SELF-PERCEIVED ORAL HYGIENE AND PERIODONTAL HEALTH AMONG DENTAL AND MEDICAL STUDENTS, DENTISTS AND PHYSICIANS IN KSA
Rakan Saifuddin Shaheen1, Abdulrahman Dahham Alsaffan2*, Raghad Saad Al-Dusari3, Rahaf Nezar Helmi3, Mohammad Abdul Baseer4
1Periodontics Division, Department of Preventive Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia.
2Community Dentistry Division, Department of Preventive Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia. [email protected]
3Department of Intern, Riyadh Elm University, Riyadh, Saudi Arabia.
4Department of Preventive Dentistry, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabi.
ABSTRACT
Dental Students, Medical Students, Dentists, and Physicians play a crucial role in community oral health promotion. Hence it is essential to know about their understanding of periodontal health and oral hygiene practices. This study aimed to evaluate oral health awareness and hygiene behavior related to gingival health. A cross-sectional survey investigated self-perceived oral hygiene and periodontal health among dental students, medical students, dentists, and physicians in Saudi Arabia. An online questionnaire consisting of five items on demographics and nineteen questions on oral hygiene and periodontal was distributed to the targeted population utilizing various social media platforms. The relationship between the categorical variables was assessed using the Chi-square test. Study sample consisted of 637 participants with 154 dental Students, 101 medical Student, 276 dentists and 106 physicians. Tooth brushing variables such as teeth cleaning method, brushing frequency, brushing duration, changing toothbrush brushing strokes, type of toothbrush differed significantly across various groups of study (p<0.05). Tongue cleaning, dental visits, and use of inter-dental aids also demonstrated significant variations among different field of participants (p<0.05). Similarly periodontal diseases perception showed a statistically significant difference across study groups (p<0.05). Dentist and dental students had a better oral hygiene regimen, especially regarding interdental cleaning and brushing frequency. Interdental cleaning was not perceived as important as tooth brushing amongst the physicians and medical students groups as the majority believed that brushing alone can prevent gingival diseases. Severe gingival problems were more perceived by the physicians and medical students.
Key words: Self-perception, Oral hygiene, Periodontal health, Medical student, Dental student, Dentist
Introduction
Periodontal diseases are the most common oral health issues that can affect not only the teeth and periodontal tissues but the general health [1], interpersonal relationships, and overall comfort and productivity of an individual [2]. Periodontal disease incidence ranges between 20%-50% in populations of developing countries [3]. In Saudi Arabia, the prevalence of gingivitis was 100% in a nationwide study [4], meanwhile, in high school students, the incidence of gingivitis was 65.1% [5], and the incidence of periodontitis was 8.6% [6]. Furthermore, the risk of cardiovascular diseases increased by 19% to 44% in elderly individuals suffering from periodontitis, and the mortality risk was 3.2 times greater in type 2 diabetic patients suffering from severe periodontitis [3].
In regards to self-perception of oral health in adults, results revealed a concern about the appearance of the teeth amongst 42.7% of the individuals, 30.1% were concerned about general teeth problems, 27.5% were concerned about teeth sensitivity, and 100% of the sample did not recognize the periodontal status as a health issue nor a quality of life factor [7]. Meanwhile, the self-perception of oral health amongst the elderly was reported to be satisfactory despite the lack of oral health care [8, 9].
Furthermore, studies examining the periodontal condition's self-evaluation of the general public showed that the evaluation was accurate for individuals with healthy periodontium but inaccurate when gingival diseases [10, 11]. The self-evaluation of dental and medical students revealed that they could identify the signs and symptoms of periodontal issues more than their medical counterparts [2]. Moreover, when a clinical assessment followed the self-evaluation of the general public, it was revealed that 50% of the patients had inaccurately assessed their periodontal health [1].
