Int J Adolesc Med Health 2015; aop

Henrique Pedro Soares Luís*, Victor Abreu Assunção and Luís Francisco Soares Luís

Oral health habits, attitudes and behaviors of Portuguese adolescents DOI 10.1515/ijamh-2014-0069 Received October 13, 2014; accepted January 1, 2015

Abstract Purpose: Oral health has a profound impact on the health of adolescents. The aim of the present study was to obtain information on habits, knowledge and oral hygiene attitudes of Portuguese teenagers and to study the gender differences concerning these issues. Methods: A total of 1203 adolescents participated in the study (55.8% females; mean age, 14.9 years). To recruit participants, a national network of community dental hygienists, working in the health centers, was created, and adolescents were contacted at the schools. A questionnaire was applied in the classroom, during school hours, under supervision of one researcher and the classroom teacher, after collection of informed consent forms. Results: Portuguese adolescents do not seem to have dental fear but have some anxiety when at the dental office; girls are more anxious than boys. Girls are also more concerned with esthetics and aware of dental problems and care about oral health of family and friends. Parental supervision is more relevant for boys in order to obtain better compliance with dental care; however, 97.2% of the adolescents do not consider maintaining teeth throughout the lifetime as relevant. Conclusions: Teenagers recognize dental professionals as educators and oral health as relevant in their lives. It is possible to assume that gender has an influence on adolescent’s habits, behavior and attitudes regarding oral hygiene. There is a difference between boys and girls concerning their habits, knowledge and attitudes in dental hygiene; this difference may show the need to create different strategies for oral health promotion for these two groups of adolescents. Keywords: adolescents; attitudes; dental hygiene; gender role; oral health. *Corresponding author: Henrique Pedro Soares Luís, PhD, Dental Hygiene Degree, Cidade Universitária, 1649-003 Lisboa, Portugal, Phone: +351 965059976, E-mail: [email protected]; and Faculdade de Medicina Dentária da Universidade de Lisboa, Lisbon, Portugal Victor Abreu Assunção: Escola Superior de Saúde, Instituto Politécnico de Portalegre, Portalegre, Portugal Luís Francisco Soares Luís: Escola Superior de Saúde, Instituto Politécnico de Portalegre, Lisbon, Portugal

Introduction Adolescence is the period of human existence in which personality is accentuated and where knowledge and habits that can last a lifetime are acquired. In what concerns to health education, adolescence is considered the most difficult period, since it is characterized by attitudes of rebellion and resistance to accept advices and information provided by parents or teachers (1). From a biological perspective, the transition from childhood to adulthood occurs during adolescence, and it is marked by radical transformations that transitionally shape the individual and carry along physical and emotional difficulties that may require monitoring by family, friends and health professionals (2). Many hazards to health may occur during adolescence, mainly because young people underestimate risks and have the perception that they are not susceptible, or vulnerable, to diseases (3, 4), and in the case of oral health, hazards come from the fact that it is not associated with general health (5), which may influence attitude towards oral care (6). The fact that oral health may be considered, by adolescents, low priority in health care can affect the development of health behaviors and the ability to obtain knowledge that promotes good oral health (6–8). It is very common to find teenagers who report “forgetting” brushing their teeth or that “have no time” to take care of their dental hygiene. These are examples of how difficult it is to find regular maintenance habits of oral health in this age group (5, 9). Poor oral hygiene has a profound impact on the overall health of adolescents, with consequences not only in the oral cavity but also in the general welfare of the individual, since it causes severe pain and difficulty in chewing, thus preventing adequate food consumption (10). A teenager with toothache has, certainly, conversation and concentration difficulties, which in turn will negatively influence educational outcomes (11). Such a fact

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2      Luís et al: Oral health of Portuguese adolescents

was observed in the United States, where common oral problems are responsible for more than 51 million school hours lost each year (12). In spite of the information that many adolescents do not pay much attention to oral health, their knowledge about oral health issues is high; as a matter of fact 90% of teenagers know the cause for dental caries and the role of tooth brushing in oral disease prevention. Lower values, on the order of 40%–60%, were found regarding the knowledge on the reasons for gingivitis and the relevance of flossing and fluoride (13). The educational level is directly related to oral health status; this means that adolescents with higher education present a greater frequency of brushing and lower risk of periodontal diseases (14); in addition to this factor, the oral health of adolescents is also related to the socio-economic and educational level of their family. It is known that adolescents from families with lower education and income have inferior tooth brushing frequency, when compared to those from families of higher socioeconomic and educational level (15). Gender is also a relevant issue when studying the oral health of adolescents. Girls usually present a better understanding of oral health, paying more attention to it and presenting better behavior (16). Concerning oral health habits, there is a similar approach between males and females (17) making gender a factor to consider when analyzing cognitive factors to modify oral health behavior. Knowledge about oral health is different between genders; girls have more knowledge than boys (18), which makes gender relevant when planning and implementing oral health programs. Oral health attitudes, acquired at this stage of existence, are fundamental to maintain good oral health habits throughout life. In order to get adolescents to change their attitudes towards oral health, it is necessary to be persuasive in the message. Generally, it is much easier to adapt to a preexisting attitude than to modify it. Adolescence is a key period to implement health promotion strategies (19). In order to implement these strategies, and the consequent development of oral health promotion and education programs, it is critical to identify habits, knowledge and attitudes of adolescents related to oral health. The application of a questionnaire for gathering this information is a necessary step. A questionnaire that allows the assessment of habits, knowledge and attitudes of adolescents in oral hygiene, created by researchers at the University of Murcia, Spain, was translated into Portuguese and validated (20) and, now, applied to 1203 Portuguese adolescents. The main

goal of the research reported here was to explore the habits, knowledge and oral hygiene attitudes of Portuguese teenagers, from every area of the country. The collected data are presented in this article.

