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Oral hygiene knowledge and practices among school children in a rural area of
southern Saudi Arabia.

Article · January 2012

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 RESEARCH
Oral hygiene knowledge and practices among school children in a
rural area of southern Saudi Arabia.
Rafi A. Togoo,1 Syed Mohammed Yaseen,2 Zakirulla M,3 Nasim VS,4 Mohammad Al Zamzami 5
ABSTRACT
Objective: The purpose of this study was to assess the oral health
knowledge and practices among 9-12 year old school children.
Materials and Methods: The study sample consisted of 917
school going boys in the age group of 9-12 years randomly
selected from 10 schools of Rijal Alma a rural area in Southern
Saudi Arabia. Data on oral health knowledge and practices was
collected by means of a self-administered questionnaire. Results:
The results of the study showed that more than half (58.4%) of
the children brushed their teeth using tooth brush and paste,
32.1% used miswak, 7.2% used toothpicks and 2.3% used dental
floss as a primary cleaning aid. About two-third (64.3%) children
brushed teeth once daily with 32.6% brushing teeth under parent
supervision. Most children (62.26%) said high sugar diet causes
dental decay while as more than half (58.45%) thought soft drinks
affect dental health. Around 57.14% were aware of gum diseases
and 51.14% opined that gum diseases can be prevented if oral
hygiene practices are followed. Nearly half (52.1%) of the children
would visit a dentist only when in pain though a majority (79.4%)
answered that regular dental checkup was essential. Fear
(67.28%) was cited as the main reason for not visiting the dentist.
Conclusion: Majority of students had adequate level of
knowledge on oral health, but followed low level of oral hygiene
practices. Comprehensive oral health educational programs are
needed to improve oral hygiene practices among children in rural
Saudi Arabia.
Key words: Oral health, Knowledge, Practices, Saudi Arabia.
Introduction
Oral diseases qualify as major public health
problems owing to their higher prevalence and
significant social impact [1]. Health is a universal need for
Patri, 2 Yoshaskam Agnihotri,3 S.Balagopal4 with isolated clusters of villages of varied
all cultural groups. General health cannot be attained or
maintained without oral health. The mouth is regarded
as the mirror of the body [2]. Oral health as an essential
aspect of general health can be defined as “a standard
of health of the oral and related tissues which enables
an individual to eat, speak, and socialize without active
disease, discomfort or embarrassment and which
contributes to general well-being”[3] . Especially among
IJCD • JANUARY,
children, oral diseases restrict activities in school, at
57
work and at home causing several school ©and 2012 Int. Journal of Contemporary
work
contributes to general well-being”[3] . Especially among
children, oral diseases restrict activities in school, at
work and at home causing several school and work
hours to be lost each year .Moreover, the psychosocial
impact of these diseases often diminishes quality of life
[4]
. Oral health knowledge is considered to be an
essential prerequisite for Health-related practices and
studies have shown that there is an association
between increased knowledge and better oral health [5].
Those who have assimilated the knowledge and feel a
sense of personal control over their oral health are
more likely to adopt self-care practices [6].
Little information is available regarding the oral health
of Children among rural Saudi population. In many
cases studies have been centered on urban areas
particularly Jeddah and Riyadh. Malik and Rehbini [7]
reported caries prevalence, pattern and severity of
dental caries among primary school children in Jeddah
and their results indicated that 96% were affected by
caries and stressed for an effective program me for
prevention of dental diseases among children. Another
study on the prevalence of periodontal diseases among
1174, 13 – 15 year old school children in Riyadh showed
that a high percentage (94%) needs periodontal
treatment [8]. It was suggested that an Oral Health
Program was needed for the whole community. Various
authors have estimated that the caries and periodontal
diseases would become a considerable problem in the
future, and recommended that country wide preventive
and educational programs should be instituted [9].
The subjects of this study were from Rijal Alma,
located in Asser province 100 kilometers from the
capital city Abha which covers a geographical area of
(2740) km2 constituting 3.3% of the Asser province land
area. The area was chosen due to its ideal rural setup
socioeconomic and educational status. The area also
has relatively less health facilities as compared to urban
areas of the province. Most of the studies regarding
oral hygiene awareness in Saudi Arabia was done in
urban populations therefore rural regions of Saudi
Arabia are worthy of investigation.
2012 • 3(1)
Materials and Methods:
Dentistry
 RESEARCH

Table 1: Oral hygiene practices among the study population (n = 917)

(n) Percentage (%)

Which one of the following do you use as a primary tooth cleaning aid?
Toothbrush and paste 536 58.4
Miswak 294 32.1
Dental floss 21 2.3
Toothpicks 66 7.2
How often do you brush your teeth?
Once daily 590 64.3
Twice daily 175 19.08
Rarely 152 16.6
Do your parents supervise you while brushing?
Yes 299 32.6
No 561 61.17
Not aware 57 6.21

Table: 2 Awareness of periodontal and gingival health among the study population (n=917)

(n) Percentage (%)

Bleeding from gums indicate which one of the following?
Gum disease due to Poor Oral hygiene 524 57.14
General illness 134 14.61
Don’t know 259 28.24

How can you keep your Gums healthy?