Observing the self-perception of pain amongst the patients remained unchanged compared to the clinical assessment. In contrast, the self-perception of malodor was exaggerated in almost 50% of the patients who reported having it. However, the clinical assessment revealed them to be malodor-free [12]. When oral malodor self-perception was observed in dental and medical students, it was shown that they were unaware of their oral malodor compared to the clinical assessment [2]. Moreover, it was found that the self-evaluation of the dental cavities was inaccurate compared to the clinical assessment, as the majority of the patients missed or misperceived a cavity [13, 14].
The self-reporting of the public regarding the use of mouthwash has shown that older and female individuals more frequently use the mouthwash [15]. Moreover, dental and medical students reported that toothbrush and toothpaste is their primary method of oral hygiene. The dental students reported a higher frequency of brushing twice daily, interdental cleaning, and changing their toothbrushes every three months compared to their medical counterparts. Hence the present study aimed to evaluate the oral hygiene among periodontal health of dental students, medical students, dentists, and physicians. The present study intends to address the central question, "Is there a difference in the oral hygiene regimens and self-perception of periodontal health between dental students, medical students, dentists, and physicians?"
Materials and Methods
Study sample
The study sample comprised medical students, dental students, practicing dentists, and physicians.
Sample size calculation
A minimum required sample of 377 study participants was estimated based on the acceptable margin of error of 5%, the confidence level of 95%, assuming the population under investigation is 20000, and a 50% distribution of response rate. However, to improve the power of the study and a final sample of 637 was considered in this study. A convenience sampling methodology was employed to select the sample. Medical students, dental students, dentists, and physicians who were active on professional social media platforms in Saudi Arabia were included in this study.
Study instrument
A structured, closed-ended, self-administered questionnaire with five sociodemographic (gender, age, region, specialty, and smoking habit) variables and twenty questions about self-perceived oral hygiene and periodontal health was utilized in this study. The main questions assessed the participant's perception of oral hygiene and overall health, materials, methods, frequency, and timing of the teeth cleaning noted. In addition, questions elicited participants' use of the toothbrushing frequency of changing toothbrush, use of inter-dental cleaning aids, visit dentist, and reason for a dental visit. Perception of oral malodor, gum disease, loss of teeth due to periodontal disease, and the relationship between periodontal disease and systemic conditions was also recorded.
Validity and reliability of the study instrument
The face validity of the questionnaire was established by taking the opinion of the experts in periodontology and dental public health. The suggestions and comments provided by the experts were implemented in the questionnaire.
A pilot study was conducted among 20 medical and dental students and professionals. The reliability of the questionnaire was measured using Cronbach's alfa (0.85), which is considered adequate for conducting the main study.
Questionnaire administration
An electronic version of the English questionnaire was prepared using Google forms. An online link was distributed to dental students, medical students, dentists, and physicians in Saudi Arabia utilizing various professional social media platforms. All the questionnaire items were mandatory, and it took 5 minutes for the participants to answer all the questions.
Statistical analysis
All the collected responses in google forms were downloaded and coded. Complete data were transferred to the statistical analysis program for analysis purposes. Statistical analysis program SPSS version 25 (IBM-SPSS, Armonk. USA) was used to perform analysis of the data. Frequency distribution and percentages were calculated for the categorical variables. A Chi-square test was applied to find the relationship between sociodemographic variables and the self-perception of periodontal disease. A p-value of p<0.05 was considered significant for all the statistical tests.
Results and Discussion
A total of 154 (24.2%) dental students, 101 (15.9%) medical students, 276 (43.3%) dentists, and 106 (16.6%) physicians participated in this study. Of 637 participants, 376 (59%) were females, and 261 (41%) were males, aged between 19 to 69 years. Most of the students belonged to the central region 447(70.2%) and 66 (10.4%) participants rarely smoked cigarettes or Hookah, as shown in Table 1.
