|Year : 2020 | Volume
| Issue : 2 | Page : 42-49
Knowledge, attitude, and practices toward oral hygiene among students of medhanealem high school, addis ababa, Ethiopia
Bizuayehu Abate1, Mahlet Ephrem1, Miskir Gebremariam1, Yodit Ayalew1, Tariku Shimels2
1 Department of Nursing, Kea Med Medical College, Addis Ababa, Ethiopia
2 St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
|Date of Submission||22-Jan-2020|
|Date of Decision||28-Feb-2020|
|Date of Acceptance||12-Mar-2020|
|Date of Web Publication||20-Jun-2020|
St. Paul's Hospital Millennium Medical College, Addis Ababa
Source of Support: None, Conflict of Interest: None
Introduction: Poor oral health can affect a person's day today as well as overall quality of life. Discomforts from experience of pain, problems with eating and chewing, embarrassment about the shape, and missing, discolored, or damaged teeth can adversely affect peoples' daily lives and well-being. The aim of this study was to assess the knowledge, attitude, and practice (KAP) of oral hygiene among preparatory students of Medhanealem High School in Addis Ababa, Ethiopia. Methods: A cross-sectional study design was conducted using a self-administered questionnaire from June to September 2019 in Medhanealem High School, Addis Ababa. Data were analyzed using SPSS v. 20, and a descriptive statistics was employed to present results on KAPs of high school students toward oral hygiene. Results: A total of 320 students have participated in the study, of whom 207 (64.7%) were female. The study revealed that 201 (62.8%) of the respondents had a poor knowledge with regard to oral hygiene, about half (52.1%) of the students had a negative attitude toward oral hygiene, and their oral hygiene practices were still low that 193 (60.4%) of the students reported inadequate practice. The chewed stick (Mefakiya) is the most common oral hygiene aid used for cleaning teeth, which was adopted by 134 (51%) students. Conclusions: The study showed that oral hygiene KAP among the secondary school students in Medhanealem Preparatory School were not satisfactory. The findings of this study suggest that awareness on the importance of oral hygiene needs to be enhanced along with regular education.
Keywords: Oral hygiene, high school, knowledge, attitude, and practice, students, Addis Ababa
|How to cite this article:|
Abate B, Ephrem M, Gebremariam M, Ayalew Y, Shimels T. Knowledge, attitude, and practices toward oral hygiene among students of medhanealem high school, addis ababa, Ethiopia. J Dent Res Rev 2020;7:42-9
|How to cite this URL:|
Abate B, Ephrem M, Gebremariam M, Ayalew Y, Shimels T. Knowledge, attitude, and practices toward oral hygiene among students of medhanealem high school, addis ababa, Ethiopia. J Dent Res Rev [serial online] 2020 [cited 2020 Aug 8];7:42-9. Available from: http://www.jdrr.org/text.asp?2020/7/2/42/287338
| Introduction|| |
Oral health is a key indication of overall health, well-being, and quality of life. The World Health Organization defines oral health as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual capacity in biting, chewing, smiling, speaking and psychosocial wellbeing.”
Maintaining oral hygiene should not be underestimated in once everyday life. It can be conceived as the method of keeping oral cavity free from pathological conditions that affect mouth such as gum diseases, cavities, mouth sores, and ulcers. Good oral hygiene is essential for the well-being of an individual. However, lack of knowledge, negative attitude, and poor oral hygiene practices may predispose to oral-related diseases., As oral health affects the overall health of a child, it is therefore of paramount importance to maintain oral hygiene of school-going children. If community-oriented oral health promotion programs are to be successful, the knowledge of the latest status of oral health of community is of vital importance. This may ultimately contribute to the reduction of oral diseases with alarming global burden and associated cardiovascular diseases, respiratory infections, stroke, and nutritional problems.
