Although more than three fourths of the 2,500 teenagers surveyed thought it was possible to prevent tooth decay, they showed a lack of knowledge about what is needed fo r optim um oral health. Nearly all the teenagers brushed, and most went to their dentists fo r checkups. Very few knew about plaque. Only a m inority used dental floss, and then fo r the removal of food particles, not plaque.
Teenagers’ attitudes, knowledge, and behaviors related to oral health
E rw in L. L in n , P h D , S a n F r a n c is c o
T eenagers are a neglected audience for dental educational efforts. Their need is obvious given their high risk o f dental disease. Information about what they know and do would be a guide to what they need to know and do, and it also could help in developing strategies to reach this age group. Y et research about teenagers has been narrow in scop e and has dealt alm ost solely with dental visits, frequency and time o f toothbrushing, or amount of oral d ise a se .1"8 This pa per presents findings from a questionnaire sur vey o f teenagers’ attitudes, know ledge, and be haviors about oral health.
T h e surve y In the fall 1969, 2,530 sophom ores in three public sch o o ls in M inneapolis and its suburbs filled in questionnaires. A ll students in attendance on the day o f distribution of the questionnaires took part. Thirteen questionnaires were discarded becau se nearly all answ ers w ere flippant. A lm ost all the students w ere white (98%), and 946 ■ JADA, Vol. 92, May 1976
the numbers o f boys and girls w ere about equal. T he mean annual fam ily incom e in 1968 for the areas in which they lived was betw een $9,000 and $10,000. T he questionnaire took about an hour to com plete. M ost questions required selection o f an answ er from a checklist. In this article, the words used are those usually used by the profession. T he questionnaire did not use these words, but rather words usually used by the public (for ex am ple, “ gum s” rather than “ gingiva” ). All differences discussed in this article are statistically significant. T he standard for signif icance was that the difference could have arisen by chance in 5% or less o f sam ples drawn from the universe. T he chi-square test was used.
A ttitu d e s T ooth decay is prevalent in nearly all young peo ple, and as would be exp ected , a high percentage o f the sophom ores (80%) thought that tooth de cay was serious.
The students showed their awareness of the risk o f occurrence of tooth decay in answers to several questions. Sixty-two percent thought it was possible that they had one or more carious lesions at the time of the survey. If they did not go to the dentist during the following year, 94% indicated that they would need treatment. Two thirds checked that something can happen to the teeth without one’s knowing it. Ninety-three percent claimed that they had a regular dentist. The inevitability o f tooth decay could lead to a fatalism that could be a barrier to dental edu cational efforts. H owever, only a minority sub scribed to statements o f fatalism. For instance, 11% agreed that “ no matter how well you take care of your teeth, eventually you will lose them .” Seventeen percent agreed that “ once you get your permanent teeth, what you eat or drink can’t affect—one way or another—how much your teeth decay.” Thirty-two percent agreed that “ some people are just bom with good teeth and others are not, and there is not much anyone can do about it.” In 1959, when the same statements were pre sented to a national sample of adults, a higher per centage agreed with each statement: 41% agreed with the first statement, 21% with the second, and 60% with the third.9 In the study of adults, agreement with each statement increased as the age of respondents increased. It can be inferred that preventive dental health education would be better received by teenagers than adults, and by younger than older adults. Eighty-four percent o f the sophomores checked that the chances were good that they would be able to prevent tooth decay. This high percentage is consistent with the majority’s re jection of the fatalistic statements about tooth decay and loss. H owever, their awareness that they can prevent tooth decay is not based on much knowledge or preventive behavior, as will be documented. Perhaps more important than fatalism are the various motives that stimulate teenagers to care for their teeth. For instance, only a third rated “ to keep your teeth as long as possible” as the most important reason for taking care o f the teeth and gingiva. A somewhat higher proportion checked “ to help your appearance” (Table 1). Asked why they went to the dentist for a check up, only 40% wrote answers about keeping their teeth or other answers that may reflect concern about oral health; the others answered that they went because their parents made them go or that it was a habit. In addition, although a majority
Table 1 ■ The most important reason for taking care of
teeth and gingiva. %
%
%
Most im portant reason____________ boys_____ girls______both To help your appearance To prevent other illnesses To avoid later expensive treatment To avoid future pain and trouble To keep your teeth as long as possible No. w ho answered the question
37 3
37 3
37 3
10
8
9
19
16
18
31
35
33
1,083
1,126
2,209
Table 2 ■ Dental conditions worried about most. °/o
%
%
Dental condition
boys
girls
both
Broken or lost permanent teeth Discolored teeth Sore or bleeding gingiva P oorly aligned teeth Tooth decay No. w ho answered the question
44 15 7 11 24 1,196
26 25 7 16 26 1,159
35 20 7 14 25 2,355
worried most about serious oral problems (tooth decay, broken or lost teeth, or sore and bleeding gingiva), another 20% worried most about discol ored teeth, again more a matter of cosm etics than oral health (Table 2).