Table 1. Distribution of the study participants (N=637)
|
Variables |
n |
% |
|
|
Gender |
Male |
261 |
41.0 |
|
Female |
376 |
59.0 |
|
|
Region |
Central Region |
447 |
70.2 |
|
Northern Region |
21 |
3.3 |
|
|
Southern Region |
13 |
2.0 |
|
|
Western Region |
76 |
11.9 |
|
|
Eastern Region |
80 |
12.6 |
|
|
Field |
Dental Student |
154 |
24.2 |
|
Medical Student |
101 |
15.9 |
|
|
Dentist |
276 |
43.3 |
|
|
Physician |
106 |
16.6 |
|
|
Do you smoke cigarettes/Hookah [shisha]? |
Yes, frequently [10 or more Cigarettes Daily/Hookah once daily] |
65 |
10.2 |
|
Yes, occasionally [5 to 10 Cigarettes Daily/Hookah once weekly] |
25 |
3.9 |
|
|
Yes, rarely [Less than 5 Cigarettes Daily/Hookah once Monthly] |
66 |
10.4 |
|
|
Never |
481 |
75.5 |
|
The majority (95.8%) of participants felt that oral hygiene is mandatory for the body's overall health. Moreover, the majority of participants (57.3%) reported cleaning their teeth twice daily [morning and evening], (17.7%) only brush their teeth once daily before sleeping, (12.6%) brush their teeth three times or more, (7.7%) brush once daily [before/after breakfast], (4.2%) brush their teeth infrequently [not daily], (0.5%) never brush their teeth. With the majority brushing their teeth for a duration of 1 to 2 minutes (55.3%). Moreover, approximately (50.4%) change their toothbrush once every three months. The top brushing motion used by (49.5%) of participants was found to be circular strokes (p<0.05). The majority (47.3%) reported using a soft toothbrush. No significant difference was observed when responses were compared across the participants (p=0.260). However, teeth cleaning method (p=0.002), brushing frequency (p<0.001), brushing duration (p<0.001), changing toothbrush (p<0.001), brushing strokes (p<0.001), and type of toothbrush (p=0.002) (Table 2).
Table 2. Comparison of oral hygiene and toothbrushing variables across study subjects
|
Variables |
Dental Students |
Medical Students |
Dentists |
Physicians |
p |
|
|
Oral hygiene and overall health |
Yes No I don't know |
94.2% 3.9% 1.9% |
97% 2% 1% |
97.1% 1.4% 1.4% |
93.4% 1.9% 4.7% |
0.260 |
|
Teeth cleaning method |
Brush and Paste Finger and Paste/Powder Brush & Powder Miswak |
98.7% 0.6% 0% 0.6% |
94.1% 2% 4% 0% |
96.7% 1.1% 0.7% 1.4% |
92.5% 1.9% 0% 5.7% |
0.002 |
|
Brushing frequency |
Once Before sleeping Once B/A Breakfast Twice Daily M&E Three times or more Infrequently Never |
16.9% 7.1% 63.6% 11% 1.3% 0% |
24.8% 14.9% 33.7% 11.9% 14.9% 0% |
14.1% 5.1% 65.9% 13.8% 1.1% 0% |
21.7% 8.5% 48.1% 12.3% 6.6% 2.8% |
<0.001 |
|
Brushing duration |
< 1 minute 1-2 minutes 3-5 minutes > 5 minutes I don't know |
5.8% 68.2% 18.8% 4.5% 2.6% |
17.8% 54.5% 25.7% 1% 1% |
10.1% 50.7% 37.3% 1.1% 0.7% |
13.2% 49.1% 30.2% 4.7% 2.8% |
<0.001 |
|
Changing toothbrush |
1 per month 1 per 3 months 1 per 6 months 1 per year When needed Not Applicable |
5.2% 53.2% 29.2% 4.5% 7.8% 0% |
5.9% 25.7% 40.6% 6.9% 19.8% 1% |
4% 60.9% 23.2% 2.9% 8% 1.1% |
7.5% 42.5% 24.5% 11.3% 12.3% 1.9% |
<0.001 |
|
Brushing strokes |
Horizontal Vertical Circular Random Not Applicable |
17.5% 16.2% 52.6% 18% 2.6% |
23.8% 9.9% 37.6% 25.7% 3% |
6.9% 19.6% 59.8% 10.5% 3.3% |
10.4% 22.6% 29.2% 27.4% 10.4% |
<0.001 |
|
Type of toothbrush |
Ultra-soft Soft Medium Hard Electronic Not Applicable |
13% 48.1% 26.6% 1.3% 10.4% 0.6% |
12.9% 48.5% 24.8% 0% 9.9% 4% |
5.8% 49.6% 34.1% 0.7% 9.8% 0% |
4.7% 38.7% 44.3% 0% 8.5% 3.8% |
0.002 |
Table 3 shows a comparison of responses on tongue cleaning and the use of interdental aids among dental students, medical students, dentists, and physicians. The tongue cleaning (p<0.001), use of dental aid (p<0.001), type of dental aid (p<0.001), dental visits (p<0.001), and maintenance dental visits (p<0.001) differed significantly among the study subjects.
