Knowledge and awareness of periodontal diseases among Jordanian University students: A cross-sectional study.

BACKGROUND: Oral health plays an important role to maintain the general health. Therefore, controlling periodontal diseases may have a profound health effect. The importance of oral health is still a neglected and ignored social issue because most of the people are unaware of the relationship between oral health and systemic diseases. The aim of this study was to assess the knowledge and awareness of periodontal diseases among Jordan University of science and technology students.
MATERIALS AND METHODS: A cross-sectional study was conducted by distributing self-administered structured questionnaires to 906 university students between the ages of 18-30 years after obtaining their verbal consents.
RESULTS: A total of 906 students completed the questionnaire. Majority of students reported that they brush their teeth regularly while only 5.1% of students admitted that they never clean their teeth. Roughly one-quarter of students could define dental plaque correctly. A high "percentage" of females and medical students were more aware concerning gum inflammation signs and symptoms than males and students from faculties of engineering and science. Students of medical specialties and females were more aware of the relationship between smoking, diabetes mellitus, and heart diseases on the one hand and periodontal diseases on the other hand compared to opposite comparative groups. A low proportion of students were aware that proper scaling was not harmful to the teeth.
CONCLUSIONS: In general, our study demonstrated that university students had poor knowledge regarding the etiology of periodontal diseases as well as the role of conventional treatment in maintaining good oral health by preventing the inflammatory process. Copyright:

INTRODUCTION

Oral health plays an important role to maintain the general health because the oral cavity is considered the gateway to the body and acts as a mirror that reflects the status of general health.[12] Periodontal diseases including gingivitis and periodontitis are infectious diseases that result from bacterial infection where the causative bacteria are found in dental plaque.[3] However, gingivitis is usually the early phase of the inflammatory process and if changed to periodontitis, will lead to periodontal tissue destruction.[4] Therefore, controlling gingivitis may have a profound health effect when it may result in a lower prevalence of destructive periodontitis.[5] Plaque-induced periodontitis is a group of diseases of the periodontium that is manifested as progressive destruction of periodontal ligament and alveolar bone, with periodontal pocket formation or gingival recession or both that may become one of the major causes of tooth loss in adult life.[678] Previous study was done in Jordan showed that the prevalence of periodontal disease is 76% for gingivitis, 2.2% for aggressive periodontitis, and 5.5% for chronic periodontitis.[9] Periodontitis was more frequent among males than females. Several epidemiological studies have identified many risk factors to be implicated in the manifestation and progression of periodontal diseases such as age, gender, oral hygiene habits, frequency of dental visits, income level, educational attainment, residence place, cigarettes smoking, diabetes mellitus, ethnicity, microbiological factors, genetic factors, immunity, social and behavioral factors, and psychological factors.[10111213] The importance of oral health is still a neglected and ignored social issue because most of the people are unaware of the relationship between oral health and systemic diseases. Therefore, there is a significant amount of emphasis to direct the efforts toward the prevention of diseases rather than the treatment. Hence, adequate awareness and knowledge about oral health and good oral hygiene practice will maintain good oral and general health. There is a common notion that educated people in society are more aware of the correlation between general health and oral diseases, but there is insufficient data in the literature to prove this view.[14]

For this reason, the current study aimed to assess the knowledge and awareness of periodontal diseases among university students who form the cornerstone of society. That is why confirmation and knowledge related to etiology of periodontal diseases and risk factors associated with its occurrence are required to establish baseline data that may help us during planning for constructing oral health educational and preventive programs to prevent and/or reduce destructive forms of periodontal diseases. Thus, the reduction and prevention of periodontal diseases will also prevent the associated pain and poor esthetics that may negatively affect the quality of life of affected individuals.

