CARIES, ORAL HYGIENE STATUS AND DATES CONSUMPTION AMONG SAUDI FEMALE UNIVERSITY STUDENTS

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1 Original Article CARIES, ORAL HYGIENE STATUS AND DATES CONSUMPTION AMONG SAUDI FEMALE UNIVERSITY STUDENTS ABSTRACT 1 ARHAM N CHOHAN 2 AHMED EL HEJAZI 3 NOURA A AL ESSA 4 MANAL A AL MUTAIRI 5 HADEEL M AL OHAILI The objectives of the present study were to determine the caries experience, oral hygiene status and consumption of dates among Saudi female University students. A total of 406 female University students were examined for dental caries and oral hygiene. The information about oral hygiene practices and consumption of dates was obtained through a self-administered questionnaire. The mean DMFT was ( 4.71) with a decay (D) component of 5.87 ( 4.28), missing (M) component of 0.83 ( 1.44) and filled component of 3.31 ( 3.92). There was a significant (p<.05) difference observed between the mean DMFT scores of the students from various age groups. Only one in every four (25.6%) students had good oral hygiene. A positive correlation (p<.0001) was exhibited between the mean DMFT scores and oral hygiene. Almost all (98.0%) the students used brush to clean their teeth. A majority of the students were cleaning their teeth twice (47.0%) or thrice (22.4%) daily and only about one in ten (12.3%) students used miswak to clean their teeth. More than three in every four (81.0%) students were eating dates and about one in every four (24.4%) students were eating 5-10 dates per day. No significant (p>.05) correlation was observed between caries and dates consumption. It was concluded that the caries prevalence and severity was very high. Only small percentage of the students had good oral hygiene and eight in every ten students were eating dates daily. Key Words: Dental caries, Oral hygiene, Date consumption, Dental students. INTRODUCTION 1 BDS, MSc, Associate Professor, Department of Operative & Pediatric Dentistry, Institute of Dentistry, CMH Lahore Medical College, Lahore, Pakistan. 2 BDS, MSc, PhD, Professor, Department of Restorative Dental Sciences, Operative Dentistry Division, King Saud University College of Dentistry, Riyadh, Saudi Arabia. 3,4 BDS, Lecturer, Department of Pediatric Dentistry and Orthodontics, King Saud University College of Dentistry, Riyadh, Saudi Arabia. 5 BDS, Dental Practitioner, Riyadh, Saudi Arabia For Correspondence: Dr Arham Chohan, Institute of Dentistry, CMH Lahore Medical College, Near Abdur Rehman Road, Lahore Cantt, Pakistan arhamnchohan@gmail.com Cell: Received for Publication: November 7, 2016 Revised: November 27, 2016 Approved: December 4, 2016 It is an established fact that in many countries the university students occupy a significant position in public life. They are considered as the role model for the society and opinion leaders of the future in their respective fields. It is assumed that significance of health perception is better understood in students of health sciences than those in other fields. Therefore, the pattern of health behaviors and beliefs of these university students are of particular importance. Dental caries is still one of the most prevalent disease in different parts of the world. Many studies conducted in Western countries have reported a general decline in caries prevalence. 1 Studies undertaken in countries in the Arabian Peninsula have reported a very high caries severity, commonly associated with relatively high and frequent consumption of sweets. 2-4 Similarly, several studies in Saudi Arabia have reported a very high caries prevalence in school children. 5-8 A study was conducted on female dental students, which also showed high caries prevalence. 9 Although, information on caries prevalence in Saudi female university students in scarce, a high caries prevalence is also expected in these students. It has been observed that optimal gingival and periodontal health is related to good oral hygiene. Studies have shown a positive correlation between oral hygiene and gingival/ periodontal disease. 10,11 Similarly, a correlation has also been reported between oral hygiene and dental caries. 12,13 A study conducted on 623