Table 3. Tongue cleaning, dental visits, and use of inter-dental aids in study subjects
|
Variables |
Dental Students |
Medical Students |
Dentists |
Physicians |
p |
|
|
Tongue cleaning |
Yes No |
76.6% 23.4% |
62.4% 37.6% |
73.6% 26.4% |
55.7% 44.3% |
<0.001 |
|
Use of interdental aid |
Yes No |
82.5% 17.5% |
46.5% 53.5% |
90.6% 9.4% |
59.4% 40.6% |
<0.001 |
|
Type of interdental aid |
Normal Floss Floss and Water floss Interdental brush Interdental brush and water floss Toothpick Not Applicable |
73.3% 6.9% 0% 1.5% 3.1% 15.3% |
37.2% 5.3% 2.1% 1.1% 6.4% 47.9% |
79.8% 8.1% 1.6% 2.4% 0.4% 7.7% |
37.1% 1.1% 2.2% 9% 16.9% 33.7% |
<0.001 |
|
Dental visits annually |
Once Twice Three times More than three times Did not visit |
43.5% 21.4% 7.8% 13.6% 13.6% |
39.6% 13.9% 5.9% 5.9% 34.7% |
38% 27.5% 5.8% 6.9% 21.7% |
33% 22.6% 8.5% 8.5% 27.4% |
0.004 |
|
Maintenance dental visits |
Once a year Twice a year More than twice When needed Never |
38.3% 27.3% 3.9% 19.5% 11% |
27.7% 8.9% 3% 43.6% 16.8% |
26.8% 27.5% 4% 33.7% 8% |
38.8% 13.2% 0.9% 38.7% 10.4% |
<0.001 |
The healthy gingival perception among study participants ranged between 66% to 79.7% for physicians and dentists. Similarly, non-injurious teeth mobility, gingival sensitivity, and self-perception of halitosis were absent in most of the dental students and dentists than medical students and physicians. A large number of dentists than others were brushing their teeth to prevent gingival disease. Lastly, most dentists, physicians, and dental students rated their knowledge about periodontal disease and its association with systemic disease as average. In contrast, medical students rated it as limited. Self-perception of gingival health (p<0.001), non-injurious teeth mobility (p<0.001), gingival sensitivity (p<0.001), gingival pain (p<0.001), self-perception of halitosis (p<0.001), brushing to prevent gingival disease (p<0.001), gingival bleeding concerning gingival problems (p<0.001), and knowledge of periodontal disease and systemic conditions (p<0.001) differed significantly among dental students, medical students, dentists, and physicians (Table 4).
