The Oral Health Status and Attitudes of Saudi Adolescent Male Students in Albaha
Province: A Cross-Sectional Study
Abdullah Ali Alzahrani*, Eltayeb Mohammed Alhassan and Mohammad Albanghali
Department of Dental Health, Albaha University, Saudi Arabia
Submission: November 15, 2018; Published: November 29, 2018
*Corresponding author: Abdullah Ali Alzahrani, Dental Health Department, Faculty of Applied Medical Sciences, Albaha University, Albaha, P.O. Box 18, Postal Code 65951, Saudi Arabia.
How to cite this article: A Ali Alzahrani, E Md Alhassan, Md Albanghali. The Oral Health Status and Attitudes of Saudi Adolescent Male Students in Albaha
Province: A Cross-Sectional Study. Adv Dent & Oral Health. 2018; 10(1): 555779. DOI: 10.19080/ADOH.2018.10.555779
Objectives: To explore and examine the oral health status of Saudi adolescent male students aged 12-15 years in Albaha province and evaluating the oral health attitudes of this population.
Methods: This was a cross-sectional study in which random sampling was used. Data was collected at schools of the subjects between November 2017 and February 2018. A clinical examination was carried out to evaluate the presence of tooth decay, plaque and gingival bleeding. Then a face-to-face interviews with the study participants were employed to measure their oral health attitudes using a pre-designed questionnaire. SPSS® version 20.0 was used to conduct the data analysis.
Results:Two hundred and forty-nine Saudi adolescent male students from three different territories in Albaha province were recruited. The rate of dental caries, plaque and gingival bleeding was determined to be high (76%, 94% and 86%, respectively). A 73% of the adolescents were seen to hold a moderate attitude towards the preservation of their oral health. Only 40% of the participants visited the dentist regularly and just 16% of the children reported brushing their teeth twice daily.
Conclusion: The oral health status of the studied population was poor. Moderately positive oral health attitudes were demonstrated overall. Further research into the implementation of oral health-based educational and preventive strategies is urgently required to advance the oral health status and practices of Albaha province community members.
There is a burgeoning amount of global literature on the impact of poor oral health status on quality of life, particularly that pertaining to adolescents. For example, tooth decay affects the willingness of children to speak, smile and eat . Likewise, the adverse effects of periodontal disease on the quality of life of individuals have been observed to be substantial . Thus, an exploration and evaluation of the oral health status of any community is warranted to inform the establishment and implementation of suitable oral health interventions to reduce these negative effects.
The prevalence of dental caries among the Saudi population, particularly among adolescents, is relatively high . Nationally, dental caries in Saudi children was estimated to be 80% and 70% for primary dentition and permanent dentition, respectively, with respective mean Decayed, Missing or Filled Teeth (DMFT) index scores of 5.0 and 3.5, as per the findings of a systematic review . Meanwhile, an overall prevalence of 73% for dental caries was
reported in a sample of 711 Saudi schoolchildren in Dammam . Similarly, a mean DMFT index score of 3.27 was found for 48 children in Tabuk . The incidence of dental caries was also determined to be ≥ 80% in 1844 schoolchildren in Riyadh . Similarly, tooth decay was identified in ≥78% of adolescents (n = 724) aged 12-14 years following a cross-sectional survey conducted in Jeddah .
Periodontal disease is regarded as one of the most common chronic illnesses worldwide. The association of periodontitis with several risk factors, including increased waist circumference, obesity, overweight and weight gain, is often used to explain the prevalence of periodontal disease . The rate of plaque and gingivitis in Saudi children aged 7-15 years in Riyadh was reported to be 46% (n = 93) in another study . A high incidence of plaque was also identified in 500 adolescents based in Jazan following a cross-sectional survey, where the mean plaque index (PI) score for male and female schoolchildren was found to be 0.69 and 0.66, respectively . Additionally, gingivitis was seen to be
pervasive in Saudi adults aged 18-40 years (n = 385, 100%), with
a mean gingival index (GI) score of 1.68±0.31, indicating moderate
gingival inflammation .
The health and well-being of individuals has been shown to
be enhanced by positive attitudes to oral health , while the
maintenance of sound oral hygiene habits and attitudes was found
to have a strong association with healthy teeth and gums . It
was established that 33% of adolescents (n = 287) aged 15-18
years did not brush their teeth following a cross-sectional survey
conducted in Riyadh . It was demonstrated in other research
on 917 Saudi schoolchildren, that despite having satisfactory
attitudes and knowledge of oral health, 59% of them practiced
poor oral hygiene .
