Predictors of Routine Dental Check-up Among Male Adolescents in Saudi Arabia.

OBJECTIVE: To evaluate the association of socioeconomic factors and self-perceived oral conditions with routine dental check-up among male adolescents.
METHODS: This cross-sectional study was conducted on male children (grade 10-12) from public schools in different cities of the Eastern province of Saudi Arabia. A multistage random sampling was used for the recruitment of study participants. A piloted questionnaire translated into the Arabic language was used for data collection.
RESULTS: There were 586 students with mean age 16.86±0.87 years. The prevalence of routine dental visit within last year was 18.9%. Half of the entire sample had dental cavities (50.5%) and tooth sensitivity (50%) followed by dental pain (42.2%). Bivariate analyses found that the children with dental cavities (OR 0.4, 95% CI 0.26, 0.61), dental pain (OR 0.63, 95% CI 0.41, 0.97), and malodor (OR 0.41, 95% CI 0.23, 0.71) had significantly lower odds of routine dental visits than those without these conditions. The final model of multivariable logistic regression showed that dental cavities (OR 0.42, 95% CI 0.27, 0.66) and malodor (OR 0.45, 95% CI 0.25, 0.78) were significantly associated with lower likelihood of visiting dental office for a regular dental check-up. No significant influence of socioeconomic factors on routine dental attendance was observed.
CONCLUSIONS: A small proportion of children performed routine dental visits. The children with dental cavities and malodor were less likely to perform routine dental visits. The awareness about the importance of regular dental check-up should be raised to reduce the burden of oral diseases in schoolchildren.

Introduction

Routine dental visits are important for the maintenance of good oral health which is an integral component of systemic health (, ). Low caries experience, reduced periodontal destruction, and low tooth loss are common in routine dental attenders (, ). It is also known that dental attendance in post-childhood is associated with improved dental health in adulthood (). Similarly, better oral health self-perception and improved oral health-related quality of life are associated with routine dental attendance (, ). Regular dental attendance provides an opportunity for early diagnosis of oral conditions, provision of preventive dental services, and timely treatment of dental problems (, ). A regular oral examination is also important for oral cancer prevention as patients with oral cancer who visit the dentist once a year demonstrate reduced tumor stage and improved health-related quality of life ().

There is an ongoing scientific debate in the international scientific community about the frequency of dental visits because oral health needs, medical and dental history, and disease risk level vary from individual to individual (, ). However, dental practitioners in many developed countries advocate dental check-up within six months (). American Dental Association also recommends regular dental visits once or twice a year, depending upon unique oral needs of each individual (). In the U.K, the National Institute of Health and Care Excellence (NICE) provides guidelines about the routine dental check-up and recommends the longest interval of 12 months between oral health examinations for patients under the age of 18 years ().

There are some reports about the factors associated with routine dental attendance among pre-school and primary schoolchildren and adults (, , ). Camargo et al. identified income and education and preventive guidance of mothers as main predictors of dental visits for the routine dental check-up in Brazilian preschool children (). A study by John et al. found that private insurance and age of children were significant predictors of routine dental attendance in primary schoolchildren in Australia (). Amarasena et al. conducted a study on Aboriginal Australians adults and observed that younger age and having no health problems were associated with performing routine dental visit ().

The data about regular dental visits are important for the reduction of oral disease burden and maintenance of optimal oral and systemic health. However, the literature lacks baseline data about the socioeconomic and oral health-related factors that influence routine dental visits among adolescents. Therefore, it was hypothesized that routine dental attendance is associated with socioeconomic factors and dental problems among adolescents. The aim of this study was to evaluate the factors associated with routine dental attendance among male adolescents in Saudi Arabia.

Material and methods

The study includes secondary analyses of data from a project related to oral health of adolescents. The ethics committee at the College of Dentistry, Imam Abdulrahman Bin Faisal University approved the project (EA# 2018009). Grade 10-12 male students (age 16-18 years) from public high schools in Dhahran, Al-Khobar, and Dammam cities participated in the study. Random selection of seven schools in these cities was carried out using a lottery method. Microsoft Excel 2010 random number generator was used to select classes and students from these schools. The administrators of selected schools provided permission to conduct the study in their respective institutions.

Data collection was carried out by using a piloted questionnaire in the Arabic language. The questionnaire was first developed in the English language and rigorously reviewed to ensure its content validity. It was then translated into the Arabic language according to the guidelines of World Health Organization (WHO) about translation and adaptation of instrument (). Later, it was administered among 30 students for pilot testing. Based on their feedback, minor modifications were made in the instrument. The data of these students were not included in the statistical analysis of the study.