2 female dental students showed that overall oral hygiene status was good. 9 Therefore, it would be interesting to determine the oral hygiene status and practices of female university students. The date palm (Phoenix Dactylifera) is one of mankind's oldest cultivated plants and important produce in many Arabian Gulf Countries. It has been used as food since approximately six thousand. 14 It could be used for the generations to come, due to its remarkable nutritional, health and economic value in addition to its environmental benefits. 15 The fruits (dates) of the date palm contain a high percentage of carbohydrate (total sugars 44-88%), fat ( %), 15 salts and minerals, proteins ( %), vitamins, a high percentage of dietary fiber ( %); with ph values for dates ranging from 5.3 to ,16 Historically, dates have been consumed as major portion of diet, which lead to high caries incidence and accelerated tooth loss; and evidence of this was found in a skeletal series from the late Iron Age in the Sultanate of Oman. 17 In literature information is scarce about the relationship between consumption of dates with caries. The objectives of the present study were: To determine the caries prevalence and severity in female university students. To determine their oral hygiene status and practices. To see if there was any difference between the students of various age groups in relation to caries and oral hygiene status. To see if there was any correlation between dates consumption and caries severity. METHODOLOGY The sample for this study consisted of Saudi female University students residing in the hostels of King Saud University (KSU) and Al-Tarbyia College. The hostels which were selected for this study had the facility where the students receive routine dental treatment for their dental problems. Prior to the commencement of the study, permission was taken from the hostel administration by stating the aims and objectives of the study. In addition, students were also informed about the study and their written consent was taken to carry out dental examinations. The students were divided into three age groups: <20, and >= 23. The students were examined by two examiners (NE and HO) on a dental chair utilizing a dental mirror and explorer, while another researcher (MM) recorded the information. The two examiners ware calibrated with a senior KSU College of Dentistry faculty member. The data obtained during the examination were recorded on a form especially designed for the study. The following indices were used to assess the caries and oral hygiene in the sample. Dental caries: The WHO criteria were used for the diagnosis of dental caries18. The caries was diagnosed on visual evidence with the help of explorer and mirror. No radiographs were taken. Oral hygiene index: The oral hygiene index described by James et al (1960) 19 was utilized by the study. The index has three categories of dental cleanliness. Good: The teeth are clean. There is no sign of food debris or materia alba. Poor: The teeth are very dirty. There is considerable long-standing food debris, materia alba. Fair: This class falls between the two preceding ones. There is some evidence of debris, but not of the degree recognized as poor. The information about oral hygiene practices, consumption of dates and sugary products, and drinking water was obtained through a self-administered questionnaire. The questionnaire was tested on 10 university students and appropriate changes were made to improve its comprehensibility by the students. The following details were covered in the questionnaire. Demographic information such as age, marital status and place of residence. Oral hygiene methods used such as toothbrush, miswak and its frequency. Use of mouthwash and dental floss. Type of drinking water used. Type of dates and its frequency. The data were then entered into a computer using the FOXPRO software and analyzed utilizing the Statistical Program for Social Sciences (SPSS) version #16. Various frequencies were generated. The Pearson Chi-square test was used to test the difference between various age groups in term of oral hygiene status, oral hygiene practices, consumption of dates and sugary products. ANOVA was utilized to test the difference in mean DMFT scores of various age groups, oral hygiene status, dates consumption and type of drinking water. RESULTS A total of 406 Saudi female students of King Saud University participated in the study with mean age of 20.38, ranging from There were 210 students from College of Arts, 37 from College of Sciences and 159 the Colleges of Health Sciences 624