Table 4. Periodontal diseases perception among different study participants
|
Variables |
Dental Students |
Medical Students |
Dentists |
Physicians |
p |
|
|
Self- Perception of Gingival Health |
Healthy gingiva Redness Bleeding Exposed roots |
69.5% 21.4% 7.8% 1.3% |
76.2% 8.9% 8.9% 5.9% |
79.7% 14.1% 5.1% 1.1% |
66% 12.3% 9.4% 12.3% |
<0.001 |
|
Non-Injurious Teeth Mobility |
Yes No I don't know |
3.2% 92.9% 3.9% |
7.9% 82.2% 9.9% |
2.2% 96.7% 1.1% |
10.4% 81.1% 8.5% |
<0.001 |
|
Gingival sensitivity |
Yes No I don't know |
8.4% 89% 2.6% |
17.8% 64.4% 17.8% |
16.3% 83.6% 1.1% |
21.7% 63.2% 15.1% |
<0.001 |
|
Gingival Pain |
Yes No I don't know |
7.8% 89.6% 2.6% |
11.9% 81.2% 6.9% |
2.9% 95.3% 1.8% |
13.2% 77.4% 9.4% |
<0.001 |
|
Self-Perception of Halitosis |
Yes No I don't know |
17.5% 75.3% 7.1% |
35.6% 50.5% 15.9% |
11.6% 79% 9.4% |
18.9% 64.2% 17% |
<0.001 |
|
Brushing to Prevent Gingival Disease |
Yes No I don't know |
24.7% 70.1% 5.2% |
27.7% 35.6% 36.6% |
33.3% 65.2% 1.4% |
24.5% 34.9% 40.6% |
<0.001 |
|
Gingival Bleeding Related to Gingival Problems |
Yes No I don't know |
86.4% 11% 2.6% |
69.3% 9.9% 20.8% |
92% 8% 0% |
71.7% 12.3% 16% |
<0.001 |
|
Knowledge of Periodontal Disease and Systemic Conditions |
None Limited Average Excellent |
2.6% 14.3% 49.4% 33.8% |
8.9% 58.4% 27.7% 5% |
1.1% 5.1% 48.2% 45.7% |
3.8% 34.9% 45.3% 16% |
<0.001 |
When it comes to self-perception of oral health, it is crucial to assess the knowledge as it is considered an essential prerequisite for health-related behavior [2]. Our present study included dental students, medical students, dentists, and physicians to examine the self-perception of oral hygiene and periodontal health. Overall, the results revealed that oral hygiene is mandatory for the body's overall health and is correlated with systemic diseases. This finding is in line with the previously reported study by Baseer et al. among health professionals in Saudi Arabia [16]. Saito et al. found that the most commonly used cleaning aid is the toothbrush and toothpaste [17], brushing twice daily, per the previous studies [18, 19]. In contrast, Saito et al. found that most participants brush once daily [17].
Furthermore, most participants brushed their teeth for 1-2 minutes, with the majority being dental students. This study finding is consistent with a previously reported investigation from Saudi Arabia [17]. On the contrary, Andhare et al. and Baseer et al. reported tooth brushing duration to range from 3-5min among health professionals [2, 16]. In this study, most participants changed their toothbrushes once every three months. This finding is compliant with the study reported by Andhare et al. among medical and dental undergraduates [2]. In this study, most participants used circular strokes with soft bristle toothbrushes. It was recommended to use bass or modified-bass technique using a soft bristle toothbrush [19, 20].
Moreover, when it comes to the tongue, more participants reported cleaning their tongue in this study. While Marchini et al. reported that 68.3% of participants did not clean their tongues [21]. When it comes to interdental cleaning aid, the use of regular floss was the most reported method, with more awareness found among dentists. Meanwhile, other participants lacked knowledge about interdental aid, similar to the previous studies supporting our findings [2, 22, 23]. Moreover, Saito et al. observed that most participants did not use dental floss in their study [17].
Regarding dental visits, most participants visit the dentist once a year, with dental students and physicians being the most common group. Surprisingly, Saito et al. found that 87% of dentists visit the dental office whenever there is a need [17]. While 32.7% only visit the dentist for oral hygiene when needed.
Our study finding suggests that the participants are far more knowledgeable than previous reports regarding self-perception of gingival health [16, 24]. Most reported no non-injurious teeth mobility, similar to Buhlin et al.'s study [25]. Severe periodontitis and smoking more than ten cigarettes per day emerged as significant predictors of self-perceived tooth mobility [24]. However, in this study, most participants felt no sensitivity or pain in the gingiva. It has been noted that people tend to misjudge the physical and pathological changes of periodontitis before pain, discomfort, and functional disability are set in [26]. During routine oral hygiene, the toothbrush, to some degree, can cause lacerations to the gingival tissue, with the possibility of causing gingival recession [27], and it often leads to root sensitivity that happens to almost half of the patients after scaling and root planning [27, 28].