In Ethiopia, the practice of oral hygiene lacks proper attention and care, whereby the habit of toothbrushing is found to a minimum., Studies conducted on primary and high school students indicate that there is a varying level of awareness to oral health ranging from 50% to 70%.,, As a result, the prevalence of dental carry ranges between 20% and 75% in different setups.,,, It was reported that tooth-related problems such as gum bleeding, dental plaques, toothache, and missing tooth were noted in a significant magnitude among college students., Similar studies also reported that dental carrying among children was associated with increased consumption of sweets, male gender and, poor habit of regular teeth cleaning.,, The studies published so far cover either on primary school children in regions of the country or college students. With two assessments, conducted earlier in the community and marginalized children in Addis Ababa, information among high school students appears to be scanty and less addressed. The objective of this study was, therefore, to assess the knowledge, attitude, and practice (KAP) of high school students toward oral hygiene in an old high school of Addis Ababa.
| Methods|| |
The study was conducted in Medhanealem High School located in Gulele subcity of Addis Ababa city administration, Ethiopia. Medhanealem Preparatory School was established on October 27, 1924, E.C. It was named after Medhanealem in Orthodox Christianity which means “Mercy of the world” and assigned to the 27th date of the month. The school was primarily established for teaching handicraft and accounting. There were also various woodwork and leather workshops. Then, the school started teaching from Grade 1 to 12.
Once it was named “Bale Abat” meaning “of for the upper class or noble men” for about two years, after the Ethio-Italy war, the teaching process was discontinued and it became residence for Ras Hailu. After two years, it was renamed as Medhanealem and continued the teaching learning process. It started with 60 students for the first time.
It has been 87 years since the school was established. Since 1996, the school has become a preparatory school, a school where preuniversity 11th- and 12th-grade students will attend for preparation. Currently, it consists of 174 employees, of which 120 are teachers (102 males and 18 females) and 54 are supportive staff and directors. The total number of students during the study period was 1704.
Study design and period
An institutional-based cross-sectional study was conducted from July to September 2019.
Source and Study Population
The source population was all high school students in Addis Ababa, whereas the study population was all regular preparatory students of Medhanealem High School.
Sample size determination
To attaining the maximum size, a single population proportion formula with a 50% prevalence was used to obtain a final sample size of 384. Because total population was only 1704 in the study setting, a final sample of 336 was estimated by considering a final population correction factor and a 5% nonresponse rate.
Sampling technique, data collection, and quality control
A self-administered structured questionnaire was used for data collection. A simple random sampling method, based on students' roster, was employed to obtain sample recruits. In cases when students from the list were not available, the next student was recruited for inclusion. Before data collection, the questionnaire applied in this study has been pretested in the same school and grade students accounting for 10% of the required sample size. Appropriate changes were to the data collection instrument. Data collectors were trained on the importance of confidentiality, ethics, and data collection procedures. Completeness and validity of the data collected were checked every day by the supervisors.
Dependent variable (s)
The dependent variables in the present study include KAP of high school students.
The independent variables in the present study include sociodemographic variables (gender, age, parents' education, grade, and family income), clinical characteristics (previous visit to a dental clinic, oral health, and history of using drugs for chronic illness), and knowledge and attitude of students and parents (which the latest two might affect practice).
The operational definitions were categorized into six groups as follows – good knowledge: those who answered >60% of knowledge questions correctly; poor knowledge: those who answered <60% of knowledge questions correctly; positive attitude: given for interviewee who answered at least 60% of attitude question positively; negative attitude: given for interviewee who answered <60% of attitude question positively; good practice: given for interviewee who answered at least 60% of practical question positively; and poor practice: given for interviewee who answered <60% of practical questions positively.
Ethical approval for conducting the research was obtained from the Research and Ethics Committee of Kea-Med Medical College. An official letter of cooperation was obtained from the department of nursing. Permission was then obtained from Medhanealem High School. Verbal consent was obtained from study participants. Confidentiality of information was assured by excluding any form of identification in the questionnaires and making aggregate analysis of data.
Data analysis and presentation
After collected data have been cleaned and coded, it was entered in to the Statistical Package for the Social Sciences version 20.0 (IBM Corp., Armonk, N.Y., USA) for analysis. Descriptive statistics was used to analyze quantitative data. Tables and charts were employed for the present results.
| Results|| |
All the 320 respondents completed the questionnaire successfully. Among the participants, 207 (64.7%) were female and 113 (35.3%) were male. The student's age ranged from 18 to 22 years where 283 (88.4) were in the 18–20 years' age group and 37 (11.6) were in the 21–22 years' age group.