3 TABLE 1: CARIES EXPERIENCE OF THE STUDENTS AND AGE GROUPS DMFT decay (Medicine and Dentistry). The intra-examiner and inter-examiner reliabilities as determined utilizing Kappa method were 0.91 (for both the examiners) and 0.89 respectively. missing filled < > Total P-Value P <.05 P >.05 P <.05 P <.05 TABLE 2: ORAL HYGIENE STATUS OF THE STUDENTS Oral hygiene Status Good Fair Poor < (27.4) 101 (60.1) 21 (12.5) (23.2) 125 (70.6) 11 (6.2) >=23 17 (27.9) 40 (65.6) 4 (6.6) Total 104 (25.6) 266 (65.5) 36 (8.9) TABLE 3: CORRELATION BETWEEN MEAN DMFT SCORES AND ORAL HYGIENE STATUS Number P value Good < Fair < Poor < Total < TABLE 4: VARIOUS ORAL HYGIENE METHODS USED BY THE STUDENTS Brush only < (98.2) (98.3) Miswak Floss * 24 (14.3) 30 (17.9) 17 (9.6) 55 (31.3) >=23 59 (96.7) 9 (14.8) 22 (36.1) Total 398 (98.0) * P < (12.3) 107 (26.4) Mouth wash 17 (10.1) 16 (9.0) 5 (8.2) 38 (9.4) TABLE 5: FREQUENCY OF TOOTH CLEANING AMONG THE STUDENTS Age group Once/ Day 39 (23.2) 40 (22.6) 12 (19.7) < >=23 Total 91 (22.4) Oral Hygiene Status Frequency of Tooth Cleaning Twice/ Thrice/ Sometime Day Day 78 (46.4) 87 (49.2) 26 (42.6) 191 (47.0) 32 (19.0) 39 (22.0) 20 (32.8) 91 (22.4) Total (11.4) 11 (6.2) 17 3 (4.9) (8.2) 406 TABLE 6: CORRELATION BETWEEN MEAN DMFT SCORES AND TYPE OF DRINKING WATER CONSUMED Type of Water Number P value Bottled > 0.05 Tap > 0.05 Bottle > 0.05 Tap Total > 0.05 TABLE 7: RESPONSES TO QUESTIONS ABOUT DATES TYPE AND CONSUMPTION Question n % Which type of date you eat? 1 Barhi Kalas Sukary Others Frequency of eating dates per day: 1 One daily Twice daily Thrice or more than three times How many dates you eat per day? 1 < 5 dates per day dates per day > 10 dates per day

4 The overall caries prevalence in the study sample was 98.8%; with 98.6% in arts students, 100% in science students and 98.7% in health sciences students. Furthermore, 97.6% of age group <20, 99.4% of age group and 100% of age group >=23 were having caries. The overall mean DMFT was ( 4.71) with decay (D) component of 5.87 ( 4.28), missing (M) component of 0.83 ( 1.44) and filled component of 3.31 ( 3.92). There was a significant (p< 0.05) difference observed between the mean DMFT scores of the students in various age groups (Table 1). The missing (M) and filled (F) component of the DMFT significantly (P<.05) increased with the increase in age (Table 1). Only one-fourth (25.6%) of the students had good oral hygiene (Table 2). A slight decline was observed in the percentage of students with poor oral hygiene from age group < 20 to >= 23 but the difference was not significant (p> 0.05) (Table 2). A strongly significant (p< 0.001) correlation was observed between mean DMFT scores and oral hygiene status (Table 3). A great majority (98.0%) of the students were using toothbrush to clean their teeth, whereas only one in ten students were using miswak as an oral hygiene tool (Table 4). The use of dental floss significantly (p< 0.05) increased in students from <20 to >=23 age group (Table 4). Majority of the students were cleaning their teeth twice (47.0%) daily or thrice (22.4%) daily. About one in ten (8.2%) students cleaned their teeth only sometimes (Table 5). No particular trend was observed in relation to different age groups in relation to oral hygiene practices (Table 5). Almost three-fourth (76.4%) of the students were drinking bottled water (Table 6). No statistically significant (p> 0.05) correlation was observed between the mean DMFT scores and the type of water consumed (Table 6). Table #7 summarizes the responses to question about the type, frequency and consumption of dates in the students. A great majority of the students were consuming dates once (81.0%) and twice (13.1%) daily; with 69.4% eating < 5 dates per day and 24.4% 5-10 dates per day. No statistically significant (p> 0.05) correlation was observed between caries experience and dates consumption. DISCUSSION The present study has provided an interesting insight into caries experience, oral hygiene status and practices, and consumption of dates among Saudi female university students. The results will be utilized in motivating the students to improve their oral health behaviors and practices. These results will also serve as base-line data for future comparisons. The mean DMFT scores in the study population were very high. However, it was not unexpected. The studies of Saudi schoolchildren and female dental students have reported similar levels of caries 6-9 and it shows that the children continue to carry the disease with them from schools to universities. Nevertheless, such a high level of caries is alarming in any population. This situation of high caries prevalence and severity in Saudi Arabia has been identified by several authors and they have pleaded for immediate measures to ameliorate preventive efforts. 