Journal of Education and Ethics in Dentistry

: 2013  |  Volume : 3  |  Issue : 1  |  Page : 26--33

Oral health attitudes, knowledge and practice among school children in Chennai, India

M Priya1, Kanagharekha Devdas2, Deepti Amarlal1, A Venkatachalapathy1,  
1 Department of Pediatric and Preventive Dentistry, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India
2 Department of Public Health, University of Sydney, New South Wales, Australia

Correspondence Address:
Deepti Amarlal
Department of Pediatric and Preventive Dentistry, Meenakshi Ammal Dental College, Alapakkam Main Road, Maduravoyal, Chennai - 600 095, Tamil Nadu


Background: Oral health is fundamental to general health and well-being. Sources of oral health information for adults have been examined but documentation of children�SQ�s sources is limited. Aim: The aim of the following study is to investigate the dental health attitudes, knowledge and practice of school children in Chennai using a questionnaire. Materials and Methods: The subjects for this study were randomly selected from five private and five government schools in the age group of 10-16 years. A total of 592 children were screened, of which 219 were males and 373 were females. Results: Overall the level of knowledge score was statistically significant with P = 0.004. There was statistically significant difference with P = 0.008 when comparing the frequency of brushing the teeth twice per day among the two different age groups. Comparing the various other factors such as gender, type of school and age groups to the visit to the dentist, it was observed that statistically significant difference with P < 0.001) was found when comparing the female children (75.3%) and male children (60.3%) and P = 0.002 observed when comparing the younger and older age group who visited the dentist. Conclusion: The overall level of oral health knowledge among the surveyed children was low.

How to cite this article:
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

How to cite this URL:
Priya M, Devdas K, Amarlal D, Venkatachalapathy A. Oral health attitudes, knowledge and practice among school children in Chennai, India. J Educ Ethics Dent [serial online] 2013 [cited 2023 Dec 8 ];3:26-33
Available from:

Full Text


Oral health is fundamental to general health and well-being. A healthy mouth enables an individual to talk, eat and socialize without experiencing active disease, discomfort or embarrassment. The two most common oral diseases are dental caries and periodontal disease and they often begin in childhood. [1] Oral diseases present a major public health problem. [2] About 90% of school children world-wide and most adults have experienced caries, with the disease being most prevalent in Asian and Latin American countries. [3] These could be attributed to several factors mainly lack of oral health awareness and over consumption of refined carbohydrate. Children who suffer from poor oral health are 12 times more likely to have restricted-activity days than those who do not. [4] More than 50 million school hours are lost annually due to oral health problems, which affect children's performance at school and success in later life. [5]

Walsh measured the dental health knowledge of 854 boys and girls with aged range from 12 to 14 years in San Francisco. [6] Although the preceding investigations vary with regard to the age groups surveyed and the types of knowledge assessed, the inadequacy of children's dental knowledge is apparent. Sources of oral health information for adults have been examined, but documentation of children's sources has been limited. [7],[8] In Chennai, survey about the oral health status of 5 years school going children reported that decayed missing filled teeth (DMFT) of boys was 3.53 ± 3.07, girls was 3.49 ± 2.83 and in a 12 years the DMFT for boys was 3.80 ± 3.43, girls was 4.11 ± 2.98. [9]

In some developing countries, the provision of emergency care, tooth extraction and basic restorative and preventive oral care may prove very important. Dental care has been systematically organized to improve dental health attitudes among children and the young. [10] Studies have showed that appropriate oral health education can help to cultivate healthy oral health practice. [11] Behavioral modeling by authority figures in a child's life such as a teacher, dentist, auxiliary or sibling can be a powerful tool. [12] Schools may be the only place for children, who are at the highest risk of dental disease, to gain access to oral health services. As children spend much time in school, teachers can assist with dental health education programs. [13] In parallel with the changing oral diseases pattern there have been significant improvements in oral health awareness, dental knowledge and attitudes of children and parents. [14],[15],[16] However comprehensive preventive programs for oral health care are still lacking, so more dental education is needed to improve oral health standards among the children in Chennai.

The change to healthy attitude and practice can be brought about by giving adequate information, motivation and practice to the subjects. [17] In order to create such health education, the assessment of knowledge, attitude and practice is essential. [18] Since sparse data is available about the oral health attitudes and behavior of children in developing country, this paper reviews the oral hygiene measures currently available and discusses strategies for promoting oral hygiene at individual and community levels. This study provides baseline data for future research and allows comparisons with children's oral health attitudes in other nations. Examining school children's knowledge of dental diseases and preventive agents was the focus of this study. Consequently, the purpose of this study was to investigate the dental health attitudes, knowledge and practices of school children in Chennai.