Knowledge of students toward oral hygiene
Most of the students know that sweet (168 [52.5%]) and fizzy drinks (231 [72.2%]) affect oral health. However, only 58 (18.1%) students know that regular dentist visit is necessary and 32 (10%) know that they should replace toothbrush every 3–4 mounts. Majority of the participants (288 [90%]) replied that they replace their toothbrush when it is destroyed. Only 43 (13.4%) reported that tooth care is as important as care of any part of the body.
Only 59 (18.4%) students knew that fluoride strengthens teeth or prevents dental decay, whereas 229 (71.6%) do not agree that fluoride strengthens teeth. Nonetheless, 32 (10%) students do never know anything about fluoride. Most of the students (263 [82.2%]) agreed that carious/decayed teeth affect tooth appearance, whereas 42 (13.1%) did not agree with this idea. The major reason for brushing teeth was to remove dental decay as responded by130 (40.6%) students [Table 1].
|Table 1: Knowledge of secondary school students toward oral hygiene in Medhanealem High School, Addis Ababa, September 2019 (n=320)|
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The overall knowledge level of the students toward oral hygiene was low in this study. Majority (201 [63%]) had low knowledge and 119 (37%) had higher knowledge, as shown in [Figure 1].
|Figure 1: Level of knowledge among secondary school students toward oral hygiene in Medhanealem High School, Addis Ababa, September 2019 (n = 320)|
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Attitude of students toward oral hygiene
Majority of the students (220 [68.7%]) answered that oral hygiene is not important for good oral health and well-being, whereas only 100 (31.3%) students believe that it is important. About 130 (40.6%) students reported that neither the parents nor the teachers showed concern about oral hygiene. Three-fourth (75%) of the students thought that visiting a dentist is important and they would advise other students to perform at home oral hygiene practices. When given a chance, about two-third (70.6%) of the students would go for a checkup. As shown in [Table 2], about 263 (82.2%) students have never visited a dentist in the past. Among those who have a history of dental visit, 9 (2.8%) had a regular dental visit, 39 (12.2%) visited a dentist only when in pain, and 9 (2.8%) visited a dentist occasionally.
|Table 2: Attitude of secondary school students toward oral hygiene in Medhanealem High School, Addis Ababa, September 2019 (n=320)|
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The reasons given for the absence of regular dental visit were high cost (87 [27.2%]), no nearby dental clinic (15 [4.7%]), and lack of time (100 [31.3%]). Meanwhile, about one-third (31.9%) of the students do not think that it is important to visit a dental clinic [Table 2].
The overall attitude evaluation showed that about half (52%) of the participants had a negative attitude and 153 (48%) participants had a positive attitude of oral hygiene [Figure 2].
|Figure 2: Types of attitude of secondary school students toward oral hygiene in Medhanealem High School, Addis Ababa, September 2019 (n = 320)|
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Practice of students toward oral hygiene
Most of the students (263 [82.2%]) clean their teeth. More than half (155 [58.9%]) of the students brush their teeth with horizontal strokes, whereas 69 (26.2%) brush with vertical strokes. Few of the students (2.7%) use circular strokes to brush their teeth. Among students who do not brush their teeth, half (51%) reported that they did not think it was necessary.
The chewed stick (Amharic; Mefakiya) is the most common oral hygiene aid used for cleaning teeth, adopted by 134 (51%), while 65 (24.7%) of the students brushed their teeth with a toothbrush with toothpaste. However, the use of dental floss was still not popular among the secondary school students, as presented in this study. About a third (30.8%) of the students brushed their teeth at least twice per day or more compared to 119 (45.2%) of the students who brushed at least once a day. Around 159 (60.5%) of the students reported that they spent 2 min or more brushing their teeth. Only 32 (12.2%) of the respondents changed their toothbrushes within 3-4 months of use. A few number of students (2.7%) reported that the time of toothbrushing was before going to bed. In addition, 24 (7.5%) students did clean their tongue.