However, despite an extensive evaluation of oral health in
the different geographical areas of Saudi Arabia and in Saudi
populations of varying ages, in which poor oral hygiene, habits and
attitudes, and widespread dental caries and periodontal disease
have been identified [5,13], yet a little is known in this regard
among adolescents in Albaha province, Saudi Arabia. Moreover,
the association of impacts resulted from oral diseases with
individuals’ quality of life and well-being is well confirmed .
Thus, those two reasons may justify the importance of conducting
the current study which aims to explore and examine the oral
health status and attitudes of Saudi adolescent male students aged
12-15 years living in Albaha province.
Three schools distributed across three different territories
(Albaha, Alatawelah and Alaquiq) in Albaha province, Saudi Arabia,
were randomly selected for inclusion in the study. Information
sheets outlining the purpose of and methodology used in the
research, and containing informed consent forms, were sent to
the parents of students between September and October 2017,
prior to conducting the study. The study subjects comprised Saudi
adolescent male students aged 12-15 years. The participants
were classified according to three different age groups; i.e., 12-13
years, 14 years and 15 years. They were interviewed to ascertain
their attitudes to their oral health, and then underwent a clinical
examination to assess for periodontal disease and dental caries to
gauge their overall oral health status.
This study was approved by the Planning, Research and Studies
Department at the Saudi Ministry of Education (Albaha branch)
(approval reference number: 39195280). It can be confirmed that
this study was conducted in accordance with ethical standards of
the Saudi Ministry of Education and Albaha University. Parents of
the participants were provided with written information sheets
that outlined the objective and procedures to be used in the study.
Informed written consent was obtained from the parents prior to
conducting the study. The parents were reassured that all personal
information would be kept confidential and were informed of the
right to contribute and of the right to withdraw from the study
without having to provide a reason why, and without prejudice,
at any time.
A randomized sampling technique was employed between
November 2017 and February 2018 to select the study sample.
The local education authority, the Albaha branch of the Saudi
Ministry of Education, provided statistical information regarding
the total number of students and details of schools in the region.
One school was randomly chosen from each of the Albaha,
Alatawelah and Alaquiq regions in Albaha province. The students
were included in the study if their parents agreed that they
could participate and if they provided informed written consent.
However, female students were excluded from the study sample,
mainly owing to cultural challenges in accessing this population
at schools, particularly as the researchers were men. The sample
size was calculated based on the total number of Saudi adolescent
male students (n = 5479) aged 12-15 years living and registered
in Albaha province, using an adjusted 95% confidence level.
The sample size thought to have enough power and validity for
the purpose of the study was consequently estimated to be 255
The study participants were clinically examined at their
schools for assessment of their periodontal and dental caries
status. The PI and GI developed and published by the World
Health Organization (WHO)  were used to assess gingival
bleeding and perform a supragingival dental calculus evaluation of
all teeth. The DMFT index, also established by the WHO  was
employed to determine the significance of the dental decay. For
quality reasons and based on the recommendations of the WHO
, 10% of the randomly selected cases (i.e., 26 adolescents)
were re-examined by an independent examiner to measure intraexaminer
consistency and agreement regarding the oral health
status evaluation. Interrater reliability was measured using
Cohen’s kappa, and the values for dental caries, gingival bleeding
and plaque were estimated to be 0.84, 0.87 and 0.91 respectively,
demonstrating high consistency and agreement between the
findings of the two examiners. The clinical examinations were
performed under clinical conditions, using portable clinic lights
and disposable examination kits, consisting of tweezers, sharp
probes (number 4), a mouth mirror, cotton, gauze, a face mask,
gloves, and CPI periodontal probes.
Prior to conducting the clinical examination, face-to-face
interviews were conducted with the participants with a view
to completing a pre-designed questionnaire on attitudes to oral
health. The questionnaire was adapted from the Hiroshima
University-Dental Behavioral Inventory , with minor modifications to ensure cultural applicability. The final version
included 15 items that focused on the attitudes of the participants
to their oral health and their sociodemographic backgrounds
To ensure that the risk of bias was kept to a minimum and
to avoid influencing the clinical examinations owing to prior
knowledge of attitudes to oral health, the investigators were
asked to record the clinical examination findings separate from
the questionnaire results.