MATERIALS AND METHODS

The investigators obtained the approval for the current cross-sectional study from the Institutional Review Board and Research Committees at Jordan University of Science and Technology (JUST). Self-administered structured questionnaires were distributed during the period from January to March 2018. A convenient sample of 910 students between the ages of 18–30 years at JUST was obtained by distributing the questionnaires in various faculties’ squares, libraries, cafeterias, and corridors after obtaining their verbal consents and explaining the aims, importance, and method of the study. The questionnaire comprised a mix of multiple choice and a few open-ended questions related to students’ sociodemographic characteristics including age, gender, residency, university year of education, and faculty to which the student belongs. Oral hygiene practices and dental visits, knowledge and awareness about definitions, main causes, signs and symptoms, some associated systemic risk factors of periodontal diseases have also been collected, but also, we added multiple choices questions testing their knowledge about the effect of smoking on the healing process of periodontal diseases, as well as the effect of proper conventional treatment on teeth and frequent cleaning of teeth by hard toothbrush. Students took 5–10 min to complete the questionnaire. The Statistical Package for the Social Sciences (SPSS) software version 11.0 (SPSS®: Inc., Chicago, IL, USA) was used to entered and analyze the data. Percentages and means and standard deviations (SDs) were calculated. In addition, Chi-square test was used to do a comparison between subgroups. The level of significance was set at (P ≤ 0.05) and considered statistically significant.

RESULTS

A total of 910 structured questionnaires were distributed, and 906 (99.56%) were returned and fully completed.

Student characteristics

The age range of the study sample was between 18 and 30 years with a mean ± SD of the age of 21.15 years (±1.65). Female participants or who reside in urban areas accounted for about two-thirds (62.8% and 65.0%, respectively) of the study sample. Approximately 44% of respondents were students studying in medical disciplines (medicine (11.1%), pharmacy (11.1%), nursing (11.0%), and applied medical sciences (10.9%). More than one-half (53.8%) of respondents were junior students from the 1st, 2nd, and 3rd years [Table 1].

Table 1

Sociodemographic variables of study sample (n=906)

Variable	n (%)
Age (years)
≤19	127 (14.0)
20	214 (23.6)
21	219 (24.2)
≥22	346 (38.2)
Mean±SD	21.15±1.65
Gender
Male	337 (37.2)
Female	569 (62.8)
Residency
Urban	589 (65.0)
Rural	317 (35.0)
Faculty
Faculty of information technology	102 (11.3)
Faculty of agriculture	101 (11.1)
Faculty of science and literature	102 (11.3)
Faculty of pharmacy	101 (11.1)
Faculty of engineering	200 (22.1)
Faculty of medicine	101 (11.1)
Faculty of nursing	100 (11.0)
Faculty of applied medical sciences	99 (10.9)
Educational year
Junior students (1st-3rd)	487 (53.8)
Senior students (≥4th)	419 (46.2)

SD – Standard deviation; n – Number of students

Students’ oral hygiene practice and dental visits importance

The majority (87.2%) of students reported that they brush their teeth on a regular basis either once, twice, or more daily. While only 5.1% of students admitted that they never clean their teeth. Regular toothbrushing was reported to be significantly higher among female students (95.8%), students who attend medical (89.0%) or scientific (90.7%) specialties and reside in urban areas (89.6%) compared with the comparative groups (P < 0.000, P = 0.046, and P = 0.001, respectively) [Table 2]. Furthermore, more than one-half (54.6%) of study respondents reported that they believe that it is necessary to visit the dentist when there is bleeding from the gums [Table 3].

Table 2

Oral hygiene practice variable of the study sample by gender, faculty, and residency (n=906)

Independent variables	How many times do you brush your teeth daily?			P (Chi-square test)
	No brushing, n (%)	<1 daily, n (%)	1-3 times daily, n (%)
Gender
Male	41 (12.2)	51 (15.1)	245 (72.7)	0.000
Female	5 (0.9)	19 (3.3)	545 (95.8)
Faculty
Science	8 (3.9)	11 (5.4)	185 (90.7)	0.046
Engineering	21 (7.0)	32 (10.6)	248 (82.4)
Medical	17 (4.2)	27 (6.7)	357 (89.0)
Residency
Urban	19 (3.2)	42 (7.1)	528 (89.6)	0.001
Rural	27 (8.5)	28 (8.8)	262 (82.6)

P – *P≤0.05 considered statistically significant; n – Number of students

Table 3

Oral hygiene practice and dentist’s visit variables of the study sample (n=906)