Brush your teeth everyday /use mouth wash/use dental floss 469 51.14
Don’t Know 448 48.85
Does Sugary diet cause dental decay?
Yes 571 62.26
No 291 31.73
Don’t know 55 5.99
Do soft drinks affect dental health?
Yes 536 58.45
No 345 37.62
Don’t know 36 3.92

Table 3: Attitudes towards Professional Dental care among the study population (n =917)

(n) Percentage (%)

How often do you visit the dentist?
Regularly/once in 6 months 233 25.40
When in pain 477 52.01
Never 207 22.57
Are regular visit to the dentist necessary?
Yes 728 79.4
No 57 6.2
Don’t know 132 14.4
Reason for your last dental visit?
Toothache 501 54.6
Parents advice 322 35.11
Dentists advice 37 4.03
Other reason 57 6.21
Reasons for not visiting dentist?
Fear 617 67.28
No clinic nearby 158 17.23
No specific reason 142 15.48

IJCD • JANUARY, 2012 • 3(1) 58

© 2012 Int. Journal of Contemporary Dentistry
 RESEARCH
Materials and Methods
The subjects for this study were recruited from
randomly selected ten public schools in Rijal Alma ‘a,
Asser province of Saudi Arabia. There are 60 primary
schools with an enrollment of 3722 students in different
locations. According to their geographic location,
schools under Rijal Alma ‘a region was divided into five
sections: Central, Eastern, Western, Northern and
Southern. Two schools were randomly selected from
each section to comprise a sample of ten schools. A
total of 946 students were invited to participate in this
study, and 917 students returned the completed
questionnaires with a response rate of 97 percent. The
study sample included only males. Subjects’ age ranged
from nine to twelve years old with a mean age of 10.5
years.
Approval of the directorate of education was
obtained, and a letter was sent to the selected schools
explaining the purpose of the study and the procedures
that would be followed during its conduct. The principal
of each school was asked to inform the students and
their parents about the study, and a day was set for
each school to collect the data. Classes that contained
children aged nine to twelve years were approached to
participate. These classes represent part of each school
as all the schools contain students aged from six to
sixteen years.
The study was approved by the ethical approval
committee at King Khalid University, Abha. Parents’
approval and the subject’s informed consent were
obtained before recruiting the children into this study.
All subjects were requested to complete a
comprehensive questionnaire in Arabic (local
Language). The questionnaire included items designed
to evaluate the knowledge and awareness of young
school children regarding oral health and oral health
practices. The subjects were asked to respond to each
item according to the response format provided at the
end of each question. One of the investigators was
always available during the completion of the
questionnaire, and the participants were encouraged to
approach him whenever they needed clarification at
any point.
The questionnaires were pretested with 50
selected school children who were requested to
complete the questionnaire on two different occasions
separated by seven days. The questionnaire was found
suitable for application among the study population as
there was high concurrence with the answers to the
items on both occasions (Kappa test coefficient for all
questions = 0.93).
Descriptive statistics were obtained and means,
standard deviation, and frequency distribution were
IJCD • JANUARY, 2012 • 3(1)
59 © 2012 Int. Journal of Contemporary Dentistry
calculated. The data were analyzed using the Statistical
Package for Social Science 11.0.
Results
Different age groups demonstrated no significant
differences in their responses, so the frequency tables
present the subjects as a whole.
58.4% of study sample brushed their teeth using tooth
brush and paste, while 32.1% of the sample used
Miswak (wooden toothbrush) as their teeth cleaning
aid. 2.3% of the study population used dental floss and
7.2% used tooth picks for cleaning their teeth.
Majority (64.3%) of the study population brushed their
teeth once daily, while 16.6% of the study population
practiced irregular tooth brushing.Only 32.6% of the
study populations were supervised by their parents.
62.26% felt that high sugar diet causes dental decay
where as 58.45% felt soft drinks affect dental health
and 51.14% of study population felt that they can keep
their gums healthy by brushing daily.
About 57.14% of the study populations were aware that
bleeding gum indicated gum disease, while 28.24%
were not aware what exactly caused bleeding gums.
Around 52.01% of the study population visited dentist
only when there was pain, while 22.57% never visited
the dentist. But 79.4% felt regular visit to dentist was
essential. However more that 67.28% responded fear
was their main reason for not visiting the dentist.
Discussion
This paper focuses on oral health knowledge
and practices among children in rural areas of Southern
Saudi Arabia. Regarding the method used for cleaning
teeth, tooth brushing was the most popular method
used for cleaning teeth by the study population,
followed by miswak. However, dental floss was the least
used method. This finding is in agreement with previous
studies by Ronis and Lang. [10, 11] However in other
studies [12,13], no differences were found in plaque scores
between miswak and tooth brush users and positive
association between the frequency of miswak and the
lower need for periodontal treatment was shown.
Because of the scientific merit of using miswak and the
emphasis of using miswak as a cultural and religious
belief among the Saudi population, the right method of
using miswak as a cleaning technique to achieve
maximum benefits can be suggested .[14] However the
benefits of using tooth brush and paste must be
stressed.
The study also demonstrated that only 64.3% of
the respondents cleaned their teeth once daily.
Thisfinding is similar to that reported by Al Tamimi and
Peterson in 1998 [15], but is far less when compared to