Methods Participants A total of 1203 adolescents participated in the study (mean age, 14.9 years; standard deviation 1.7 years), distributed as 532 boys (44.2%) and 671 girls (55.8%). Most of the participants live in the Lisbon area (46.7%), and the lowest numbers of participants live in the northern area of Portugal (6.3%). To recruit participants, a national network of community dental hygienists, working in the health centers, was created, and adolescents were contacted at the schools. Data were collected during years 2012 and 2013. Participants were informed about the purpose of the study and about the voluntary basis of their participation. Confidentiality of their responses was assured, and they provided an informed consent. For participants under 18 years old, a written informed consent was obtained from their parents. Consent forms were also obtained from every school director and from every health center director. The study was approved by the Ethics Committee at the Faculdade de Medicina Dentária at the Universidade de Lisboa.

Procedure Questionnaires were applied in the classroom, during school hours, with all participating adolescents present, under supervision of one researcher and the classroom teacher, after collection of informed consent forms. Questionnaires were analyzed at the Faculdade de Medicina Dentária facilities in Lisbon. The collected information are anonymous; for personal information only gender and age were recorded.

Materials Participants completed the Oral Health Habits, Attitudes and Behaviors of Portuguese Adolescents questionnaire.

The questionnaire The questionnaire is organized in five dimensions, in a total of 28 statements. Agreement with statements is expressed in five-item Likert scales, ranging from totally agree to totally disagree. Questionnaire dimensions are on dental fear (nine statements), esthetic and dental hygiene (six statements), concern with health (four statements), dental problems prevention (six statements) and general health (three statements). To the original version of the questionnaire, the authors added three multiple-choice questions on tooth brushing frequency,

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Luís et al: Oral health of Portuguese adolescents      3

instruments used for dental hygiene and time of tooth brushing. Data on questionnaire translation and validation are presented elsewhere (20).

Statistical analysis Descriptive data were collected for sample characterization and analysis of answers. Independent samples Student’s t-test was used to examine the differences between genders for the study variables. The level of significance was set at α  ≤  0.05. All statistical analysis was calculated with SPSS 19.0 for windows (IBM Company, New York, NY).

Results A total of 1203 adolescents participated in the study (mean age, 14.9 years; standard deviation 1.7 years), distributed as 532 boys (44.2%) and 671 girls (55.8%). In the study of the questionnaire dimensions it is possible to notice that, for “dental fear” dimension, the sample of adolescents do not seem to have dental fear, since the agreement with the fear-related statements is always below 20% of the respondents, except when a majority of adolescents (54%) state that a visit to the dental office is a stressful event and also that the fear of pain makes 61.8% of them attentive to dental caries prevention. For the “esthetic and dental hygiene” dimension, there is a conscientious approach towards esthetics since 96.6% of the adolescents disagree with the statement that prefers not cleaning teeth because no one notices it. Also, 98.9% disagree with the statement that prefers not brushing teeth because it is not worth it, and 93.1% disagree with the statement on not being concerned with the way teeth look. It is, however, significant that 97.2% of the adolescents consider it not relevant to maintain teeth throughout the lifetime; this may be related to cultural issues and also to the assumed fact that teeth can be easily replaced by dentures. It is also possible to notice the rebellious attitude of adolescents with 94.1% of them agreeing that they do not take care of their oral health in spite of their parents reminding them. For the “concern with health” dimension the majority of adolescents are attentive to personal, and also to family and friends’, oral health. Examples of that concern are the 95.4% of agreement with the statement referring to the intention of maintenance of a good oral health and also the 87.4% agreement with the statement on the intention of working for family and friends to have a good oral health. Dentists are widely accepted as health advisers

by 78.1% of the adolescents, who would look for dentists for dental care in the same percentage, and the dentist’s advices are accepted by 88.7% of the adolescents. The “dental problems prevention” dimension shows that there is an attitude of disease prevention in this sample of adolescents, and a percentage above 50% in agreement is always observed when answering the statements revealing a preventive option. Education on dental problems prevention in childhood is considered to be relevant by 95.2% of the adolescents. This dimension also provides us with a clear sign of the need for education on gingival disease prevention for adolescents, since this oral condition is not considered, by 91.9% of the adolescents, as relevant for their health. Also for “general health” dimension there is a strong belief on the relationship between oral health and general health, since at least 88% of the adolescents agree with the statements that affirm this rapport. The study of the three multiple-choice questions on tooth brushing frequency, on instruments used for dental hygiene and on time of tooth brushing reveals that 2.7% of the adolescents never brush their teeth, 12% brush once a day, 54.1% brush twice a day and 35.2% brush their teeth more than twice a day. For the use of oral hygiene instruments, the vast majority (98.4%) use toothbrush and toothpaste, 26.4% also floss and 32.5% use a fluoride mouth rinse. The time of day for toothbrush is for most of the respondents (89.2%) in the morning. Eighty-five percent also brush before going to bed and 35.1% after breakfast.

Differences between genders When looking for gender differences, it is possible to verify, in the “dental fears” dimension, that boys do not seek dental care independently and present a statistically significant increased fear for dental treatment than girls (p = 0.013). Girls are, however, more nervous than boys at the dental office (p 

Oral health habits, attitudes and behaviors of Portuguese adolescents.

Oral health has a profound impact on the health of adolescents. The aim of the present study was to obtain information on habits, knowledge and oral h...
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