Knowledge
■ Periodontal disease: Only 25% attempted to write a description o f periodontal disease (Table 3). Twenty-two percent wrote something about the gingiva, though the answers ranged from a correct description of symptoms to the mention o f tooth decay as well. Three percent wrote about tooth decay but did not say anything about the gingiva. ■ Tooth decay: It was expected that all the teen agers knew that candy, at least, could be a cause of tooth decay. Yet, when asked what causes tooth decay, only a third wrote candy, sweet foods, sugar, or the “ wrong foods” (Table 4). Table 3 ■ Description of periodontal disease. % boys
Description* A disease of the gingiva Sore, swollen, bleeding gingiva Teeth fall out, tooth m obility Other answers about gingiva Teeth decay, disease o f teeth Other (for example, bad breath) Did not know or did not write a description No. w ho answered the question
% girls
% both
8 5 4 3 2 —
16 14 9 5 4 1
12 10 7 4 3 —
83
66
75
1,282
1,200
2,482
*lf given, tw o answers per person were coded. If more than two codes applied, preference was given to symptoms described (for example, gingiva, tooth mobility). Linn: TEEN AG ERS'ORAL HEALTH ■ 947
Table 6 ■ What you can do if you don’t have your
Table 4 ■ W h a t c a u s e s to o th d e c a y . Cause of tooth decay* Sweet foods, sugar, w rong foods Food particles caught between teeth; decaying food Not brushing; im proper brushing Lack o f care; not cleaning Germs; bacteria Acid Not going to dentist Other No. w ho answered the question
% girls
% both
30
39
34
What you can do*
31 26 14 13 10 1 3
26 40 16 9 6 4 5
28 32 15 11 8 3 4
1,060
1,093
2,153
Rinse with water; use mouthwash Chew gum Eat fru it; eat vegetables Use fingers Floss Toothpicks Other No. w ho answered the question
T ab le 5 ■ How a person can take good care of his teeth
and gingiva.
Brush teeth Go to dentist; have checkups Avoid sweets; watch w hat you eat Good food; balanced diet Floss Massage or brush gingiva Other: chew gum; rinse; use oral irrigating device; fluo ride treatm ent No. w ho answered the question
% boys
% girls
% both
96 29 14 7 4 4
95 50 21 15 6 6
93 40 17 12 5 5
6 967
6 1,077
6 2,044
*lf given, three answers per person were coded.
An additional 25% wrote about food caught be tween the teeth but did not specify that it be sweet or “ wrong.” Eleven percent said that bac teria or germs and 8% said that acid causes tooth decay. Only six respondents knew about “ plaque” ; this answer was included in “ other” in Table 4. In most populations, prevention is equated with toothbrushing.10 In this sample, 32% report ed that not brushing or improper brushing is the cause o f tooth decay. In addition, 15% answered vaguely about lack of care or cleaning (Table 4). ■ M eans o f preventing oral disease: When asked how a person could take very good care o f his teeth and gingiva, 93% o f the teenagers wrote about brushing. Forty percent answered, “ go to the dentist.” Seventeen percent men tioned the avoidance of sweet foods or drinks, and 12% suggested a good or balanced diet. Only 5% said, “ U se floss” (Table 5). Rinsing with water or using a mouthwash was the most frequent answer (Table 6) to the ques tion, “ What can you do if you don’t have your toothbrush with you?” “ Chew gum” ranked next in frequency. This answer probably came mainly from an advertisement by a gum manufac turer that presents its product as an oral health aid, without adding that it contains sugar. Some teenagers did specify sugarless gum, but added occasionally names of gums that are not sugarless. There were relatively few other kinds of 948 ■ JADA, V ol. 92, May 1976
% boys
% girls
% both .
44 37 7 9 3 8 4
55 36 11 10 6 3 4
50 35 9 9 5 5 4
923
1,061
1,984
*lf given, tw o answers per person were coded.
*lf given , tw o answers per person were coded.
How to take good care*
toothbrush.
% boys
answers (Table 6). N ine percent suggested eat ing apples, other fruits, or vegetables. These alternatives to brushing are now considered of questionable value for plaque removal because o f conflicting evidence about their detergent effects.11 The use o f floss, recommended by most dental health educators, was noted by only 5%.of the teenagers. Sixty-eight percent agreed that the gingiva can be kept in good condition if teeth are cleaned regularly in a dental office. However, 78% agreed with the statement that one can help pre vent tooth decay by having his teeth cleaned in a dental office. It cannot be concluded, there fore, that the teenagers had discriminating knowledge that a professional prophylaxis can help prevent periodontal disease.
Behaviors
■ Brushing: Ninety-nine percent o f the teen agers said that they had a toothbrush at home. Ninety percent said that they brushed at least once a day, and only 1% said they never brushed. Brushing is obviously a daily behavior for nearly all the sophomores as it is for all other age groups whose dental health practices have been stud ied .10 Brushing after breakfast and right before bed were each reported by two thirds o f the teen agers. These times are also the most frequently reported in other studies of children or young adults.12-8 Other times were mentioned much less frequently, with the exception o f the girls’ brushing “ before going out” (Table 7). Brushing is rarely done elsewhere than at home. Only 5% said they carried a brush with them. Two percent claimed that they had a brush at school. Motivating teenagers to brush elsewhere than at home probably would be difficult. When asked why most teenagers did not brush at school,
Table 7 ■ W h e n te e th a re b ru s h e d .
Table 10 ■ E x p e r ie n c e w ith o r a l h y g ie n e a id e s.
% boys
Time of brushing’ Before breakfast After breakfast After lunch After supper Before going out After snacks Before sleep Other times No. w ho answered the question
% girls
% both
23 58 3 12 20 3 55 3
33 72 7 26 61 8 77 7
28 65 5 19 40 5 66 5
1,233
1,184
2,417
'M u ltip le answers were coded.
