Oral Hygiene Practices and Knowledge about Dental Caries among 15 years Old School Students in Lahore Population a cross sectional survey

Background: Dental Caries is one of the most prevalent chronic diseases in childhood in developed and underdeveloped countries. As oral hygiene, dietary habits, behavioral factors, sociodemographic factors, awareness of the disease and its prevention are concerned, all are important to be known by an individual of a community or society. Fifteen years age group adolescents have erupted all permanent teeth in the oral cavity and this age group children are developing their habits, so these habits will persist through out their life. It was important to know their oral hygiene habits and the concept about the dental caries. It is beneficial to identify children at increased risk and associated predictive factors of caries and tooth brushing in childhood and adolescence in our population. This study was designed to determine the prevalence of dental caries (DMFT), oral hygiene practices and knowledge about tooth decay in 15 years age school going children.


Introduction
Dental caries is an important public health problem across the world [1]. It affects school children 60-90% reported by the World Health Organization (WHO) [2]. Burden of dental caries is declined in developed countries due to public health interventions such as water fluoridation, healthier lifestyles, and improved oral hygiene practices, however its burden is still high in developing countries and in Asia [1]. Oral Health Education intervention is effective in enhancing knowledge, attitude, and practices toward positive oral health [3] .Consequences of dental caries can be major public health issue such as tooth loss and impaired quality of life. This burden is due to structure of society, living conditions, lifestyles, and the existence of preventive oral health systems [4]. Different strata of population have different caries prevalence and prevalence of dental caries is more observed in the underprivileged population groups, such as people with low literacy rate, poor living conditions, and poor oral hygiene practices and with poor health seeking behavior [1,5] Reduction in prevalence of dental caries is observed by introducing effective brushing in school children [6].
Good oral hygiene is an important primary preventive procedure that can prevent dental caries. Children, who brush their teeth less than once a day, and do not use fluoride toothpastes, have a higher risk of dental caries [7] A suitable oral health behavior during childhood perpetuates more effectively into adulthood.
School going children have little knowledge about oral health in developing countries [8]. Plaque removal is an important element of oral health in order to prevent dental caries, [9] by toothbrushes, rinses, floss, and dentifrices containing fluoride [10,11]. Oral health status depends on a dynamic interplay of several factors, including the individual's personal attribute, behavior, and perception. It is of relevant concern for oral health professionals to impart a positive oral health knowledge and behavior in the society in order to promote health and reduce burden of disease [12]. Modifiable risk behaviors such as oral hygiene practices, dietary habits, and basic knowledge about the disease are considered important. An appropriate range of policies, strategies and approaches to disease prevention and health promotion can be generated only if a range of risks is known [13]. The aim of this study was to measure prevalence of dental caries in fifteen years old school students and to assess their oral hygiene practices. Furthermore, their knowledge regarding dental caries was also assessed.

Material and Methods
A cross sectional survey was conducted in summer camp of schools in Lahore in July 2015 after the approval of institutional review board. Lahore is the provincial capital of Punjab Province. Study participants were school children, aged 15 year of 9th and 10th classes. Written and verbal consent was taken from the students. Those who gave their consent were taken into the study. Study participants were examined by two dentists using for dental caries using DMFT index. Dental Caries were recorded as present when a carious cavity was apparent on visual inspection under examination light, mouth mirror and dental probe. If doubt existed in arrested caries and active lesion, the surface was investigated with a probe. Unless the point entered the cavitated lesion, the surface was recorded as sound. The catching of the probe in a pit and fissure was not enough to warrant the diagnosis of caries unless there was additional visual evidence. Average DMFT was calculated.
Demographic characteristics were recorded such as identification number, age, gender, parents' education level, financial status or income of family, house ownership and availability of flowing water were asked from the respondent.
Parents' education was asked as Low (less than 10 years of education), Medium (11-12 years of education) and High (more which were doing that thrice a day. 80% subjects said that they knew that what is tooth decay and 96.7% replied that they had idea about its few common causes. For Teeth decay management people prefer to go to private hospital as recorded in this study, because 2/3rd of sample used to go to private hospitals. Almost every subject (92%) answered that they knew what the negative impact this this caries created negative impact on their life and its quality. Chi square test of association has shown that higher the level of education, lower will be the chances of decay and vice versa. Similarly, mother education has shown same impact on the caries status. This relationship was also significant at prescribed level of significance. Lower financial status was linked with higher incidence of caries. Total 16 students out of 25 having caries belong to lower financial status. Three significant variables i.e., brushing after every meal, usage of Miswak and brush after dinner were playing significant protective role from teeth decay. Final logistic model will be Z= 10.503-2.602 (Brush after every meal)-2.391 (usage of Miswak)-2.320 (Brush after Dinner).
Conclusion: Findings of this study have shown that brushing twice a day and after every meal, brushing after dinner and before sleeping, using Miswak and having awareness about teeth protection or brushing were the significant data or practices for avoiding teeth decay. This study has explored that father's and mother's education level has strong positive impact on caries. Similarly, higher the financial position, lower are the incidence of dental caries. than 12 years of education). Family income was also asked in Pakistani currency as less than Rs. 15000, between Rs.15001-50000 and more Rs. > 50001. Finally, availability of water was also asked.
All of these demographics' variables were noted on individual data Performa. Oral hygiene habits mean practices of an individual for oral cleanliness. These practices include tooth brushing with paste, Miswak, powder (Manjan), dental floss, tongue musculature, rinses with water and combination of any two methods. About these practices two options were given to respondents as yes or no. Each practice was asked one by one from the respondents. Timings of teeth cleanings were also asked from the respondents in seven categories like teeth cleaning before breakfast, after breakfast, before lunch, after lunch, before dinner or after dinner and before nimaz. Last component was frequency of teeth cleanings like once a day, twice a day, three times or more and none.
All tools of oral hygiene practices like tooth brushing with paste, Miswak, powder and Manjan, dental floss, tongue musculature was asked in four options such as once a day, twice a day, three time or more and none. Similarly, thirty-four different questions were asked from respondent about the oral hygiene practices who gave answer as yes or no. Final part of the questionnaire was knowledge about the dental caries. Fifteen questions about this theme were asked from the respondents. These answers were recorded on individual data Proforma as yes or no. Students who do not give consent and were above or below the age of 15 year excluded from the study. Missing teeth due to trauma or non-carious reasons, and those who have anomaly or any chronic disease having medications were excluded from the study. Data was entered and analyzed using SPSS version 20. Descriptive part of the study was analyzed in the Percentage and frequency. Cross tabulation was done between the variables (socioeconomic, oral hygiene and knowledge about the disease) and presence of dental caries. The impact of demographic variables on status of carries was noted. For this purpose, parents education was an important variable. Chi square test of association was performed to see the relationship between parent's education and caries status. This regression was performed by using backward elimination method at five steps. Logistic Regression for the prediction of caries status on basis of oral hygiene habits was used. P-value ≤0.05 will be taken as significant.