The questionnaire inquired information about demographic variables, routine dental check-up, and self-perceived oral conditions. The schoolchildren were asked about having dental pain, dental cavities, bleeding gums, tooth sensitivity, oral malodor, and dryness of mouth. In addition, information about smoking was also sought. Ethical standards were maintained during the conduct of the study. Informed consent was obtained from the parents of the study participants. The schoolchildren were provided with the details of the study and its potential benefits. They were informed about their voluntary participation in the study. The ambiguity in understanding the questions was addressed by ensuring effective communication during questionnaire administration. The questionnaire was provided to those who were willing to participate in the survey. The study was conducted according to the principles of Helsinki Declaration.

SPSS software (IBM SPSS Statistics for Windows, version 22.0. Armonk, NY: IBM Corp) was used for data analyses. Descriptive statistics included frequency, percentage, and 95% confidence interval. Bivariate and multivariable logistic regression analyses were performed to investigate the influence of independent variables on the dependent variable, routine dental check-up. Independent variables included academic grades in previous year, monthly family income, father's education level, mother's education level, having dental cavities, bleeding gums, tooth sensitivity, oral malodor, dryness of mouth, and smoking habit. In addition, the final best model was created using backward LR selection method due to its good predictive power. A p-value of < 0.05 was considered statistically significant.

Results

There were 586 children in the study and their mean age was 16.86 ± 0.87 years. The prevalence of routine dental attendance during the last 12 months was 18.9% (n=111). Most children (n= 493, 84.1%) scored more than 80% grades in previous academic year. The majority of children had university-educated parents. About two-thirds (n=401, 68.4%) had a monthly family income of less than 10,000 SAR (equivalent to $U.S. 2665). Half of the sample had dental cavities (n=296, 50.5%) and tooth sensitivity (n=293, 50%) followed by dental pain (n=247, 42.2%). Approximately, one-third of them had bleeding gums and oral malodor (Table 1).

Table 1

Descriptive statistics of study participants

Variables	N/%N=586	95% CI
Routine dental visits	111 (18.9)	(16, 22.3)
Academic grades    More than 80%    Less than 80%	493 (84.1)93 (15.9)	(80.9, 86.8)(13.1, 19.1)
Family income    ≥ SAR 10000 (Equal to US$ 2665)    < SAR 10000 (Equal to US$ 2665)	185 (31.6)401 (68.4)	(27.9, 35.4)(64.5, 72.1)
Father's education    ≥ University education    ˂ School education	393 (67.1)193 (32.9)	(63.1,70.7)(29.2, 36.8)
Mother's education    ≥ University education    ˂ School education	366 (62.5)220 (37.5)	(58.4, 66.3)(33.7, 41.5)
Smoking	199 (34.0)	(30.2, 37.9)
Bleeding gums	180 (30.7)	(27.1, 34.6)
Dental cavities	296 (50.5)	(46.5, 54.5)
Dental pain	247 (42.2)	(38.2, 46.2)
Tooth sensitivity	293 (50.0)	(45.9, 54.1)
Dryness of mouth	137 (23.4)	(20.1, 27)
Malodor	163 (27.8)	(24.3, 31.6)
Age	Mean (SD)16.86 (0.87) years

Table 2 demonstrates the influence of individual socioeconomic factors and perceived oral conditions on routine dental check-up among schoolchildren. Bivariate statistical analyses revealed significant associations between having dental cavities, tooth sensitivity, malodor and regular dental visits. The children with dental cavities (OR= 0.4, 95% CI=0.26, 0.61), dental pain (OR= 0.63, 95% CI= 0.41, 0.97), and malodor (OR=0.41, 95% CI=0.23, 0.71) had significantly lower odds of performing routine dental visits. No significant influence of academic grades, family income, and parental education was observed.

Table 2

Bivariate analysis: Predictors of routine dental check-up among male adolescents

Variables	Un-adjusted OR(95% CI)	P-value
Academic grades    More than 80%    Less than 80%	1.15 (0.64, 2.06)	0.641
Family income    ≥ SAR 10000 (Equal to US$ 2665)    < SAR 10000 (Equal to US$ 2665)	1.22 (0.79, 1.89)	0.369
Father's education    ≥ University education    ˂ School education	1.27 (0.81, 1.99)	0.307
Mother's education    ≥ University education    ˂ School education	0.94 (0.61, 1.44)	0.773
Smoking	1.29 (0.84, 1.98)	0.238
Bleeding of gums in the past month	1.16 (0.75, 1.8)	0.507
Dental cavities	0.4 (0.26, 0.61)	<0.001*
Dental pain in the past month	0.63 (0.41, 0.97)	0.037*
Tooth sensitivity in the past month	0.71 (0.47, 1.08)	0.114
Dryness of mouth	1.07 (0.66, 1.73)	0.794
Malodor	0.41 (0.23, 0.71)	0.001*