% boys
Has ever used o r done Mouthwash Rinse with water after eating Fluoride dentifrice Chew gum Toothpicks Breath freshener Floss or tape Electric toothbrush Water spray device Gingiva stimulators Mouth m irror Disclosing tablets, w afers No. w ho answered the question
% girls
% both
68 46 74 72 67 42 35 29 3 2 8 4
81 53 81 84 55 67 47 29 4 1 7 6
74 50 77 78 61 54 41 29 4 2 8 5
1,215
1,174
2,389
Table 8 ■ How often teenager gets a new toothbrush. % How often
%
________boys_____ girls
Less than every six m onths Six m onths up to one year Every year to a year and a half Less frequently than every year and a half When it wears out; when I need one No. w ho answered the question
% both
22 23 28
25 28 20
23 26 24
14 14 945
6 22 982
10 18 1,927
some were surprised that the question would be asked at all; they answered, “ You must be kidding.” More than half wrote in something about lack o f facilities, the crowdedness, the lack of time, and other inconveniences. Only 10% said that brushing at school was not needed. The questionnaire asked how often a new brush was obtained (Table 8). A s might be ex pected, many could only guess and nearly a fourth did not answer the question at all, prob ably because they did not know. Another 20% said they obtained a new one when the old brush wore out. Perhaps the maximum number of those who had usable brushes can be estimated to be fewer than a fourth of those who reported getting a new brush every six months or less, although a brush used daily might be worn out within three months. ■ A ctivities other than brushing: When asked to write what else they did at home, other than brushing, to take care o f their teeth and gingiva, only 20% reported another activity (Table 9). Flossing was most frequently reported (11% o f all respondents flossed). It can be assumed that Table 9 ■ Other measures taken at home for care of teeth
and gingiva. %
%
Other measures_____________________ boys_____ girls Floss Mouthwash Eat nutritious foods Avoid sweet foods Chew gum O ther(forexam ple, toothpicks) Do not do anything else No. w ho answered the question
7 3 2 1 1 2 84 1,218
14 3 2 1
% both
2 78
11 3 2 1 1 2 80
1,154
2,372
—
floss was used for the removal o f food lodged between the teeth rather than for the removal of plaque. Three percent used a mouthwash or rinsed with water. Two percent said they ate nu tritious foods, and 1% cut down on sweet foods. One percent chewed gum. Less than 1% used toothpicks. When asked to mark off on a checklist the items that they ever had used, the percentages reporting some of the activities described in the previous paragraph were much higher. Fortyone percent checked floss, 78% checked chew ing gum, and 74% checked mouthwash (Table
10). Even with the bias of the checklist, only 5% reported that they had ever used disclosing tab lets, and 8% that they ever used mouth mirrors. Moreover, in the response to the open-ended question described in the previous paragraph, disclosing tablets and mirrors were not men tioned (Table 9). It can be inferred that few veri fied the adequacy o f their brushing and that the verification was very infrequent. ■ Sweet fo o d s and drinks: Forty-five percent of the teenagers checked that the snacks they usu ally ate were sweet foods. In another study, the same percentage of 11th graders checked a sim ilar category.5 It may be that 45% is an under estimate because the word “ snack” did not rep resent in the teenagers’ minds the occasional candy bar, ice cream cone, milk shake, or soft drink. In answer to other questions, 43% re ported that they had candy once a day or more; 30% reported having ice cream, milk shakes, or sodas once a day or more; and 47% reported hav ing soft drinks once a day or more. The questions about these items did not specify that the food or drink be a snack; so for each category as snacks the percentages would be less. H ow ever, there are many sweet foods commonly eaten by teen agers about which no questions were asked. Linn: TEENAGERS’ ORAL HEALTH ■ 949
Table 13 ■ Why advice or inform ation was not asked for. Table 11 ■ Person who makes dental appointment. Person Mother Father Parents I make it Other: dentist, other relative No. w ho answered the question
% boys
% girls
% both
81 5 1 7 5
82 3 1 8 5
82 4 1 8 5
898
932
1,830
Didn’t need, already know, haven't had trouble w ith my teeth D idn't care, didn’t w ant to, not interested Didn’t thin k about it Told w ithou t asking Didn’t have any questions M other asks Other D on't know why I never asked No. who answered the question
% boys
% girls
% both
45
36
41
16 11 6 3 1 3 14 305
11 17 14 5 1 6 9 317
14 14 10 4 1 4 12 622
T able 12 ■ K in d s o f in fo r m a tio n o r a d v ic e a s k e d a b o u t. Inform ation asked about Brushing: how to, how long, how often General care, cleaning o f teeth Dentifrice (what to buy) Braces Food, sweet food Floss Other questions about home care (for example, how to get teeth white, what brush to buy, bleeding gingiva) Other questions about professional care No. w ho answered the question
% boys
% girls
% both
37 27 7 6 3 2
21 16 16 8 6 4
28 20 13 7 5 3
15
23
20
2 222
6 356
4 578
■ D ental visits: Eighty-five percent reported that they have gone to a dentist for a checkup at least occasionally. Such a high percentage could indicate that most knew that a checkup was rec ommended. A better measure of preventive vis its would be the 42% who said they went for a checkup more than once a year, excluding those in orthodontic treatment. Eighty-two percent o f the teenagers said their mothers made the dental appointment; only 8% said they them selves made it (Table 11). ■ Asking the dentist or hygienist fo r informa tion: Nearly a half said they had asked the den tist or hygienist for information or advice at one time or other. Twenty-eight percent had asked something about brushing: how to, how long, or how often. A fifth reported asking about the gen eral care o f the teeth. Only 3% had asked about floss, and only 5% had asked about food. This is additional evidence for the low awareness of the relation o f food and floss to preventive dentistry (Table 12). Among those who had never asked for infor mation or advice, the most frequent reason given was that they had no need because they already knew or had no trouble with their teeth (41%). Similar to this misconception about preventive dentistry were answers (Table 13) about not be ing interested, not thinking about asking, or not having any questions (32%). In short, most o f those who did not ask for ad vice or information about oral hygiene did not realize any need or were not motivated suffi950 ■ JADA, Vol. 92, May 1976
ciently to ask. And most of those who had asked were not aware o f newer emphases on the use of floss or the curtailment o f sw eet snacks (an in ference much in evidence in the answers to other questions already discussed).
