Knowledge, Practices, and Perceptions about Tooth Whitening among Female Population in Saudi Arabia - A Cross-Sectional Study.

BACKGROUND: Tooth-whitening procedures have gained wide popularity among the Saudi population. The present study aimed to assess the knowledge, attitude, and perception about tooth-whitening procedures among Jeddah's general population.
MATERIALS AND METHODS: A face-to-face interview was conducted on randomly selected female patients attending dental clinics. A pretested and structured questionnaire was used to record the response by calibrated interviewers. The responses regarding knowledge, attitude, and perceptions were recorded and subjected to statistical analysis.
RESULTS: The findings showed that the prevalence of tooth whitening among the participants was 43.7%, and about 8.7% reported that they did it once every year. In-office bleaching was the most preferred method (31.4%), followed by whitening toothpaste (8.7%). An increased frequency of bleaching was reported by participants belonging to younger age group (P < 0.001).
CONCLUSION: The knowledge related to the mechanism of action and adverse effects was average among the participants. Younger age groups were more concerned about tooth-whitening procedures compared to the older ones. Copyright:

INTRODUCTION

A beautiful smile is one of the characteristics everyone desires to have on their face irrespective of age, and to possess healthy and white teeth is a strong imperative. Tooth bleaching or whitening is one of the easiest and cost-effective methods that people often opt for treating tooth discoloration.[1] Different types of bleaching procedures are performed on vital and nonvital teeth, including in-office bleaching, at-home bleaching, whitening toothpaste, and strips.[23] Each procedure's efficacy depends on discoloration of the particular tooth that can be either intrinsic or extrinsic staining. Intrinsic staining is attributable to many host factors such as age, genetics, high levels of systemic fluoride consumption, medicines, and developmental disorders. Extrinsic staining mainly happens due to environmental factors, including smoking, pigments in beverages and foods, medications, and metals such as iron or copper.[4]

In tooth whitening, the physical removal of the stain or a chemical reaction makes the teeth lighter, mainly by the degradation of the chromophores or chromogens.[5] It has been reported that tooth whitening is safe and effective when done under a dentist's supervision.[6] Various agents have been tried since the 1800s for removing tooth stains such as oxalic acids, chlorine, and cyanide of potassium but were discontinued due to adverse effects.[78] Even though tooth whitening is considered the most popular esthetic treatment, people are not aware of the type, mechanism of action, duration of bleaching effect, and side effects. Studies show a steep increase in the demand for tooth-whitening procedures, as people desire to have a Hollywood smile.[910] This study aimed to assess the knowledge, attitude, and practices about tooth whitening among Saudi female citizens living in Jeddah, Kingdom of Saudi Arabia.

MATERIALS AND METHODS

A cross-sectional face-to-face interview was conducted among female patients visiting various dental clinics using a pretested and validated questionnaire. Only Saudi nationalities in the age range of 18–60 years were included to respond to the questionnaire recorded by trained and calibrated personnel. People attending five dental clinics were randomly selected based on the availability and consent. A total of 229 samples were randomly chosen from considering a minimum sample of 176 calculated based on the standard deviation of scores obtained on a pilot study of 25 participants. Validations of the questionnaire were done by conducting face, content, and construct validity. Face and content validity were done by expert evaluation and group discussions, and exploratory factor analysis was applied to analyze the construct validity of the items. Internal consistency with a Cronbach's α coefficient >0.70 was preferred. The final questionnaire included ten close-ended items that measured the knowledge, attitudes, and practices related to tooth whitening.

All the data obtained were entered and cleaned in Microsoft Excel and then transferred to SPSS version 23 for statistical analysis done by an independent biostatistician. Frequencies and percentages were used for presenting categorical data, and any relationship between the categorical item variables was analyzed using Pearson's Chi-square test. P < 0.05 was considered statistically significant.

RESULTS

The sociodemographic characteristics showed that 33.6% (n = 77) of the participants belonged to the age group of 18–24 years, 20% (n = 45) to 25–30 years, 17% (n = 40) to 31–40 years, and 29% (n = 67) belonged to 41–60 years. The prevalence of bleaching in our study population was found to be 43.6% (n = 100) and out of this, 4% (n = 4) did bleaching once in 3 months, 15% (n = 15) had it done every 6 months, 20% (n = 20) did it once in a year, and the remaining 61% (n = 61) had done it once in a lifetime. The most preferred bleaching method by the participants was “in-office” bleaching (49.3%) followed by at-home bleaching (25.3%). Regarding recommending their preferred bleaching method to their family and friends, 39.3% agreed that they would do it, whereas 30.1% reported that they will not recommend it [Table 1]. When questions regarding knowledge were asked, 39% of the participants agreed that they know the duration effect of bleaching, 23.6% believed that side effects of the bleaching were irreversible, and 63.8% agreed that bleaching would cause tooth sensitivity. When the participants were asked that whether bleaching will lead to bleeding gums, 25.3% agreed that it would do and 70.7% agreed that there is difference between tooth bleaching and tooth polishing.