*Statistically significant

Multivariable logistic regression analysis showed that children with dental cavities and oral malodor were 43% and 39% respectively are less likely to visit dental office for routine dental check-up than those without dental cavities and oral malodor (P < 0.05) (tab. 3). All nine of two-way interactions of dental problems with routine dental visits from final multivariable logistic regression model are shown in Table 4. Dental cavities and malodor (P <0.001), dental cavities and bleeding gums (P <0.006), dental cavities and sensitivity (P <0.007), dental cavities and pain (P <0.001), and malodor and pain (P 0.012) showed significant interactions with routine dental check-ups. The interaction of dental cavities and malodor with routine dental check-up demonstrated that inequity in routine dental check-up between those who had dental cavities and malodor than those who did not have dental cavities and malodor. In other words, dental cavities mediated the relationship between oral malodor and routine check-up. Similarly, significant interactions of other dental problems were demonstrated in the study.

Table 3

Multivariable logistic regression analysis: Predictors of routine dental check-up among male adolescents

Variables	Un-adjusted OR(95% CI)	P-value
Academic grades    More than 80%    Less than 80%	1.07 (0.57, 2.01)	0.834
Family income    ≥ SAR 10000 (Equal to US$ 2665)    < SAR 10000 (Equal to US$ 2665)	1.15 (0.73, 1.82)	0.542
Father's education    ≥ University education    ˂ School education	1.45 (0.88, 2.41)	0.147
Mother's education    ≥ University education    ˂ School education	0.75 (0.46, 1.23)	0.261
Smoking	1.33 (0.88, 2.1)	0.221
Bleeding of gums in the past month	1.53 (0.94, 2.5)	0.085
Dental cavities	0.43 (0.26, 0.7)	0.001*
Dental pain in the past month	0.86 (0.51, 1.45)	0.586
Tooth sensitivity in the past month	0.85 (0.53, 1.37)	0.515
Dryness of mouth	1.37 (0.8, 2.36)	0.249
Malodor	0.39 (0.21, 0.7)	0.002*

*Statistically significant

Table 4

Interaction of dental problem variables of the study with routine dental check-up

Variables	Un-adjusted OR(95% CI)	P-value
1. Dental cavities x malodor	0.61(0.51,0.74)	<0.001*
2. Dental cavities x bleeding gums	0.78 (0.65, 0.93)	0.006 *
3. Dental cavities x pain	0.73 (0.62, 0.87)	<0.001*
4. Dental cavities x sensitivity	0.72 (0.57, 0.92)	0.007*
5. Dental cavities x dryness of mouth	0.98 (0.76, 1.27)	0.884
6. Malodor x dryness of mouth	1.06 (0.82, 1.37)	0.632
7. Malodor x Sensitivity	0.83 (0.65, 1.06)	0.134
8. Malodor x pain	0.71 (0.55, 0.93)	0.012*
9. Malodor x bleeding gums	1.15 (0.88, 1.49)	0.300

The results of final "best model" using backward LR selection method are presented in Table 5. After controlling for other covariates in the model, having dental cavities (OR=0.42, 95% CI=0.27, 0.66) and malodor (OR=0.45, 95% CI=0.25, 0.78) were significantly associated with lower odds of visiting dental office for regular dental check-up (Table 5).

Table 5

Final Model Backward LR: Predictors of routine dental check-up among male adolescents

Variables	Un-adjusted OR(95% CI)	P-value
Dental cavities	0.42 (0.27, 0.66)	<0.001*
Malodor	0.45 (0.25, 0.78)	0.005*

*Statistically significant

Discussion

The study investigated the factors associated with routine dental visits among schoolchildren and demonstrated that dental cavities and oral malodor were significantly associated with lower odds of visiting a dental office. Bivariate and multivariable logistic regression analyses failed to identify socioeconomic factors as significant predictors of routine dental attendance in our study. These significant study findings underscore the importance of raising awareness about visiting the dentist for routine dental check-up, particularly among children with dental conditions. This also reflects that children with oral problems are more likely to further deteriorate their oral health by not visiting the dentist for routine dental check-up.

In New Zealand, the prevalence of routine dental attendance during previous year was 82.1% among children aged 15 years (). Similarly, 77% of Aboriginal Australian children visited the dentist for a regular check-up during the past 12 months; however, this prevalence figure fell to 53% during the last six months (). In contrast, the present study showed that 18.9% of children performed routine dental visit during previous year. Likewise, even a lower prevalence of routine dental visits (9.3%) among schoolchildren aged 13-14 years was reported in a previous study from the Eastern province of Saudi Arabia (). These variations in the prevalence of routine dental visit in different populations can be attributed to parental education, family income, oral health awareness, availability of insurance coverage, and access to healthcare services (, , ). Nevertheless, our study findings call for increasing the awareness about the significance of routine dental attendance among adolescents in the country.