Differences by occupation of father Professional dental care has been shown in sev eral studies to be correlated with the family so cioeconom ic status.12 Other dental behaviors are less correlated or not at all correlated. In this study o f teenagers, there was only one measure o f socioeconom ic status: father’s occupation. The occupational level of the father was associ ated positively with orthodontic care and with the number of dental visits within the past five years. But the occupational level was associated little with the teenagers’ attitudes, knowledge, or preventive behavior. There would be no rea son to qualify any educational efforts according to the occupation o f fathers. For example, the father’s occupational level was positively asso ciated with the reporting that bacteria or acid was a cause of tooth decay, but the percentage giving these answers, even among the teenagers whose fathers were in professions, was still too small to infer that most o f them would not need instruc tion about the cause o f tooth decay.
Differences by sex of respondent There were more differences in attitudes and behaviors by sex of respondent than by father’s occupation. Girls seem more worried than boys about their own dental appearance and breath. For instance, more girls worried about discolored teeth (Table 2). They more likely brushed before going out (Table 7) and used breath freshener (Table 10). They tended more to recommend rinsing with water or using mouthwash as a substitute for
toothbrushing (Table 6). Girls ranked higher than boys on a number of preventive behaviors and in preventive orienta tion. They more likely brushed at unusual times (Table 7) and more likely used other oral health aids with the exception o f toothpicks (Tables 9 and 10). (The less frequent use of toothpicks may reflect their greater concern about using them in public.) Girls were more likely to know the symptoms o f periodontal disease (Table 3). Few er of them reported eating candy daily, and more of them reported that sweet foods can be a cause of tooth decay (Table 4). More than the boys, they suggested that curtailment of sweet foods or drinks was a means of taking good care o f the teeth (Table 5). A somewhat greater percentage of the girls had a regular dentist and reported his name. Girls tended more to report going for checkups. They more likely asked for advice or informa tion about oral hygiene. The consistency o f the differences and the number of facets of the girls’ greater preventive behavior and orientation about dental health may indicate greater motivation to achieve good oral health. They seemingly would be a more ac cepting audience for preventive dental health efforts than the boys. However, in the use of floss and awareness of the value o f curtailing sweet foods, only a minority of the girls gave positive answers, although moreso than the boys.
Summary and implications This survey documents the meagerness o f teen agers’ knowledge and behavior about dental health. They knew that brushing before bed and checkups are desirable. Otherwise, they were sorely lacking in fundamental knowledge about what is needed for optimum oral health. Except for 6 of the 2,517 sophomores, there was no evi dence that they knew about plaque. Small minor ities thought about using floss and then for re moval of food, not plaque. Fewer than a fourth knew that periodontal disease was a disease of the gingiva. Brushing was the major oral health practice. But it was rarely checked with disclosing tablets and mouth mirrors. It is questionable whether most knew about these. Flossing was rarely done. Curtailment of sweet foods or drinks as an oral health measure was even rarer. One would expect some improvement in the
six years since this study was done, given the greater emphasis on plaque control in dentistry. Yet, the possibility that many more o f a similar group o f teenagers at this time would be preven tively oriented seems unlikely. Plaque control programs are not that common in dentistry. And only 42% of the sample studied could be said to go to the dentist for preventive checkups in the first place. Moreover, recent interviews I have done with patients at a public clinic did not.un cover much awareness or behaviors related to plaque control. The respondents in the study reported here were students in their tenth year of public school. Their schooling was preparing them for many things, including common problems o f everyday life. Very few problems are as common as tooth decay and periodontal disease. Y et the teenagers knew little about and were doing relatively little to prevent these problems. Obviously, their need for instruction is great.
The questionnaire was developed by Joanna Samuels, School of Dentistry, University o f M innesota, in cooperation w ith A lice Fusillo, Behavioral Studies, Division of Dental Health, US P ublic Health Service. Dr. Linn is a research sociologist. His address is Institute fo r S cie n tific Analysis, 210 Spear St, San Francisco, 94105. 1. Dahl, L.O., and Davis, B.B. Oral hygiene habits o f young children. J Periodontol 25:209 July 1954. 2. Dahl, L.O., and Muhler, J.C. Oral hygiene habits of young adults. J P eriodontol 26:43 Jan 1955. 3. Dudding, N.L., and Muhler, J.C. W hat m otivates children to practice good oral hygiene? J Periodontol 31:141 A pril 1960. 4. Kriesberg, L., and Treiman, B.R. Preventive utilization of dentists’ services among teenagers. J Am Coll D ent 29:28 March 1962. 5. Love, W.C. A n assessment o f the know ledge and the prac tice of oral health by selected school children in Kalamazoo, M ich. J P ublic Health Dent 28:153 Summ er 1968. 6. Metz, A.S., and Richards, L.G. C hild re n ’s preventive dental visits. J Am Coll Dent 34:204 O ct 1967. 7. M uhler, J.C. Frequency o f food ingestion, too thbrushin g habits and dental caries experience of freshm an high school students. JADA 69:738 Dec 1964. 8. S ignorile, V. Dental hygiene in the fam ily setting. Report of salient characteristics from the C heektowaga (B uffalo) fam ily dental hygiene study. Bethesda, D ivision of Dental Health, USPHS, 1968. 9. National Opinion Research Center. P u b lic attitudes and practices in the field o f dental care: m arginal results and basic cross-tabulations. Chicago, NORC, University of Chicago, June 1960. 10. Young, M.A.C. Dental health education o f adults. In Rich ards, N.D., and Cohen, L.K., eds. Social sciences and dentistry. A critical bibliography. The Hague, A. S ijthoff, 1971, p 241. 11. Bergenholtz, A. Mechanical cleaning in oral hygiene. In Frandsen, A., ed. Oral hygiene. A sym posium held in Malmo, Sweden. Oslo, AS Denofa og Litlleb org Fabrlker, 1972. 12. Richard, N.D. U tilization o f dental services. In Richards, N.D., and Cohen, L.K., eds. Social sciences and dentistry. A c rit ical bibliography. The Hague, A. S ijthoff, 1971, p 209. L in n : T E E N A G E R S ’ O R A L H EALTH ■ 951
Teenagers’ attitudes, knowledge, and behaviors related to oral health
E rw in L. L in n , P h D , S a n F r a n c is c o
T eenagers are a neglected audience for dental educational efforts. Their need is obvious given their high risk o f dental disease. Information about what they know and do would be a guide to what they need to know and do, and it also could help in developing strategies to reach this age group. Y et research about teenagers has been narrow in scop e and has dealt alm ost solely with dental visits, frequency and time o f toothbrushing, or amount of oral d ise a se .1"8 This pa per presents findings from a questionnaire sur vey o f teenagers’ attitudes, know ledge, and be haviors about oral health.