6-8 AlDossai et al (2001) 20 and Wyne et al (2002) 7 have suggested to organize school based preventive programs which will impart awareness and knowledge about oral health. There was statistically significant (p< 0.05) difference observed between the mean DMFT scores of the students from various age groups and also the mean DMFT scores continued to increase across the. More and more students got their carious teeth restored or extracted, probably as a result of increased awareness about the disease. Similar results were reported in the study conducted in young adults 10 but not in agreement with results reported in Danish 20 and Saudi 9 dental students. It has been reported that women in general have cleaner teeth than men, and that the trend prevails within various age groups. 21 In our study population one-fourth of the students had good oral hygiene. However, overall small improvement in oral hygiene was observed with the advancement in age. This improvement in oral hygiene could be because of the awareness from different sources and as well as from peer interaction. The results were in agreement with those of Lang et al (1977) 22 and Howat et al (1979) 23 who reported an improvement in oral hygiene through the in students. A significant correlation was observed between mean DMFT scores and oral hygiene, which meant that the prevalence and caries severity increased because of bad oral hygiene. A great majority of the students were using toothbrush to clean their teeth whereas very few students were using miswak. Similar results were reported in female dental students. 9 Several studies have reported on the usefulness of miswak for dental health. 24,25 Therefore, it would be beneficial to use a combination of brush and miswak for optimum oral health. Most importantly, the use of miswak has been encouraged through the religious and cultural hygiene guidelines and traditions. The increased use of dental floss could also be attributed to increased awareness about oral health and also to increased number of restored teeth, which sometime makes it compulsory to clean the interproximal areas with dental floss. The results are in agreement with the study by Al-Zahrani et al (2004). 9 It was observed in our study that majority of the students had appropriate brushing habits. Moreover, three-fourth of the students were drinking bottled water that contains fluoride, which prevents dental caries. However, the study sample had high caries prevalence and severity. It is important that the students be educated in appropriate tooth brushing methods. In addition, these students dietary habits also need to be explored. 626

5 A large number of students were consuming dates. Dates contain a high concentration of sugar. The carbohydrate in dates mainly helps in reducing sugars in the form of glucose, fructose, mannose and maltose and non-reducing sugars (primarily sucrose), as well as small amounts of polysaccharides such as cellulose and starch. 26 So because of these properties of dates; it could be inferred that dates consumed in small quantity may not directly causes dental caries. The responses obtained through a questionnaire have to be considered with caution. There is a potential tendency towards favorable response. The possibility of a bias created by favorable response could not be ruled out. Nevertheless, it is hoped that the study has provided useful information about the caries, oral hygiene and dates consumption in the study population. The university students should be screened for dental disease at the time of entrance to their studies and encouraged to seek treatment immediately. A follow-up mechanism and continuous reinforcement for healthy oral hygiene and dietary practices should be provided. CONCLUSION The caries prevalence and severity was very high among the Saudi female university students. Only one-fourth of the students had good oral hygiene. A great majority of the students were using toothbrush to clean their teeth. A positive correlation was observed between the mean DMFT scores and poor oral hygiene. ACKNOWLEDGEMENT The authors wish to thank the hostel administration of the KSU for granting the permission to carry out the study. The participation and cooperation of all the participating students is deeply appreciated. The authors are also thankful to Dr Nazeer Khan for helping in statistical analysis. REFERENCES 1 Bansal A, Ingle NA, Kaur N, Ingle E. Recent Advancements in Fluorides. J Int Soc Perv Community Dent 2015; doi: / Soparkar P, Taraves M, Hussain J, Babeely K, Behbehani J, Al -Za'abi F. Nursing bottle syndrome in Kuwait. 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