The literature shows improved oral health outcomes among individuals with regular dental attendance. Routine attenders exhibit an improved self-perceived and clinical oral health demonstrated by low caries experience and fewer tooth loss due to caries (, ). A recent study from the Eastern province of Saudi Arabia also reported lower odds of dental pain associated with routine dental check-ups among 6-12 years old schoolchildren (). Similarly, a previous study from Brazil observed positive self-perception of oral health associated with the habit of visiting the dentist for a regular dental check-up (). Furthermore, a routine dental attendance and improved oral health behaviors have considerable effects on oral health-related quality of life (). In the present study, poor oral health shown by dental cavities and oral malodor were significantly associated with lower odds of performing routine dental visits. In addition, poor regular attendance among our study participants with dental cavities can be related to dental anxiety which can arise from anesthetic injections and drilling of teeth during treatment (). It is known that dental anxiety affects oral care seeking behaviors and it is more prevalent among those who perform irregular dental visits than those who visit dentist regularly (). A recent study observed significantly higher dental anxiety score among those subjects who avoid visiting dental office ().

On the other hand, the results of a previous study showed that good oral health demonstrated by not having oral health problems including being caries-free increased the likelihood of dental attendance for routine check-up in Aboriginal Australians (). This reflects that individuals with improved oral health have healthy preventive behaviors particularly better healthcare seeking practices, whereas those who have poor oral health status demonstrate poor health-related behaviors. A possible explanation for better oral health and preventive behavior including improved oral hygiene could be related to oral health advice and dental care received from a dental professional during a routine dental visit ().

[REMOVED HYPERLINK FIELD]Family income and parental education are used to determine socioeconomic status (). It is known that educated parents have improved knowledge and attitudes towards oral health which affect their children's oral health care behaviors (). Similarly, family income determines access to oral care services because the cost of dental treatment is a major barrier to the provision of dental care (, ). Therefore, parents with high income and education pay greater attention to the oral health care of their children (). In addition, parent's education and socioeconomic factors are also important for children's adherence to regular dental attendance (). Interestingly, a previous study showed that children of mothers with low education were more likely to perform routine dental visits in Australia ().

Although majority of children (68.9%) had low family income, however, no significant associations of family income with routine dental attendance were observed in the present study. Similarly, our study found no significant influence of parental education on regular dental visits. These findings contradict the observations made by Camargo et al. who identified higher education of mother and high economic status as major predictors of regular dental attendance in Brazilian children (). It is known that more dental visits for symptomatic relief are made by the children of low educated mother than those with university educated mothers (). Low education attainment and low household income are associated with increased likelihood of no performing dental visits within last one year or visiting the dentist for emergency care (). Likewise, underprivileged children also demonstrate poor regular attendance pattern and it was found that 50.3% of low-income children compared with 77.7% of children from middle and high income were regular attenders ().

Multistage random sampling and adequate sample size in the present research provides reliable evidence about the low probability of performing routine dental visits among adolescents with dental problems. The significant study findings highlight unhealthy oral care seeking behavior that can worsen oral health of those children who already have oral problems. There are certain limitations of the study which are 1) inclusion of male study participants, 2) a cross-sectional study design, 3) self-reported oral conditions, and 4) data collection from public schools in urban locations. The cultural norms in the country do not favor data collection by male researchers from female institutions. The cross-sectional study design precludes a causal inference of results. There is a possibility of inaccuracy in self-reported data of oral conditions. The inclusion of data from male participants and from schools in urban locations can compromise the generalizability of study findings. Moreover, the influence of dental anxiety on dental visits was not evaluated in the study because primary data did not include dental anxiety. In the future, a large multicenter clinical study should include examination of oral conditions and recording of routine dental visits by adolescents.

Conclusions

The study demonstrated a low prevalence of routine dental visits among schoolchildren. Dental problems, particularly dental cavities and tooth sensitivity were highly prevalent. The children with dental cavities and malodor were less likely to visit dental office for routine dental check-up than those without dental cavities and malodor. No significant influence of socioeconomic factors on routine dental attendance was observed. Given the high prevalence of oral disease and low routine dental check-up, the study findings are significant for the prevention of oral problems through the promotion of routine dental attendance.

Oral health campaigns should raise awareness about the significance of routine dental check-up for the maintenance of oral health in schoolchildren. Healthcare professionals should provide advice, particularly to children with dental cavities and oral malodor to regularly visit the dentist to maintain optimal oral health. Decision makers in healthcare organizations should use these findings for policy development to reduce the burden of oral disease among adolescents.