Variable	n (%)
How many times do you brush your teeth daily?
No brushing	46 (5.1)
<One time daily	70 (7.7)
Regular toothbrushing (1-3)	790 (87.2)
Do you think you need to visit the dentist when there is a bleeding from the gum?
Yes*	495 (54.6)
No	311 (34.3)
Do not know	100 (11.0)

* – number of the sample, n – Number of students

Students’ knowledge and awareness of plaque, signs of periodontal diseases, and the related risk factors

Only about one-quarter (27.9%) of students could define dental plaque correctly [Table 4]. High proportion (89.1%) could identify all signs of gingival inflammation since female students (92.8%) and medical specialties’ students (93.0%) were highly more aware concerning gum inflammation signs and symptoms compared to males and students belonging to faculties of engineering and science (82.8%, 86.0%, and 85.8%, respectively) (P < 0.000) [Tables 5 and 6]. More than one-half (52. 2%) of students could define periodontitis as a disease of supporting structures of the tooth, where higher proportion (58.9%) of students with medical specialties correctly define it compared to the other groups (44.6% and 48.5%) (P = 0.001) [Table 5]. About 45% of students mentioned that dental plaque and calculus were the main causative factors for gum diseases. The majority (89.5% and 88.5%) of students believed that smoking could not only increase the probability of occurrence of periodontal diseases but can also be a major risk factor. Females were significantly more aware regarding those issues (93.3% and 92.4%, respectively) compared to males (83.1% and 81.9%, respectively) (P < 0.000) [Table 5]. Diabetes mellitus and heart diseases were reported as systemic risk factors increase the chance of developing periodontal diseases by 65.9% and 32.2% of students, respectively. Furthermore, females were more aware regarding the effect of systemic diseases on the development of periodontal diseases in comparison with males (P < 0.000) [Table 5].

Table 4

Knowledge about definition-, cause-, sign-related risk factors of periodontal diseases among the study sample (n=906)

Variable	n (%)
What is dental plaque?
Soft deposit*	253 (27.9)
Gingival inflammation can cause?
Bleeding, swelling, and change of color*	807 (89.1)
Periodontist means?
A disease of supporting structures of the tooth*	473 (52.2)
The main causative factor of gum disease is?
Bacterial plaque and calculus*	409 (45.1)
Smoking can?
Increase gum disease*	811 (89.5)
Do you think that diabetes mellitus increases the chance of developing gum disease?
Yes*	597 (65.9)
No	87 (9.6)
Do not know	222 (24.5)
Do you think that heart disease is associated with gum disease?
Yes*	292 (32.2)
No	292 (32.2)
Do not know	322 (35.5)
Do you think that smoking increases the chance of developing gum disease?
Yes*	802 (88.5)
No	52 (5.7)
Do not know	52 (5.7)

* – number of the sample, n – Number of students

Table 5

Knowledge about signs of gingival inflammation, risk factors that may affect the development of periodontal diseases among study sample by gender (n=906)

Variable	Gender		P (Chi-square test)
	Male, n (%)	Female, n (%)
Gingival inflammation can cause?
Bleeding, swelling, and change of color	279 (82.8)	528 (92.8)	0.000
Smoking can?
Increase gum disease*	280 (83.1)	531 (93.3)	0.000
Do you think that diabetes mellitus increases the chance of developing gum disease?
Yes*	204 (60.5)	393 (69.1)	0.007
No	44 (13.1)	43 (7.6)
Do not know	89 (26.4)	133 (23.4)
Do you think that heart disease is associated with gum disease?
Yes*	88 (26.1)	204 (35.9)	0.004
No	127 (37.7)	165 (29.0)
Do not know	122 (36.2)	200 (35.1)
Do you think that smoking increases the chance of developing gum disease?
Yes*	276 (81.9)	526 (92.4)	0.000
No	36 (10.7)	16 (2.8)
Do not know	25 (7.4)	27 (4.7)

P – *P≤0.05 considered statistically significant; n – Number of students

Table 6

Knowledge about definitions, main causes, signs of periodontal diseases among study sample by the faculty (n=906)