Among the reported sources of student's information about oral health practice, parents were the most popular (120 [45.6%]), followed by friends (93 [35.4%]). However, the role of parents in the supervision of their children's oral hygiene was poor accounted only by 35 (13.3%). About 107 (40.7%) parents advised but did not watch their children as they brushed their teeth, whereas the rest 121 (46%) indicated that they did not care to supervise their children's oral hygiene practice. On the other hand, 37 (14.1%) students did not agree to stop cleaning if their gum bleeds when cleaning their teeth [Table 3].
|Table 3: Practice of secondary school students toward oral hygiene in Medhanealem High School, Addis Ababa, September 2019 (n=320)|
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This study showed that the overall oral hygiene practice among the high school students was inadequate (193 [60%]) [Figure 3].
|Figure 3: Practice level of secondary school students toward oral hygiene in Medhanealem High School, Addis Ababa, September 2019 (n = 320)|
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| Discussion|| |
Oral health is considered as one of the most important health issues worldwide. In Ethiopia, there are very little epidemiological data concerning oral hygiene and it implications. Today, oral hygiene including toothbrushing is considered as an easy and affordable procedure for people of different age groups. Adequate knowledge on the causes, prevention, and signs of dental disease depicts that students can retain their oral hygiene.
The rapid changes in the pattern of oral disease have been noted at the global label during the past decade. Most people in the developed countries show great interest in oral hygiene and that 16%–18% of boys in 32 countries in Europe and North America practiced toothbrushing more than once a day, whereas girls reported better compliance ranging from 26% to 89%.
This study evaluated the oral hygiene KAPs of secondary school students found in Medhanealem Preparatory School in Addis Ababa city. A total of 336 students have participated and fulfilled the required sample size making a 100% response rate.
The current study showed that 62.8% of the students had poor knowledge toward oral hygiene. This might be due to the lack of an organized and systematic oral health education program in the schools and the community at large. Lack of knowledge toward oral hygiene could reflect that the information on dental health is most likely limited to a certain level of understanding. This result is lower than the previous study done in Debre Tabor town where 60% of the students had good oral hygiene knowledge and a finding from India which reported about 90% level of knowledge.
On the other hand, the figure is higher compared to findings from India and Saudi Arabia. In spite of that, a significant proportion of the students do not know that sweet and fizzy drinks affect health, only few have a history of visiting dental clinics and some do not know that they should replace toothbrush every 3–4 mounts which may imply awareness gaps to be assisted by parents and schools. This finding is not in accordance with the results of a similar study conducted by Priya et al.
In the present study, the attitude scale showed that more than half (52.1%) of the participants had a negative attitude toward oral hygiene. This result is still lower than a figure by a previous study done in Debre Tabor town. However, it is higher than a finding reported in Indian students in which majority (79.8%) had a favorable attitude toward oral hygiene. This is also explained by some proportion of students who did not agree that gum bleedings can be prevented by brushing teeth. The magnitude of such belief has shown a remarkable variation from other studies.,,
The level of practice to maintain proper oral hygiene practice is inadequate for majority of the students in the present study. The chewed stick (Mefakiya) is the most common oral hygiene aid used by half proportion of the respondents. These findings are lower than the figure by studies conducted in Nigeria and most African countries which traditionally used the stick for cleaning and strengthening the teeth., The choice of chewing sticks to be used in most cases depends on its cleansing action on the teeth, the therapeutic value, or preferred taste or flavor. A lower figure of using the local chewed stick was documented by a study in Fitche town in Central Ethiopia.
Likely, 81 (30.8%) students brushed their teeth at least twice per day, whereas 119 (45.2%) reported to have brushed at least once a day. Even though the overall estimate is measured by a stronger criterion (60% or more satisfactions of practice questions), the study shows that a reasonable gap exists to implement oral hygiene among the students. Apart from knowledge and attitude issues, affordability of the materials was mentioned as one of the challenges. These findings are also supported by the studies conducted in Fitche Preparatory School. The result is higher compared to a finding in three regions of Ethiopia. The difference, however, could most likely be due to time and socioeconomic variations by the fact that the earlier survey was conducted many years back in different regions of the country.
Majority of the students reported that they change their toothbrushes when they get discolored or bended, and only a few proportion responded to changing them within 3–4 months. This shows that proper practice is not in place to utilize toothbrushes. The American Dental Association (ADA) recommends using a toothbrush that has soft bristles, and also, people should change their toothbrush every 3 months or when the ends start to look destroyed.