the findings reported in few developing countries, [16]
Which might be attributed in part to the establishment
of preventive dental public health programs in these
countries.
Furthermore, the results showed that only
32.6% of the children were supervised by their parents
while brushing; this is in contradiction with previous
study on Saudi parents attitude towards their children
dental health, which reported that tooth brushing was
considered as an important mode for reducing dental
caries indicating that they had an acceptable level of
awareness on dental health. [17] Therefore it may be
considered that parents in urban region have more
dental awareness than the parents in rural region.
The study sample showed awareness of gingival
bleeding as an indicator of periodontal disease, a
finding that agreed with the results of previous studies.
[18]
However concerning knowledge, most of the
subjects knew that the use of toothbrush helps in
preventing periodontal diseases, however, more than
two-third of school students were unaware that dental
floss helps prevent periodontal disease. This result
indicates that improvement in knowledge toward the
use of dental floss is needed. Interventions to increase
the knowledge and subsequent use of flossing are
essential and are in agreement with other studies. [19]
However, high awareness of dental caries
including its cause and prevention in comparison to
periodontal health could be attributed to the fact that
dental caries is more prevalent in children than
periodontal disease. This will eventually improve the
children’s knowledge regarding dental caries as they
attend dental clinics seeking treatment for it, thus, they
may receive more professional advice in this regard.
Most of the study subjects reported irregular
dental attendance, and this finding is consistent with
the findings of other studies.[20] A surprising finding in
this regard was that most participants were aware of
the importance of regular dental attendance. Some
findings in this study might offer an explanation for the
irregular dental attendance among the participants. A
high proportion of the subjects reported that they did
not attend due to fear from dental treatment and high
costs of dental care in private clinics. Lack of parental
encouragement and advice to visit the dentist might
also contribute to the irregular dental attendance. Lack
of parents’ regular dental attendance might be
reflected in their children. Dental attitudes displayed by
parents might also offer an explanation for the lack of
regular dental attendance.
Fear of dental treatment was found to be high
among the study population; this coincided with
previous study on school children of Arab region.[21] This
might be attributed to the lack of proper oral health
IJCD • JANUARY, 2012 • 3(1)
© 2012 Int. Journal of Contemporary Dentistry
RESEARCH
education programs for both children and parents,
which in addition to the above mentioned reasons
rendered dental treatment undesired. Pain was the
main reason for visiting the dentist which is similar to
that reported other studies. [22] Reasons for this drastic
behavior might be lack of knowledge regarding the
importance of visiting the dentist regularly
POTENTIAL LIMITATIONS:
The limitation of this research is being
evaluated on the basis of self-reported data.
Measurement error due to misinterpretation of
questions and memory errors are subject to occur.
This project was dependent on self-reported
data derived from 9-12 years old school children with
varying levels of familiarity with completion of
questionnaires and varying levels of language ability,
which may have influenced the selection of responses.
This might limit the study due to misinterpretation and
misunderstanding of questionnaire items by the
subjects. However, the questionnaire was pretested
before the study was conducted with positive results,
and the items were written at a language level that
should have allowed comprehension by even the
youngest subjects (age nine years).
Conclusion
Majority of students had adequate level of
knowledge on oral health, but low level of oral health
practices. The results of this study might help us to
evaluate the efficacy of public education programs in
future. The results of this study also suggest, parents of
rural region have less awareness on their child’s dental
health. Hence parents’ education must be included in
any program that promotes preventive oral care in
schools as well as in other oral health educational
programs aimed at general public.
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61 © 2012 Int. Journal of Contemporary Dentistry
 RESEARCH

About the Authors

1. Dr. Rafi A. Togoo, MDS

Associate Professor,
Department of Pedodontics.
College Of Dentistry, King Khalid
University, Abha, Saudi Arabia

2. Dr. Syed Mohammed Yaseen. MDS

Assistant Professor,
Department of Pedodontics.
College Of Dentistry, King Khalid
University, Abha, Saudi Arabia

3. Dr. Zakirulla M , MDS

Assistant Professor,
Department of Pedodontics.
College Of Dentistry, King Khalid
University, Abha, Saudi Arabia

4. Dr. Nasim VS MDS

Assistant Professor,
Department of Pedodontics.
College Of Dentistry, King Khalid
University, Abha, Saudi Arabia

5. Dr. Mohammad Al Zamzami ,BDS

Intern, College of Dentistry
College Of Dentistry, King Khalid
University, Abha, Saudi Arabia

Correspondence Address

Dr. Rafi A. Togoo

Department of Preventive Dental Sciences,
Division of Pedodontics,
King Khalid University College of Dentistry,
Abha, Kingdom of Saudi Arabia.
Phone numbers: +966-7-2418046
E-mail address : ratogo@kku.edu.sa

IJCD • JANUARY, 2012 • 3(1) 62

© 2012 Int. Journal of Contemporary Dentistry
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