Results
In Logistic regression dependent variable is caries status    Caries free respondents were 58.3% while 41.7 % had caries. 61 totals decayed teeth, 04 missing and 07 teeth were found in this study. The average DMFT in this study was 1.12 the detail is given below.     Note: Classification Table   Table 6e.
Step by Abdullah [20]; the mean DMFT was 0.14 by Adekoya-Sofowora et al. [21]; The mean DMFT was 0.53 by Sohi et al. [22]; mean DMFT was 0.97 by Hou et al. [23]; DMFT score was 1.4 by Leghari et al. [24]; the mean DMFT was 3.70 by Ali et al. [25]; and mean DMFT score was 2.22 ± 2.19 by Ali et al. [26]. This study has explored that father and mother education has strong positive impact on caries.
As parents have higher level of education there will be higher chances to avoid from caries or other teeth problems and vice versa. It is simple that if parents have higher level of education then they will be better aware from diseases and their management. So, their education play significantly protective role for caries status.
Similarly, economic background or financial position matters in this study. As higher the financial position lower will be the chances of getting this disease of caries. These are few researches which have supported this argument that demographic has strong impact on caries status is the relevant studies in this case [15,27].

Conclusion
Findings of this study have shown that brushing twice a day and after every meal, brushing after dinner and before sleeping, using Miswak and having awareness about teeth protection or brushing were the significant data or practices for avoiding teeth decay. Other practices have insignificant or less significant role in this study. This study has explored that father's and mother's education level has strong positive impact on caries. As parents have higher level of education there will be fewer chances to have caries or other teeth problems and vice versa. So, their education plays a significantly protective role for caries status. As higher the financial position, lower are the incidence of dental caries.

Some Recommendations to Reduce Burden of Dental Caries in Local Settings
a. Changes in lifestyle ought to adopt like reduce the intake of food containing free sugars to four times a day and thereby limit the amount of free sugars consumed. Individuals need to encourage using fluoride toothpaste twice a day after meal. Use of Dental floss, rinsing with water after meal, and cleanings of teeth with tongue after every meal can also reduce incidence of caries. Regular visit to dentist is recommended.
b. Pakistan is currently undergoing nutrition transition do not have adequate exposure to fluoride. There is need to promote adequate fluoride exposure via appropriate vehicles, for example affordable toothpaste, water, salt and milk.
Guidelines for health promotion and disease prevention should be incorporated in the syllabus of pre-school and school level.
c. Availability of health care center and human resource for management of the dental caries ought to ensure in every union council. Referral system of affected individuals should be initiated from different schools, institute and organization to health care center for secondary prevention of dental caries by restoration of the affected teeth. d.
Health education campaigns and health promotion websites need to encourage which are particularly famous in youth population. Mass media campaigns have to start for oral health promotion in order to reduce dental caries incidence.
Oral hygiene campaign needs to start in our community to reduce dental caries prevalence in the; schools' colleges, universities and madrasas. Services of various health promotion programs can be utilized to reduce dental caries incidence and prevalence.