In our study, reported sources of student's information about oral health practice parents were the most popular, followed by friends. This result is not in accordance with the finding from the similar studies conducted by Nigeria which showed that teachers, media (television), and parents accounted for descending ranks. This may indicate that parents may account a greater role in promoting family health, whereas teachers' role is limited to assist with their students' healthy behavior in schools of the study area. The fact that students gain oral health experience through peer interaction is an important aspect built during their socialization process.
In the present study, only the practice of dental visit is poor. Among those (57 [18%]) students with a practice of dental checking, few (16%) reported to do it regularly, whereas majority (68.4%) visited a dentist when only in pain. In addition to the inverse difference in proportion of adolescents who visit dental clinics, a study by Yusuf and Booyen reported that the principal reason for brushing teeth was related to cosmetic purpose unlike prevention of dental health reported in our study. Yet, studies suggest that children and adolescents should see a dentist every 6 months to help prevent cavities, whereas adults who practice good dental hygiene every day need to go less frequency.
More than half (58.9%) of the students in the present study reported to brush their teeth with horizontal strokes, followed by about a quarter of them (26.2%) who brush with vertical strokes. This result is not in agreement with a finding from India where majority used a combined technique of brushing. It was also noted that most of the respondents do not clean their tongue. Even among those who clean their teeth, only few brush when going to bed or both when going to bed and in the morning. The result is lower to a report in India and in disagreement with the ADA recommendation.
The current study reported that the use of dental floss was still not popular among the secondary school students. In contrast, the studies conducted in Nigeria, the use of dental floss was recognized by slightly more than a third of the students and over two-third of adolescent pregnant women in Australian. The latter higher figure could be due to population variation despite little existent of the practice in Ethiopian culture. This may be because the use of floss is to find less popularity and accessibility in our environment. The ADA recommends flossing once a day. Flossing is used to remove food particles or plaques lodged between teeth more efficiently than toothpicks.
This study is tried to describe the current characteristics of high school students' KAPs toward oral hygiene in Addis Ababa. Generalizability could not be drawn for all high school students in other areas, and recall biases might affect the magnitude of estimated reported. Further researches would be warranted with larger populations and robust analytic methods to find a more precise measurement and determinants of students' KAP.
| Conclusions|| |
The current study showed that 62.8% of the students had poor knowledge toward oral hygiene. Similarly, more than half proportion of Medhanealem High School students had a negative attitude toward oral hygiene. The level of practice to maintain proper oral hygiene practice was found inadequate among majority of the students. The chewed stick (Mefakiya) is the most common oral hygiene aid used by half proportion of the respondents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haque M, Sartelli M, Haque SZ. Dental Infection and Resistance-Global Health Consequences. Dent J (Basel) 2019;7. pii: E22.
Harikiran AG, Pallavi SK, Hariprakash S, Ashutosh., Nagesh KS. Oral health-related KAP among 11- to 12-year-old school children in a government-aided missionary school of Bangalore city. Indian J Dent Res 2008;19:236-42.
] [Full text]
GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390:1211-59.
Bjertness E. The importance of oral hygiene on variation in dental caries in adults. Acta Odontol Scand 1991;49:97-102.
Zeru T. Prevalence of dental caries and associated factors among aksum primary school students, Aksum Town, Ethiopia. J Dent Oral Health 2019;5:130-5.
Berhane H, Worku A. Oral Health of Young Adolescents in Addis Ababa – A community-based study. Open J Prev Med 2014;4:640-8.
Gualie YT, Tayachew AT. Assessment of knowledge, attitude, and practice toward oral hygiene among governmental secondary school students in Debre Tabor Town, Amhara Region, North Central Ethiopia 2018: Institutional-based cross-sectional survey. Int J Oral Health Sci 2018;8:92-8. Available from: http://www.ijohsjournal.org/text.asp?2018/8/2/92/247805
. [Last accessed on 2019 Nov 22].
Darout IA. Knowledge and behavior related to oral health among Jimma University Health Sciences students, Jimma, Ethiopia. Eur J Gen Dent 2014;3:185-9. Available from: http://www.ejgd.org/text.asp?2014/3/3/185/141663
. [Last accessed on 2019 Nov 22].