T h e surve y In the fall 1969, 2,530 sophom ores in three public sch o o ls in M inneapolis and its suburbs filled in questionnaires. A ll students in attendance on the day o f distribution of the questionnaires took part. Thirteen questionnaires were discarded becau se nearly all answ ers w ere flippant. A lm ost all the students w ere white (98%), and 946 ■ JADA, Vol. 92, May 1976
the numbers o f boys and girls w ere about equal. T he mean annual fam ily incom e in 1968 for the areas in which they lived was betw een $9,000 and $10,000. T he questionnaire took about an hour to com plete. M ost questions required selection o f an answ er from a checklist. In this article, the words used are those usually used by the profession. T he questionnaire did not use these words, but rather words usually used by the public (for ex am ple, “ gum s” rather than “ gingiva” ). All differences discussed in this article are statistically significant. T he standard for signif icance was that the difference could have arisen by chance in 5% or less o f sam ples drawn from the universe. T he chi-square test was used.
A ttitu d e s T ooth decay is prevalent in nearly all young peo ple, and as would be exp ected , a high percentage o f the sophom ores (80%) thought that tooth de cay was serious.
The students showed their awareness of the risk o f occurrence of tooth decay in answers to several questions. Sixty-two percent thought it was possible that they had one or more carious lesions at the time of the survey. If they did not go to the dentist during the following year, 94% indicated that they would need treatment. Two thirds checked that something can happen to the teeth without one’s knowing it. Ninety-three percent claimed that they had a regular dentist. The inevitability o f tooth decay could lead to a fatalism that could be a barrier to dental edu cational efforts. H owever, only a minority sub scribed to statements o f fatalism. For instance, 11% agreed that “ no matter how well you take care of your teeth, eventually you will lose them .” Seventeen percent agreed that “ once you get your permanent teeth, what you eat or drink can’t affect—one way or another—how much your teeth decay.” Thirty-two percent agreed that “ some people are just bom with good teeth and others are not, and there is not much anyone can do about it.” In 1959, when the same statements were pre sented to a national sample of adults, a higher per centage agreed with each statement: 41% agreed with the first statement, 21% with the second, and 60% with the third.9 In the study of adults, agreement with each statement increased as the age of respondents increased. It can be inferred that preventive dental health education would be better received by teenagers than adults, and by younger than older adults. Eighty-four percent o f the sophomores checked that the chances were good that they would be able to prevent tooth decay. This high percentage is consistent with the majority’s re jection of the fatalistic statements about tooth decay and loss. H owever, their awareness that they can prevent tooth decay is not based on much knowledge or preventive behavior, as will be documented. Perhaps more important than fatalism are the various motives that stimulate teenagers to care for their teeth. For instance, only a third rated “ to keep your teeth as long as possible” as the most important reason for taking care o f the teeth and gingiva. A somewhat higher proportion checked “ to help your appearance” (Table 1). Asked why they went to the dentist for a check up, only 40% wrote answers about keeping their teeth or other answers that may reflect concern about oral health; the others answered that they went because their parents made them go or that it was a habit. In addition, although a majority
Table 1 ■ The most important reason for taking care of
teeth and gingiva. %
%
%
Most im portant reason____________ boys_____ girls______both To help your appearance To prevent other illnesses To avoid later expensive treatment To avoid future pain and trouble To keep your teeth as long as possible No. w ho answered the question
37 3
37 3
37 3
10
8
9
19
16
18
31
35
33
1,083
1,126
2,209
Table 2 ■ Dental conditions worried about most. °/o
%
%
Dental condition
boys
girls
both
Broken or lost permanent teeth Discolored teeth Sore or bleeding gingiva P oorly aligned teeth Tooth decay No. w ho answered the question
44 15 7 11 24 1,196
26 25 7 16 26 1,159
35 20 7 14 25 2,355
worried most about serious oral problems (tooth decay, broken or lost teeth, or sore and bleeding gingiva), another 20% worried most about discol ored teeth, again more a matter of cosm etics than oral health (Table 2).
Knowledge
■ Periodontal disease: Only 25% attempted to write a description o f periodontal disease (Table 3). Twenty-two percent wrote something about the gingiva, though the answers ranged from a correct description of symptoms to the mention o f tooth decay as well. Three percent wrote about tooth decay but did not say anything about the gingiva. ■ Tooth decay: It was expected that all the teen agers knew that candy, at least, could be a cause of tooth decay. Yet, when asked what causes tooth decay, only a third wrote candy, sweet foods, sugar, or the “ wrong foods” (Table 4). Table 3 ■ Description of periodontal disease. % boys
Description* A disease of the gingiva Sore, swollen, bleeding gingiva Teeth fall out, tooth m obility Other answers about gingiva Teeth decay, disease o f teeth Other (for example, bad breath) Did not know or did not write a description No. w ho answered the question
% girls
% both
8 5 4 3 2 —
16 14 9 5 4 1
12 10 7 4 3 —
83
66
75
1,282
1,200
2,482
*lf given, tw o answers per person were coded. If more than two codes applied, preference was given to symptoms described (for example, gingiva, tooth mobility). Linn: TEEN AG ERS'ORAL HEALTH ■ 947
Table 6 ■ What you can do if you don’t have your
Table 4 ■ W h a t c a u s e s to o th d e c a y . Cause of tooth decay* Sweet foods, sugar, w rong foods Food particles caught between teeth; decaying food Not brushing; im proper brushing Lack o f care; not cleaning Germs; bacteria Acid Not going to dentist Other No. w ho answered the question
% girls
% both
30
39
34
What you can do*
31 26 14 13 10 1 3
26 40 16 9 6 4 5
28 32 15 11 8 3 4
1,060
1,093
2,153
Rinse with water; use mouthwash Chew gum Eat fru it; eat vegetables Use fingers Floss Toothpicks Other No. w ho answered the question
T ab le 5 ■ How a person can take good care of his teeth
and gingiva.