Variable	Faulty			P (Chi-square test)
	Science, n (%)	Engineering, n (%)	Medical, n (%)
Gingival inflammation can cause?
Bleeding, swelling, and change of color*	175 (85.8)	259 (86.0)	373 (93.0)	0.003
Periodontist means?
A disease of supporting structures of the tooth*	91 (44.6)	146 (48.5)	236 (58.9)	0.001
Do you think that diabetes mellitus increases the chance of developing gum disease?
Yes*	115 (56.4)	177 (58.8)	305 (76.1)	0.000
No	17 (8.3)	41 (13.6)	29 (7.2)
Do not know	72 (35.3)	83 (27.6)	67 (16.7)
Do you think that heart disease is associated with gum disease?
Yes*	53 (26.0)	77 (25.6)	162 (40.4)	0.000
No	65 (31.9)	103 (34.2)	124 (30.9)
Do not know	86 (42.2)	121 (40.2)	115 (28.7)

P – *P≤0.05 considered statistically significant; n – Number of students

Students’ knowledge and awareness of the consequences of long-standing periodontal diseases, healing, and conventional treatment

Roughly three-quarters (74.7%) of students were aware that long-standing periodontal diseases will cause teeth mobility followed by early loss of teeth as a consequence of advanced bone loss resulting from the inflammatory process. A higher proportion (77.0%) of female students was significantly more aware of this fact compared to males (P = 0.043). Furthermore, 84.9% of students were aware that tobacco smoking has a negative effect on the healing process of periodontal diseases by delaying wound healing where females accounted the largest proportion (88.0%) in comparison with other group [Table 7]. Less than one-third (29.6%) of students were aware that proper conventional treatment such as scaling is not harmful to the teeth. It was also reported that scaling may be harmful to the teeth by chipping of the outer layer, scratching of teeth, and discoloring of teeth by 50.6%, 14.5%, and 5.4% of students, respectively. About two-thirds of students were aware that frequent cleaning using hard toothbrush could cause gingival recession [Table 8].

Table 7

Knowledge about the effect of smoking on healing of periodontal diseases, effect of proper scaling on teeth, and frequent cleaning of teeth by hard toothbrush among study sample by gender (n=906)

Variable	Gender		P (Chi-square test)
	Male, n (%)	Female, n (%)
Long-standing periodontal disease cause?
Mobility, advanced bone loss leading to early loss of teeth*	239 (70.9)	438 (77.0)	0.043
Does smoking affect negatively on healing of periodontal diseases
Yes*	268 (79.5)	501 (88.0)	0.002
No	34 (10.1)	30 (5.3)
Do not know	35 (10.4)	38 (6.7)
Frequent cleaning of teeth by a hard toothbrush may?
Causes receding gums*	191 (56.7)	388 (68.2)	0.001

P – *P≤0.05 considered statistically significant; n – Number of students

Table 8

Knowledge and awareness about consequences of long-standing periodontal diseases, the effect of smoking on healing of periodontal diseases, effect of proper scaling on teeth, and frequent cleaning of teeth by hard toothbrush among study sample (n=906)

Variable	n (%)
Long-standing periodontal disease cause?
Mobility of teeth and advanced bone loss resulted in early loss of teeth*	677 (74.7)
Does smoking affect negatively on healing of periodontal diseases
Yes*	769 (84.9)
No	64 (7.1)
Do not know	73 (8.1)
Proper scaling may be harmful to the teeth by?
Not harmful*	268 (29.6)
Frequent cleaning of teeth by a hard toothbrush may?
Causes receding gums*	579 (63.9)

* – number of the sample, n – Number of students

DISCUSSION

To the best of our knowledge, studies are scarce regarding the awareness and knowledge of oral/dental health or periodontal disease among university students in Jordan, the main aim of which is estimating the awareness and knowledge of etiology of periodontal diseases and some associated local or systemic risk factors.[151617181920] A limitation of this study is related to using self-reported questionnaire, so answers may be subject to bias or inaccuracy. A verbal rather than written consent was taken from these participants because many of them had limited time to read and sign such consent and prefer to give their consents verbally. The comparison between our findings and those of others may be difficult to some extent due to variations and inconsistencies among studied populations, required studied variables, study design and sampling, selection criteria, the subjectivity of self-reporting questions by participants, and data processing and analyses differences. Therefore, our results will not be fully compared with others.