Meanwhile, when asked about halitosis, 35.6%. Medical students reported having it compared to other groups. Regarding smoking, the majority were nonsmokers, whereas Romano et al. found a correlation between heavy smoking and malodor, with smoking being defined as an irrelevant factor for oral halitosis [24].
Additionally, most participants agree that gingival bleeding is a sign of a gingival problem, supported by Romanos et al. [24]. Furthermore, the participants thought that brushing alone does not prevent gingival diseases. In a study done by Hayasaki et al. [19], a corroborating finding concluded that more than 40% of plaque would not be removed no matter how experienced the person is. Improvement in the quality of daily brushing is indispensable to prevent periodontal disease. Moreover, toothbrushing, interdental aid, and mouthwash can help improve oral health status.
Lastly, when associating periodontal diseases with systemic conditions, the majority rated their knowledge as average similar to what was reported in Baseer et al.'s study [16]. However, in our study, medical students rated their knowledge as limited, which is in line with Andhare et al. among medical and dental undergraduate students [2].
Conclusion
Dentists and dental students had a better oral hygiene regimen, especially in interdental cleaning and frequency of brushing. Interdental cleaning was not perceived as necessary as toothbrushing among physicians, and medical students since most believed brushing alone could prevent gingival diseases. The self-perception of minor gingival problems was higher in dentists and dental students, while more severe gingival problems were commonly self-perceived by physicians and medical students. Knowledge of the relationship between oral health and systemic conditions among the various study participant was considerably good, with only the medical students reporting having limited knowledge.
Acknowledgments: Authors would like to thank the research and innovation center of Riyadh Elm University for supporting and granting this study.
Conflict of interest: None
Financial support: None
Ethics statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Research and Innovation Center of Riyadh Elm University (SRS/2020/22/205/201).
1. Romano F, Perotto S, Bianco L, Parducci F, Mariani GM, Aimetti M. Self-Perception of Periodontal Health and Associated Factors: A Cross-Sectional Population-Based Study. Int J Environ Res Public Health. 2020;17(8):2758.
2. Andhare MG, Dhonge RP, Dhuldhwaj RM, Dede RA, Sayyad IFN. A comparative evaluation of awareness regarding periodontal health and oral hygiene practices among dental and medical undergraduate students in Beed District of Maharashtra. Indian J Dent Sci. 2017;9(4):215.
3. Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim). 2017;11(2):72-80.
4. Idrees MM, Azzeghaiby SN, Hammad MM, Kujan OB. Prevalence and severity of plaque-induced gingivitis in a Saudi adult population. Saudi Med J. 2014;35(11):1373-7.
5. AlGhamdi AS, Almarghlani AA, Alyafi RA, Kayal RA, Al-Zahrani MS. Gingival health and oral hygiene practices among high school children in Saudi Arabia. Ann Saudi Med. 2020;40(2):126-35.
6. AlGhamdi A, Almarghlani A, Alyafi R, Ibraheem W, Assaggaf M, Howait M, et al. Prevalence of periodontitis in high school children in Saudi Arabia: a national study. Ann Saudi Med. 2020;40(1):7-14.
7. Zaitsu T, Ueno M, Shinada K, Ohara S, Wright FA, Kawaguchi Y. Association of clinical oral health status with self-rated oral health and GOHAI in Japanese adults. Community Dent Health. 2011;28(4):297-300.
8. Mendes MSS, Chester LN, Fernandes Dos Santos JF, Chen X, Caplan DJ, Marchini L. Self-perceived oral health among institutionalized older adults in Taubate, Brazil. Spec Care Dentist. 2020;40(1):49-54.
9. Asgari I, Soltani S, Sadeghi SM. Effects of iron products on decay, tooth microhardness, and dental discoloration: a systematic review. Arch Pharm Pract. 2020;11(1):60-82.
10. Blicher B, Joshipura K, Eke P. Validation of self-reported periodontal disease: a systematic review. J Dent Res. 2005;84(10):881-90.