Brush teeth Go to dentist; have checkups Avoid sweets; watch w hat you eat Good food; balanced diet Floss Massage or brush gingiva Other: chew gum; rinse; use oral irrigating device; fluo ride treatm ent No. w ho answered the question
% boys
% girls
% both
96 29 14 7 4 4
95 50 21 15 6 6
93 40 17 12 5 5
6 967
6 1,077
6 2,044
*lf given, three answers per person were coded.
An additional 25% wrote about food caught be tween the teeth but did not specify that it be sweet or “ wrong.” Eleven percent said that bac teria or germs and 8% said that acid causes tooth decay. Only six respondents knew about “ plaque” ; this answer was included in “ other” in Table 4. In most populations, prevention is equated with toothbrushing.10 In this sample, 32% report ed that not brushing or improper brushing is the cause o f tooth decay. In addition, 15% answered vaguely about lack of care or cleaning (Table 4). ■ M eans o f preventing oral disease: When asked how a person could take very good care o f his teeth and gingiva, 93% o f the teenagers wrote about brushing. Forty percent answered, “ go to the dentist.” Seventeen percent men tioned the avoidance of sweet foods or drinks, and 12% suggested a good or balanced diet. Only 5% said, “ U se floss” (Table 5). Rinsing with water or using a mouthwash was the most frequent answer (Table 6) to the ques tion, “ What can you do if you don’t have your toothbrush with you?” “ Chew gum” ranked next in frequency. This answer probably came mainly from an advertisement by a gum manufac turer that presents its product as an oral health aid, without adding that it contains sugar. Some teenagers did specify sugarless gum, but added occasionally names of gums that are not sugarless. There were relatively few other kinds of 948 ■ JADA, V ol. 92, May 1976
% boys
% girls
% both .
44 37 7 9 3 8 4
55 36 11 10 6 3 4
50 35 9 9 5 5 4
923
1,061
1,984
*lf given, tw o answers per person were coded.
*lf given , tw o answers per person were coded.
How to take good care*
toothbrush.
% boys
answers (Table 6). N ine percent suggested eat ing apples, other fruits, or vegetables. These alternatives to brushing are now considered of questionable value for plaque removal because o f conflicting evidence about their detergent effects.11 The use o f floss, recommended by most dental health educators, was noted by only 5%.of the teenagers. Sixty-eight percent agreed that the gingiva can be kept in good condition if teeth are cleaned regularly in a dental office. However, 78% agreed with the statement that one can help pre vent tooth decay by having his teeth cleaned in a dental office. It cannot be concluded, there fore, that the teenagers had discriminating knowledge that a professional prophylaxis can help prevent periodontal disease.
Behaviors
■ Brushing: Ninety-nine percent o f the teen agers said that they had a toothbrush at home. Ninety percent said that they brushed at least once a day, and only 1% said they never brushed. Brushing is obviously a daily behavior for nearly all the sophomores as it is for all other age groups whose dental health practices have been stud ied .10 Brushing after breakfast and right before bed were each reported by two thirds o f the teen agers. These times are also the most frequently reported in other studies of children or young adults.12-8 Other times were mentioned much less frequently, with the exception o f the girls’ brushing “ before going out” (Table 7). Brushing is rarely done elsewhere than at home. Only 5% said they carried a brush with them. Two percent claimed that they had a brush at school. Motivating teenagers to brush elsewhere than at home probably would be difficult. When asked why most teenagers did not brush at school,
Table 7 ■ W h e n te e th a re b ru s h e d .
Table 10 ■ E x p e r ie n c e w ith o r a l h y g ie n e a id e s.
% boys
Time of brushing’ Before breakfast After breakfast After lunch After supper Before going out After snacks Before sleep Other times No. w ho answered the question
% girls
% both
23 58 3 12 20 3 55 3
33 72 7 26 61 8 77 7
28 65 5 19 40 5 66 5
1,233
1,184
2,417
'M u ltip le answers were coded.