Table 1

Practices and attitudes toward bleaching

	n (%)
Frequency of bleaching the teeth
Every 3 months	4 (1.7)
Every 6 months	15 (6.6)
Once per year	20 (8.7)
Once in a lifetime	61 (26.6)
Never	129 (56.3)
Type of bleaching/tooth-whitening methods used
Home bleaching	15 (6.6)
In-office bleaching	72 (31.4)
Whitening dentifrices	20 (8.7)
Whitening strips	16 (7.0)
Never use	106 (46.3)
Bleaching/tooth-whitening methods preferred to use
Home bleaching	58 (25.3)
In-office bleaching	113 (49.3)
Whitening dentifrices	28 (12.2)
Whitening strips	30 (13.1)
Recommend bleaching to family and friends
Yes	90 (39.3)
No	69 (30.1)
Not sure	70 (30.6)

The relationship of frequency of bleaching with age showed that participants aged below 30 years (18–24 and 25–30 years) did bleaching at least once in 6 months or less compared to the higher age group, and this association was statistically significant (χ2 (12,229) = 35.062, P < 0.001) [Table 2]. It was also observed that the age group of 18–24 years used “home bleaching” and whitening strips more commonly compared to other age groups. Whereas, the age group of 41–60 used “in-office bleaching” comparatively more than others, and this was statistically significant (χ2 (12,229]) = 24.243, P < 0.019) [Table 3].

Table 2

Relationship of age of the participants with prevalence of bleaching

Age (years)	Frequency of bleaching (%)					Total (%)	P*
	Every 3 months	Every 6 months	Once per year	Once in a lifetime	Never
18-24	2 (2.6)	7 (9.1)	2 (2.6)	17 (22.1)	49 (63.6)	77 (100)	<0.001
25-30	2 (4.4)	7 (15.6)	1 (2.2)	15 (33.3)	20 (44.4)	45 (100)
31-40	0 (0.0)	0 (0.0)	9 (22.5)	8 (20.0)	23 (57.5)	40 (100)
41-60	0 (0.0)	1 (1.5)	8 (11.9)	21 (31.3)	37 (55.2)	67 (100)

*A P<0.05 is considered statistically significant

Table 3

Relationship of age with type of bleaching used

Tooth-whitening methods use	Age of the participants (years)				Total	P*
	18-24	25-30	31-40	41-60
Home bleaching	8 (53.3)	1 (6.7)	2 (13.3)	4 (26.7)	15 (100)	0.019
In-office bleaching	13 (18.1)	20 (27.8)	15 (20.8)	24 (33.3)	72 (100)
Whitening dentifrices	10 (50.0)	3 (15.0)	4 (20.0)	3 (15.0)	20 (100)
Whitening strips	9 (56.3)	5 (31.3)	1 (6.3)	1 (6.3)	16 (100)
Never use	37 (34.9)	16 (15.1)	18 (17.0)	35 (33.0)	10 (100)

*A P<0.05 is considered statistically significant

DISCUSSION

The current study findings showed that the prevalence of bleaching among our study population was 43.6%. No studies have been done in Saudi Arabia that assessed the prevalence of tooth-whitening procedures except some studies that assessed the knowledge, desires, and previous bleaching experiences.[1112] The selection of appropriate tooth-bleaching or tooth-whitening methods and products is dependent on the correct diagnosis of the discoloration.[13] The prevalence of discoloration in the urban population ranges from 41% to 50%, and tooth whitening is the commonly applied treatment for this purpose.[1415]

People need to be aware of the different types of bleaching methods and products to help them make optimal decisions about the treatment they need to do, considering the cause of tooth discoloration. In our study, in-office bleaching was the frequently used and preferred method by the participants. Hydrogen peroxide (H2O2) is the active ingredient that is commonly used in most tooth-bleaching products.[416] H2O2 usually causes undesirable effects in the oral cavity such as mucosal irritation, teeth sensitivity, microcracks on enamel, root resorption, and pulpitis.[17] People need to understand these adverse effects well in advance to prepare themselves, thus minimizing the complaints about treatments done by dentists. In-office bleaching is always the recommended method, as it will reduce the adverse effects and help the patient achieve immediate visible results.[18] The majority of the participants (64%) in our study were aware that bleaching causes tooth sensitivity. In contrast, only fewer participants knew that it would cause gingival bleeding or inflammation when misused.

Participants who belonged to lower age groups underwent tooth whitening comparatively more than older age groups. This could be explained based on the fact that people in these age groups have greater concerns about self-esteem, appearance, and smiles.[19] Another important factor patients should be aware of themselves is the type of stain they have, as this will influence the satisfaction with the outcome of bleaching procedures. Extrinsic stains result from the accumulation of chromatogenic substances on the external tooth surface and are easily removed compared to intrinsic stains.[20] In this study, 17% of the participants claimed that they know the duration of effect that bleaching is going to produce. Surprisingly, there is very little evidence of the exact duration of the bleaching effect on the teeth' color. It depends on various factors such as the type of bleaching agents and procedures used, reoccurrence of the causes of tooth discoloration, and patient compliance.[21] These findings are similar to that of a study done by Attin et al., which also suggested that it is mandatory to have a thorough knowledge of the technique and agent used to reduce the adverse effects.[22] The usage of whitening dentifrices and strips was also reported in our study, but to a very less extent. Studies have also reported that whitening dentifrices and strips effectively remove extrinsic stains, and people could use these products as they are easily available and ready to use with very few undesirable effects on the oral cavity.[2324]

CONCLUSION

In the present study, more than half of the participants never underwent tooth bleaching, and the people who did it more frequently belonged to younger age groups. The use of different techniques and methods also significantly differed among various age groups. The participants demonstrated moderate knowledge related to the adverse effect of tooth bleaching on the oral mucosa. Dentists need to understand each patient's level of knowledge and perceptions about whitening, products, and methods, which would help them have better compliance during and after treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.