Students’ oral hygiene practice and importance of dental visits

Our study revealed that the majority (87.2%) of students reported that they brush their teeth on a regular basis once or more daily, while only 5.1% of students admitted that they never clean their teeth. Our finding was in agreement with previous studies conducted in Jordan were in 71.4%–96.8% university students admitted that they brush their teeth regularly and only very few proportions of them never clean their teeth.[151819] Although our study illustrated that a high percentage of students claimed that they brush their teeth regularly, this does not guarantee the validity of their claims or they may brush their teeth for the inadequate duration or brushing technique, using incorrect brush. The findings of the current study illustrated that regular toothbrushing was reported to be significantly higher among female students (95.8%), students who attend medical (89.0%) or scientific (90.7%) disciplines and reside in urban areas (89.6%) compared to comparative groups. Our finding was regarding gender differences in agreement with findings of the study conducted by Al-Omari and Hamasha.[16] Better oral hygiene practice found among females may reflect their interest in maintaining good appearance due to higher female concerns about the body and facial image.[21] Based on the finding of the current study, more than one-half of respondents reported that they believe it is necessary to visit the dentist when there is bleeding from the gums. This finding is almost similar to the findings of the study conducted by Al-Batayneh et al. which revealed that 47.0% of students reported that they visit the dentist when they have pain or bleeding gums.[19] On the other hand, another study conducted among nursing students at University of Jordan by Smadi and Nassar showed a significantly higher percentage (86.0%) of students compared to our findings.[20]

Students’ knowledge and awareness of plaque, signs of periodontal diseases, and some related risk factors

In the present study, a low proportion of students could define dental plaque correctly. Previous studies conducted by other researchers such as El-Qaderi and Smadi and Nassar among Jordanian University students showed that higher proportions (38.0% and 51.8%, respectively) of students were able to correctly identify the definition of dental plaque.[1520] Moreover, a high proportion could identify all signs of gingival inflammation since female students and medical disciplines’ students were highly more aware in comparison with males and students belonging to faculties of engineering and science. Students with medical specialties could correctly define periodontitis compared with the opposite groups. This could be explained by students’ curriculum containing medical-related information such as physiology, anatomy, histology, and microbiology. The overwhelming majority of students believed that there is a relationship between smoking and periodontal diseases development. Our finding is similar to the finding of Al-Batayneh et al. who revealed that about 80% of students believed smoking has harmful effects on oral health.[19] Similarly, a study conducted by Al-Zarea found that students with scientific disciplines were more aware of the relationship between smoking, diabetes mellitus, and heart diseases on the one hand and periodontal diseases on the other hand compared to students of the humanities disciplines.[22] This can be explained by students of scientific disciplines who may be more interested in issues related to health and thus obtaining a type of public health education, which could involve some oral health issues and their relations to general health. Hence, differences in oral health knowledge in the study sample may reflect the students’ interests, education, and their curriculum.

Our study revealed that a high proportion of students was aware that long-standing periodontal diseases will cause teeth mobility leading to early loss of teeth as a consequence of advanced bone loss resulting from the inflammatory process. In addition, female students were significantly more aware of this fact compared to males. Furthermore, the majority of students with a predominance of females were aware that tobacco smoking negatively affects healing of periodontal diseases by delaying wound healing. This could be explained by females that are generally more health conscious supported by the fact that smoking is more frequent among males than females.[1011] A low proportion of students was aware that proper conventional treatment such as scaling is not harmful to the teeth while reporting that scaling may be harmful to the teeth by chipping of the outer layer, scratching of teeth, and discoloring of teeth. This could be explained due to the absence of the role of both faculties of dentistry and applied medical sciences regarding the use of various educational methods such as brochures, lectures, and writing in university newspapers that directed for university students but also for not including mandatory courses related to oral/dental health in curriculum during preuniversity and university education. Moreover, a good percentage of students were aware that frequent cleaning using hard toothbrush could cause gingival recession.

CONCLUSIONS

The study demonstrated that there is relatively a lack of knowledge and awareness regarding the etiology of periodontal diseases as well as the effect of local and systemic factors on periodontal health among university students. Furthermore, there is a poor knowledge about the effect of proper conventional treatment in maintaining and preventing further destruction of periodontal tissues and the effect of oral health on body health and vice versa.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.