The total number of statements reflective of a positive oral
health attitude were added together to calculate the final score
for attitudes to oral health based on the 15 items. The final score
varied from 0-15; with a poor attitude to oral health classified as
a score of 1-5, a moderate attitude categorized as a score of 6-10
and a sound attitude graded as a score of 11-15. The DMFT index,
the PI and the GI were stratified as low or high strata, based on the
median for each index. Statistical Package for the Social Sciences®
version 20.0 was used to analyze the data. The chi-square test was
employed to investigate an association between the categorical
variables. Fisher’s exact test was utilized, as appropriate. The
Kruskal-Wallis H test (a nonparametric [distribution free] test)
was used to compare the medians from the different groups.
Two hundred and eighty Saudi male adolescent students aged
12-15 years were invited from three schools to participate in the
study. Eighteen students were absent on the day of the clinical
examination and 13 students decided against participating.
Thus, 249 adolescents were finally included in the research (i.e.,
a response rate of 89%). The sociodemographic characteristics
of the participants were recorded according to their age and the
geographical location of the school (Table 2).
The prevalence of dental caries in the studied population
was considerably high. Of the 249 participants, tooth decay was
identified in 189 (76%) of them at the time of examination.
Significantly, the DMFT values were observed to violate the
normality assumption. The calculated mean for the DMFT value
was 0.47±0.58. The percentage of filled teeth (FT) and decayed
teeth (DT) according to the DMFT index was 2% and 77%,
respectively. The mean DT, missing teeth (MT) and FT index
scores were 0.52±0.60, 0.00±0.02 and 0.00±0.01, respectively. The
difference in the DMFT index score for the different age groups
and regions was statistically significant (p=<0.001 and 0.036,
respectively) (Figure 1 & 2). The overall prevalence of dental
caries, plaque and gingival bleeding in the different age groups
and regions is summarised in Table 3.
The prevalence of plaque and gingival bleeding was
significantly high in the current study, affecting 235 (94%) and 215
cases (86%), respectively. Although the PI and GI values violated
the normality assumption, the mean PI and GI value was 1.40 ±
0.67 and 1.08 ± 0.90, respectively. The difference in the GI scores
for the different regions was found to have statistical significance
(p = 0.003). However, this was not the case with respect to the
difference in GI scores for the different age groups (p = 0.058). By
contrast, statistical significance was attributed to the difference
in PI values for the participants in the different regions and age
groups (p= 0.025 and 0.004, respectively) (Figure 1 & 2).
Three quarters of the adolescents (n = 186, 73%) were seen
to hold a moderate attitude towards the preservation of their oral
health. The approach to oral health was found to be poor for 61 of
the study participants (25%) and sound for only six of them (2%).
The identified differences in attitudes to oral health among the
different age groups and regions (schools) was without statistical
Surprisingly, 43% (n = 106) of the participants had not visited
the dentist and only 16% (n = 39) reported brushing their teeth twice daily. A third of the sample (n = 89, 36%) preferred to clean
their teeth using a toothbrush and toothpaste rather than miswak,
an herbal chewing stick. Only 9% and 14% of the participants
regularly used dental floss and mouthwash, respectively.
Nevertheless, most of them admitted to being concerned about
the color and appearance of their teeth and gums (81% and 77%,
respectively). The attitudes of the study participants to their oral
health are detailed in Table 4.
The association between the pooled scores for attitudes
to oral health and the DMFT index and the GI was not found to
be statistically significant (p = 0.741 and 0.352, respectively).
Interestingly, statistical significance was reported for the
association between the pooled scores for attitudes to oral health
and the PI (p = 0.023). Several of the attitudes to oral health were
shown to have a statistically significant association with the DMFT
index, PI and GI on bivariate analysis. The correlation between
activities such as visiting the dentist, using mouthwash, being
concerned about bad breath, going for regular dental check-ups
(even in the absence of toothache or complications) and using
dye to identify plaque on the teeth and the DMFT index score
was statistically significant (p = 0.001, 0.048, 0.01, 0.003 and
0.006, respectively). Likewise, the correlation between attitudes
towards and factors linked to the preservation of oral health, such
as visiting the dentist, brushing the teeth carefully, the absence
of bleeding gums during brushing, and going for regular dental
check-ups (even in the absence of toothache or complications)
and the PI and GI scores was statistically significant. The findings
of the bivariate analysis of the association between attitudes to
oral health and the DMFT index scores, and PI and GI scores are
detailed in Table 4.