11. Ramos RQ, Bastos JL, Peres MA. Diagnostic validity of self-reported oral health outcomes in population surveys: literature review. Rev Bras Epidemiol. 2013;16(3):716-28.
12. Kaufmann ME, Hofer D, Wiedemeier DB, Attin T, Schmidlin PR. Oral status and aesthetics after nonsurgical periodontal treatment: Do patient's perception and dentist's evaluation agree? Clin Exp Dent Res. 2019;5(6):601-10.
13. Singh R, Shah H, Chaudhary N, Pawar A. Cross sectional survey to assess self perception of oral health status reported by IGNOU students versus clinical diagnosis. J Dent Spec. 2020;6(1):34-7.
14. Albisher GM, Alghamdi HM, AlAbbadi SH, Almukhyzim NI, Al RA, Fayez HA, et al. Oral Health Knowledge among Private Primary School Teachers in Riyadh City, Kingdom of Saudi Arabia. Arch Pharm Pract. 2021;12(3):121-4.
15. Hamdan AA. Factors influencing self-reported use of mouthwashes among dental patients in Amman, Jordan. 2019.
16. Baseer MA, Alenazy MS, AlAsqah M, AlGabbani M, Mehkari A. Oral health knowledge, attitude and practices among health professionals in King Fahad Medical City, Riyadh. Dent Res J. 2012;9(4):386.
17. Sahito MA, Samejo I, Mirani SA. Health awareness; exploring periodontal health awareness and practices among patients at Larkana. Professional Med J. 2019;26(3).
18. Neeraja R, Kayalvizhi G, Sangeetha P. Oral health attitudes and behavior among a group of dental students in Bangalore, India. Eur J Dent. 2011;5(02):163-7.
19. Hayasaki H, Saitoh I, Nakakura-Ohshima K, Hanasaki M, Nogami Y, Nakajima T, et al. Tooth brushing for oral prophylaxis. Jpn Dent Sci Rev. 2014;50(3):69-77.
20. Ganss C, Schlueter N, Preiss S, Klimek J. Tooth brushing habits in uninstructed adults—frequency, technique, duration and force. Clin Oral Investig. 2009;13(2):203.
21. Marchini L, Vieira PC, Bossan TP, Montenegro FL, Cunha VP. Self-reported oral hygiene habits among institutionalised elderly and their relationship to the condition of oral tissues in Taubate, Brazil. Gerodontology. 2006;23(1):33-7.
22. Al-Hussaini R, Al-Kandari M, Hamadi T, Al-Mutawa A, Honkala S, Memon A. Dental health knowledge, attitudes and behaviour among students at the Kuwait University Health Sciences Centre. Med Princ Pract. 2003;12(4):260-5.
23. Neeraja R, Kayalvizhi G, Sangeetha P. Oral Health Attitudes and Behavior among a Group of Dental Students in Bangalore, India. Eur J Dent. 2011;5(2):163-7.
24. Romano F, Perotto S, Bianco L, Parducci F, Mariani GM, Aimetti M. Self-Perception of Periodontal Health and Associated Factors: A Cross-Sectional Population-Based Study. Int J Environ Res Public Health. 2020;17(8):2758.
25. Buhlin K, Gustafsson A, Andersson K, Håkansson J, Klinge B. Validity and limitations of self‐reported periodontal health. Community Dent Oral Epidemiol. 2002;30(6):431-7.
26. Tseveenjav B, Suominen AL, Varsio S, Knuuttila M, Vehkalahti MM. Do self-assessed oral health and treatment need associate with clinical findings? Results from the Finnish Nationwide Health 2000 Survey. Acta Odontol Scand. 2014;72(8):926-35.
27. West N, Lussi A, Seong J, Hellwig E. Dentin hypersensitivity: pain mechanisms and aetiology of exposed cervical dentin. Clin Oral Investig. 2013;17(1):9-19.
28. Von Troil B, Needleman I, Sanz M. A systematic review of the prevalence of root sensitivity following periodontal therapy. J Clin Periodontol. 2002;29:173-7.