% boys
Has ever used o r done Mouthwash Rinse with water after eating Fluoride dentifrice Chew gum Toothpicks Breath freshener Floss or tape Electric toothbrush Water spray device Gingiva stimulators Mouth m irror Disclosing tablets, w afers No. w ho answered the question
% girls
% both
68 46 74 72 67 42 35 29 3 2 8 4
81 53 81 84 55 67 47 29 4 1 7 6
74 50 77 78 61 54 41 29 4 2 8 5
1,215
1,174
2,389
Table 8 ■ How often teenager gets a new toothbrush. % How often
%
________boys_____ girls
Less than every six m onths Six m onths up to one year Every year to a year and a half Less frequently than every year and a half When it wears out; when I need one No. w ho answered the question
% both
22 23 28
25 28 20
23 26 24
14 14 945
6 22 982
10 18 1,927
some were surprised that the question would be asked at all; they answered, “ You must be kidding.” More than half wrote in something about lack o f facilities, the crowdedness, the lack of time, and other inconveniences. Only 10% said that brushing at school was not needed. The questionnaire asked how often a new brush was obtained (Table 8). A s might be ex pected, many could only guess and nearly a fourth did not answer the question at all, prob ably because they did not know. Another 20% said they obtained a new one when the old brush wore out. Perhaps the maximum number of those who had usable brushes can be estimated to be fewer than a fourth of those who reported getting a new brush every six months or less, although a brush used daily might be worn out within three months. ■ A ctivities other than brushing: When asked to write what else they did at home, other than brushing, to take care o f their teeth and gingiva, only 20% reported another activity (Table 9). Flossing was most frequently reported (11% o f all respondents flossed). It can be assumed that Table 9 ■ Other measures taken at home for care of teeth
and gingiva. %
%
Other measures_____________________ boys_____ girls Floss Mouthwash Eat nutritious foods Avoid sweet foods Chew gum O ther(forexam ple, toothpicks) Do not do anything else No. w ho answered the question
7 3 2 1 1 2 84 1,218
14 3 2 1
% both
2 78
11 3 2 1 1 2 80
1,154
2,372
—
floss was used for the removal o f food lodged between the teeth rather than for the removal of plaque. Three percent used a mouthwash or rinsed with water. Two percent said they ate nu tritious foods, and 1% cut down on sweet foods. One percent chewed gum. Less than 1% used toothpicks. When asked to mark off on a checklist the items that they ever had used, the percentages reporting some of the activities described in the previous paragraph were much higher. Fortyone percent checked floss, 78% checked chew ing gum, and 74% checked mouthwash (Table
10). Even with the bias of the checklist, only 5% reported that they had ever used disclosing tab lets, and 8% that they ever used mouth mirrors. Moreover, in the response to the open-ended question described in the previous paragraph, disclosing tablets and mirrors were not men tioned (Table 9). It can be inferred that few veri fied the adequacy o f their brushing and that the verification was very infrequent. ■ Sweet fo o d s and drinks: Forty-five percent of the teenagers checked that the snacks they usu ally ate were sweet foods. In another study, the same percentage of 11th graders checked a sim ilar category.5 It may be that 45% is an under estimate because the word “ snack” did not rep resent in the teenagers’ minds the occasional candy bar, ice cream cone, milk shake, or soft drink. In answer to other questions, 43% re ported that they had candy once a day or more; 30% reported having ice cream, milk shakes, or sodas once a day or more; and 47% reported hav ing soft drinks once a day or more. The questions about these items did not specify that the food or drink be a snack; so for each category as snacks the percentages would be less. H ow ever, there are many sweet foods commonly eaten by teen agers about which no questions were asked. Linn: TEENAGERS’ ORAL HEALTH ■ 949
Table 13 ■ Why advice or inform ation was not asked for. Table 11 ■ Person who makes dental appointment. Person Mother Father Parents I make it Other: dentist, other relative No. w ho answered the question
% boys
% girls
% both
81 5 1 7 5
82 3 1 8 5
82 4 1 8 5
898
932
1,830
Didn’t need, already know, haven't had trouble w ith my teeth D idn't care, didn’t w ant to, not interested Didn’t thin k about it Told w ithou t asking Didn’t have any questions M other asks Other D on't know why I never asked No. who answered the question
% boys
% girls
% both
45
36
41
16 11 6 3 1 3 14 305
11 17 14 5 1 6 9 317
14 14 10 4 1 4 12 622
T able 12 ■ K in d s o f in fo r m a tio n o r a d v ic e a s k e d a b o u t. Inform ation asked about Brushing: how to, how long, how often General care, cleaning o f teeth Dentifrice (what to buy) Braces Food, sweet food Floss Other questions about home care (for example, how to get teeth white, what brush to buy, bleeding gingiva) Other questions about professional care No. w ho answered the question
% boys
% girls
% both
37 27 7 6 3 2
21 16 16 8 6 4
28 20 13 7 5 3
15
23
20
2 222
6 356
4 578
■ D ental visits: Eighty-five percent reported that they have gone to a dentist for a checkup at least occasionally. Such a high percentage could indicate that most knew that a checkup was rec ommended. A better measure of preventive vis its would be the 42% who said they went for a checkup more than once a year, excluding those in orthodontic treatment. Eighty-two percent o f the teenagers said their mothers made the dental appointment; only 8% said they them selves made it (Table 11). ■ Asking the dentist or hygienist fo r informa tion: Nearly a half said they had asked the den tist or hygienist for information or advice at one time or other. Twenty-eight percent had asked something about brushing: how to, how long, or how often. A fifth reported asking about the gen eral care o f the teeth. Only 3% had asked about floss, and only 5% had asked about food. This is additional evidence for the low awareness of the relation o f food and floss to preventive dentistry (Table 12). Among those who had never asked for infor mation or advice, the most frequent reason given was that they had no need because they already knew or had no trouble with their teeth (41%). Similar to this misconception about preventive dentistry were answers (Table 13) about not be ing interested, not thinking about asking, or not having any questions (32%). In short, most o f those who did not ask for ad vice or information about oral hygiene did not realize any need or were not motivated suffi950 ■ JADA, Vol. 92, May 1976
ciently to ask. And most of those who had asked were not aware o f newer emphases on the use of floss or the curtailment o f sw eet snacks (an in ference much in evidence in the answers to other questions already discussed).