Dental epidemiology is performed to evaluate the oral health
needs of a community to assist with the planning, assessment,
implementation and auditing of preventive strategies and/or oral
healthcare programmes to reduce the prevalence of dental disease
[20,21]. However, there is a lack of studies in the dental literature
on the oral health status and attitudes of schoolchildren in Albaha
province, Saudi Arabia, and particularly those of adolescents aged
12-15 years. This is reflective of the significance of conducting a
cross-sectional study in this regard, especially since dental disease
is a public health problem globally , and such a study has not
yet been published.
The overall incidence of dental caries, plaque and gingival
bleeding in the studied population was found to be significantly
high in the current study, consistent with the findings of previous
research conducted in Saudi Arabia across several cities, including
Dammam, Tabuk, Riyadh and Jeddah [5-8,10-12]. This might
indicate that dental caries and periodontal disease in Saudi
Arabia are not treated regularly, similar to conditions in several
developing countries [22,23]. Nonetheless, there might be an
essential need to develop focused oral disease prevention and
health-promoting strategies, such as promoting the application of
pit and fissure sealant and/or establishing oral health education
school programmes across these communities [24,25].
The oral health status of Saudi children in Albaha province was
shown to be relatively poor in the current study, with a statistically
significant variation in the DMFT index, GI and PI values among
the children in the different school regions. These findings might
indicate that the unequal distribution of dental services and/
or challenges with accessibility and transportation to existing
dental services in the Albaha region could be possible reasons for
the variation in the DMFT index, PI and GI values . Further
research is warranted to explore this area in depth and validate the
study findings in order to ensure that similar treatment protocols
are applied across the different territories.
Interestingly, although the prevalence of dental caries, plaque
and gingival bleeding was high in the current study, moderate
attitudes to oral health were attributed to most of the study
subjects (73%). These findings are like those of previous research
carried out on Saudi children . This may suggest the need for
the implementation of a combination of several oral health-related
educational and practice programmes at schools, in addition
to a follow-up of the progress of and effort made by children to
improve their oral health status [28,29].
It was demonstrated in the current study that roughly half of
the participants (40%) believed in the importance of attending
dental check-ups regularly, even in the absence of toothache or
complications, but only 16% of them brushed their teeth twice
daily and had been taught how to do it properly. Yet, evidence has
shown that the oral health practices of parents’ influence their
children’s dental status . Potentially, this may signify that
there is a crucial need to motivate parents and schoolchildren to
adhere to sound oral health practices and lifestyles, particularly
about controlling sugar consumption prior to and at bedtime, and
using fluoride toothpaste [30,31].
There were limitations to the study. Female adolescents
were not included in the study sample, mainly owing to cultural
challenges in accessing this population at school, particularly as the
researchers were men, thus impeding the ability to generalize the
study findings. Even though this was a cross-sectional survey and
that it involved a limited sample size, it nevertheless offers insight
into the oral health status and attitudes of Saudi adolescent male
students in Albaha province. A further limitation was the potential
inhibition of the ability to evaluate the causal relationships
between the study variables owing to the cross-sectional design.
For instance, it was difficult to definitively claim that the high
prevalence of dental caries was caused by poor attitudes to oral
health. However, the study focus was to examine and explore the
oral health conditions and attitudes of adolescents, rather than to
measure causal associations.
A high prevalence of dental caries, plaque and gingival
bleeding was identified in Saudi adolescent male students aged
12-15 years in Albaha province, following an exploration of their
attitudes to oral health and an evaluation of their oral health status
via a clinical examination. Nevertheless, most of the participants
were observed to have moderate attitudes to their oral health.
This may highlight the need for the implementation of oral health promotional and educational programs, in conjunction with the
development of suitable oral health preventive strategies to ensure
the restriction of sugar consumption, the use of fluoride toothpaste
and the application of pit and fissure sealant. Future research may
also be warranted into discrepancies in the distribution of dental
services throughout the country and/or accessibility to existing
dental services in Albaha province.