1.31±1.60 1.55±2.00 1.42±1.79
*P≤0.05 statistically significant, +Extrinsic motivation <18, #Intrinsic motivation >18. OHI‑S=Simplified Oral Hygiene Index,
CI‑S=Simplified Calculus Index, DI‑S=Simplified Debris Index, DT=Decayed teeth, MT=Missing teeth, FT=Filled teeth, DMFT=Decayed,
missing, filled teeth

Table 6: Correlation between oral parameters and dental In the present study, CI‑S and OHI‑S were significantly
intrinsic motivation scale influenced by type of motivation. However, intrinsically
Oral parameters Correlation coefficient P motivated females had a higher significant score for CI‑S and
DI‑S −0.05 0.36 OHI‑S, indicating that most of the extrinsically motivated
CI‑S −0.08 0.13 persons seemed to propose superficial reasons and relate to
OHI‑S −0.07 0.16 nonappreciation of dental care more often than intrinsically
DT 0.07 0.18 motivated.
MT −0.03 0.51 A strong negative correlation was noticed between DIM‑S,
FT −0.07 0.19 oral hygiene status, and caries status, except for DT
DMFT 0.07 0.20 and DMFT components. It was assumed that people are
OHI‑S=Simplified Oral Hygiene Index, CI‑S=Simplified Calculus influenced by powerful others externality which may increase
Index, DI‑S=Simplified Debris Index, DT=Decayed teeth, the dependence on health professionals for their health
MT=Missing teeth, FT=Filled teeth, DMFT=Decayed, missing,
maintenance and it may be reflected as poorer oral hygiene
filled teeth
behavior. However, a study done by Syrjälä et al.[6] showed
that positive feedback should be used more often in a
disagreed that brushing their teeth carefully gives them
dental context to increase intrinsic motivation. Hence, it
pleasure  (Q10). This could be because individuals are more is necessary to motivate through appropriate oral health
likely to perform behaviors they perceived as controllable education programs, and it further helps to adapt and endure
and might be particularly powerful when individuals had health‑promoting lifestyles and practices among the young
a strong intrinsic motivation to perform the behavior. adults.
Furthermore, Syrjälä et al.[14] among Oulu population
reported that extrinsic motivation was greater among those The present study acknowledges certain limitations such as
who mentioned the purposelessness of brushing their the cross‑sectional nature of the study which was confined
teeth, lack of time, lack of interest, laziness, and failure to to engineering students of single institute; hence, the results
appreciate the seriousness of dental care. should be generalized with caution. The effects of age,
gender, and education in the etiology and motivation in
In this study, it was observed that most of the students dental care could not be clearly established. Finally, there
were extrinsically motivated  (69%) and students motivated was a lack of correlation between DIM‑S and caries status.
intrinsically were only 31%. On the contrary, among Oulu
population,[6] many of the students were intrinsically oriented. Conclusion
However, in the present study, higher percentages of males The present study states that to motivate people
were extrinsically motivated when compared to females. This successfully, one not only has to give them information but
could be due to the fact that males were less self‑determining also has to pay attention to the individual reasons which
and competent about health behavior. Hence, the perception restrict their behavior. Based on the present study, it can be
of independence and their far‑reaching ideas on preserving concluded that both intrinsic and extrinsic motivation plays
their teeth form a good basis for further dental instruction. an important role in determining oral health.

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Kumar, et al.: Motivation among young adults
Acknowledgment
We would like to thank the administration of Nagole
Institute of Technology and Science for giving permission
to carry out the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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