Differences by occupation of father Professional dental care has been shown in sev eral studies to be correlated with the family so cioeconom ic status.12 Other dental behaviors are less correlated or not at all correlated. In this study o f teenagers, there was only one measure o f socioeconom ic status: father’s occupation. The occupational level of the father was associ ated positively with orthodontic care and with the number of dental visits within the past five years. But the occupational level was associated little with the teenagers’ attitudes, knowledge, or preventive behavior. There would be no rea son to qualify any educational efforts according to the occupation o f fathers. For example, the father’s occupational level was positively asso ciated with the reporting that bacteria or acid was a cause of tooth decay, but the percentage giving these answers, even among the teenagers whose fathers were in professions, was still too small to infer that most o f them would not need instruc tion about the cause o f tooth decay.
Differences by sex of respondent There were more differences in attitudes and behaviors by sex of respondent than by father’s occupation. Girls seem more worried than boys about their own dental appearance and breath. For instance, more girls worried about discolored teeth (Table 2). They more likely brushed before going out (Table 7) and used breath freshener (Table 10). They tended more to recommend rinsing with water or using mouthwash as a substitute for
toothbrushing (Table 6). Girls ranked higher than boys on a number of preventive behaviors and in preventive orienta tion. They more likely brushed at unusual times (Table 7) and more likely used other oral health aids with the exception o f toothpicks (Tables 9 and 10). (The less frequent use of toothpicks may reflect their greater concern about using them in public.) Girls were more likely to know the symptoms o f periodontal disease (Table 3). Few er of them reported eating candy daily, and more of them reported that sweet foods can be a cause of tooth decay (Table 4). More than the boys, they suggested that curtailment of sweet foods or drinks was a means of taking good care o f the teeth (Table 5). A somewhat greater percentage of the girls had a regular dentist and reported his name. Girls tended more to report going for checkups. They more likely asked for advice or informa tion about oral hygiene. The consistency o f the differences and the number of facets of the girls’ greater preventive behavior and orientation about dental health may indicate greater motivation to achieve good oral health. They seemingly would be a more ac cepting audience for preventive dental health efforts than the boys. However, in the use of floss and awareness of the value o f curtailing sweet foods, only a minority of the girls gave positive answers, although moreso than the boys.
Summary and implications This survey documents the meagerness o f teen agers’ knowledge and behavior about dental health. They knew that brushing before bed and checkups are desirable. Otherwise, they were sorely lacking in fundamental knowledge about what is needed for optimum oral health. Except for 6 of the 2,517 sophomores, there was no evi dence that they knew about plaque. Small minor ities thought about using floss and then for re moval of food, not plaque. Fewer than a fourth knew that periodontal disease was a disease of the gingiva. Brushing was the major oral health practice. But it was rarely checked with disclosing tablets and mouth mirrors. It is questionable whether most knew about these. Flossing was rarely done. Curtailment of sweet foods or drinks as an oral health measure was even rarer. One would expect some improvement in the
six years since this study was done, given the greater emphasis on plaque control in dentistry. Yet, the possibility that many more o f a similar group o f teenagers at this time would be preven tively oriented seems unlikely. Plaque control programs are not that common in dentistry. And only 42% of the sample studied could be said to go to the dentist for preventive checkups in the first place. Moreover, recent interviews I have done with patients at a public clinic did not.un cover much awareness or behaviors related to plaque control. The respondents in the study reported here were students in their tenth year of public school. Their schooling was preparing them for many things, including common problems o f everyday life. Very few problems are as common as tooth decay and periodontal disease. Y et the teenagers knew little about and were doing relatively little to prevent these problems. Obviously, their need for instruction is great.
The questionnaire was developed by Joanna Samuels, School of Dentistry, University o f M innesota, in cooperation w ith A lice Fusillo, Behavioral Studies, Division of Dental Health, US P ublic Health Service. Dr. Linn is a research sociologist. His address is Institute fo r S cie n tific Analysis, 210 Spear St, San Francisco, 94105. 1. Dahl, L.O., and Davis, B.B. Oral hygiene habits o f young children. J Periodontol 25:209 July 1954. 2. Dahl, L.O., and Muhler, J.C. Oral hygiene habits of young adults. J P eriodontol 26:43 Jan 1955. 3. Dudding, N.L., and Muhler, J.C. W hat m otivates children to practice good oral hygiene? J Periodontol 31:141 A pril 1960. 4. Kriesberg, L., and Treiman, B.R. Preventive utilization of dentists’ services among teenagers. J Am Coll D ent 29:28 March 1962. 5. Love, W.C. A n assessment o f the know ledge and the prac tice of oral health by selected school children in Kalamazoo, M ich. J P ublic Health Dent 28:153 Summ er 1968. 6. Metz, A.S., and Richards, L.G. C hild re n ’s preventive dental visits. J Am Coll Dent 34:204 O ct 1967. 7. M uhler, J.C. Frequency o f food ingestion, too thbrushin g habits and dental caries experience of freshm an high school students. JADA 69:738 Dec 1964. 8. S ignorile, V. Dental hygiene in the fam ily setting. Report of salient characteristics from the C heektowaga (B uffalo) fam ily dental hygiene study. Bethesda, D ivision of Dental Health, USPHS, 1968. 9. National Opinion Research Center. P u b lic attitudes and practices in the field o f dental care: m arginal results and basic cross-tabulations. Chicago, NORC, University of Chicago, June 1960. 10. Young, M.A.C. Dental health education o f adults. In Rich ards, N.D., and Cohen, L.K., eds. Social sciences and dentistry. A critical bibliography. The Hague, A. S ijthoff, 1971, p 241. 11. Bergenholtz, A. Mechanical cleaning in oral hygiene. In Frandsen, A., ed. Oral hygiene. A sym posium held in Malmo, Sweden. Oslo, AS Denofa og Litlleb org Fabrlker, 1972. 12. Richard, N.D. U tilization o f dental services. In Richards, N.D., and Cohen, L.K., eds. Social sciences and dentistry. A c rit ical bibliography. The Hague, A. S ijthoff, 1971, p 209. L in n : T E E N A G E R S ’ O R A L H EALTH ■ 951