Goldberg I. Purification and properties of a methanol-oxidizing enzyme in Pseudomonas C. Eur J Biochem 1976;63:233-40.
Simon C, Tesfaye F, Berhane Y. Assessment of the oral health status of school children in Addis Ababa. Ethiop Med J 2003;41:245-56.
Burnett D, Aronson J, Asgary R. Oral health status, knowledge, attitudes and behaviours among marginalized children in Addis Ababa, Ethiopia. J Child Health Care 2016;20:252-61.
Ayele FA, Taye BW, Ayele TA, Gelaye KA. Predictors of dental caries among children 7-14 years old in Northwest Ethiopia: A community based cross-sectional study. BMC Oral Health 2013;13:7.
Reich E. Trends in caries and periodontal health epidemiology in Europe. Int Dent J 2001;51:392-8.
Maes L, Vereecken C, Vanobbergen J, Honkala S. Tooth brushing and social characteristics of families in 32 countries. Int Dent J 2006;56:159-67.
Wahengbam PP, Kshetrimayum N, Wahengbam BS, Nandkeoliar T, Lyngdoh D. Assessment of oral health knowledge, attitude and self-care practice among adlescents-A state wise cross-sectional study in Manipur, Nourth Eastern India. J Clin Diagn Res 2016;10:zc65-70.
Reddy V, Bennadi D, Gaduputi S, Kshetrimayum N, Siluvai S, Reddy CV. Oral health related knowledge, attitude, and practice among the pre-university students of Mysore city. J Int Soc Prev Community Dent 2014;4:154-8.
Amin TT, Al-Abad BM. Oral hygiene practices, dental knowledge, dietary habits and their relation to caries among male primary school children in Al Hassa, Saudi Arabia. Int J Dent Hyg 2008;6:361-70.
Priya M, Devdas K, Amarlal D, Venkatachalapathy A. Oral health attitudes, knowledge and practice among school children in Chennai, India. J Educ Ethics Dent 2013;3:26-33. [Full text]
Farsi JM, Farghaly MM, Farsi N. Oral health knowledge, attitude and behaviour among Saudi school students in Jeddah city. J Dent 2004;32:47-53.
Ogundele BO, Ogunsile SE. Dental health knowledge, attitude andpractice on the occurrence of dental caries among adolescents in a Local Government Area (LGA) of Oyo State Nigeria. Asian J Epidemiol 2013;1:64-71.
Rotimi VO, Mosadomi HA. The effect of crude extracts of wine Africanchewing sticks on oral anaerobes. J Med Microbiol 1987;23:55-60.
Ogundiya MO, Okunade MB, Kolapo AL. Antimicrobial activities of some Nigeria chewing sticks. Ethnobotanical Leaf 2006;10:265-71.
Shukure R, Shuke D. Assessment of Knowledge and Practice on Oral Health and Oral Hygiene Status among Fitche Preparatory School Students in Fitche Town, Oromia, Ethiopia. Int J Clin Oral Maxillofacial Surg 2015;3:30-4. doi: 10.11648/j.ijcoms.20170306.11.
Yayehyirad K, Asmelash G, Bedru B. Dental Health Condition of Students in Ethiopia: A finding from the development through cooperation campy. Ethiop Med J 1982;20: 1967-77.
Ayo-Yusuf OA, Booyens S. Principal motives for tooth brushing in a population of South African adolescents: Implications for oral health promotion. SADJ 2011;66:174-8.
Flaherman VJ, Epstein J, Amendola L, Inge R, Featherstone JD, Okumura M. Preventive Dental Care at 6-Month Intervals Is Associated With Reduced Caries Risk. Clin Pediatr (Phila) 2018;57:222–226. doi:10.1177/0009922817691823. Available from https://journals.sagepub.com/doi/10.1177/0009922817691823
[last accessed on 2019 Nov 22].
Jamieson LM, Parker EJ, Roberts-Thomson KF, Lawrence HP, Broughton J. Self-efficacy and self-rated oral health among pregnant aboriginal Australian women. BMC Oral Health 2014;14:29.
Chalmers NI, Wislar JS, Boynes SG, Doherty M, Nový BB. Improving health in the United States: Oral health is key to overall health. J Am Dent Assoc 2017;148:477-80.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]