 Materials and Methods

The research work was carried out between January and March 2012. The participants for this study were selected by convenience sampling from five private schools and five government schools in Chennai. Letter was sent to the selected schools explaining the purpose of the study and the procedures that would be followed during its conduct. The principal of each school was asked to inform the students and their parents about the study and a day was set for each school to collect the data. The inclusion criteria for this study were children aged 10-16 as they were a little older to understand and complete the questionnaire by themselves. A convenience sample of grade 6 to grade 12 school children was selected. A total of 592 students were invited to participate in this study, of which the data were collected using a self-structured questionnaire used by Al-Omiri et al. for a similar study in North Jordan. [19] The questionnaire included 33 items without any names and identification numbers of the subject designed to evaluate the demographic background, oral health knowledge, attitudes and practice of young school children regarding their oral health and dental treatment. Because the children were at different grade levels, it was necessary to design the questionnaire to be readable and understandable for the youngest children. The questionnaire was typed in English only and was not translated [Figure 1]. The children responded to each question either by choosing one or more responses from the provided list of options or write-in the response or sometimes could be a combination of the two. The subjects were briefed about how to score their responses and were informed that more than one response format is possible for some items. Thus the subjects were free to choose more than one response for the same item. One of the investigators was available to clarify their doubts about any point during the course of completing the questionnaire. All questionnaires were completed and data collected in the classroom, under the supervision of survey staff specially trained for this activity. The study was approved by the ethical approval committee at Meenakshi University. Descriptive statistics, t-test to compare the mean values, Chi-square test to compare the proportions were used. Statistical Package for Social Sciences version 17.0 Chicago: SPSS Inc. was used to analyze the data. Statistical significance is fixed at P < 0.05.{Figure 1}


A total of 592 children in the age group often to 16 with a mean age of 13.26 years were screened, Of these 219 were males (37%) and 373 were females (63%). The schools were categorized as low and high socio-economic school groups based on the fees structure, of which 292 children were studying in government schools and 300 children were studying in private schools respectively. Majority of the children (83%) were of the younger age group of 10-14 years, while (17%) were of the older age group of 15-16 years.

Oral hygiene practices

The oral hygiene habits of our study sample indicated that 58.30% of the children would brush their teeth twice per day, whereas 36.10% would brush only once per day. There was statistically significant difference with P = 0.008 when comparing the frequency of brushing the teeth twice per day among the two different age groups namely 10-14 years children (60.9%) and 15-16 years children (46.5%). It was seen that 98% of the children used tooth brush and tooth paste to clean their teeth, while most subjects about 90% preferred to brush in the morning. However there were more female children (92%) when compared with male children (86.8%) with statistically significant difference with P = 0.041 comparing the oral hygiene practice of brushing in the morning. About 45.30% of the subjects brushed their teeth for more than 2 min, while 41.90% brushed for at least 2 min. When questioned about the role of parents in their daily oral care, it was found that 61.70% of the parents only advice their children without watching them. While 14.70% of the children reported that they were advised and watched while brushing. On the contrary, 9.60% of the children reported that their parents neither advised them nor watched them while brushing [Table 1].{Table 1}

Awareness of gingival and periodontal health

Almost 41% of the subjects were not aware of bleeding gums; only 35.60% knew the correct answer that it meant inflamed gums. In order to prevent gingivitis 31.10% of the children knew that tooth brushing and flossing would help them, whereas nearly equal proportions of children 31.30% reported that vitamin C would help them to prevent gingivitis. About 14.90% of the children only knew that dental plaque leads to inflammation on gum, whereas 37.80% failed to report a link between dental plaque and any of these conditions. It was seen that 27.20% related dental plaque to cause dental caries [Table 2].{Table 2}

Knowledge and awareness of dental and general health

Even though, there were 68.60% of students who reported having no caries, 74.50% were aware that caries tooth can affect the appearance of the teeth and 33.80% reported having no filled teeth. There were only 9% of subjects who knew the correct number of deciduous teeth, while there were 63% who knew the correct number of permanent teeth. The major factors that cause dental problems according to the child's opinion were sweets (81.80%) and fizzy drinks (77.70%). Hence the children knew brushing their teeth (73.50%) and usage of fluoride (55.60%) can prevent dental decay. It was seen that 71.80% of the subjects related dental diseases to their general body health and 80.20% of them cared about their teeth as much as any other organs in their body [Table 3].{Table 3}

Attitudes toward professional dental care

It was observed that 39.29% of the subjects would visit a dentist when they experienced pain, whereas 30.20% reported that they have never visited the dentist. Only 19.10% of the subjects would visit their dentist regularly once in every 6-12 months. Approximately 41.20% of them had their last dental visit 6 months back. Majority of the subjects (69.70%) visited their dentist for a routine dental examination, whereas the remaining subjects had undergone treatment such as filling (8.50%) and radiograph (5.50%). Dental pain was the initiating factor for their last visit in 32.40% of the children. However 32.20% of them reported that they were slightly afraid during their first visit and 31.60% of them experienced little dental pain during their visit. Even though 71.60% of the children knew that regular visit to the dentist is mandatory. The most common reason for not visiting their dentist regularly is that they did not experience pain. Majority of the subjects (91.40%) reported that the dentist explains the problem and solve it and 87.50% were happy as the dentist examines and takes care of his patients. However, 51% of them felt that the dentist cares about treatment but not about prevention [Table 4].{Table 4}

Comparing the various other factors such as gender, type of school and age groups to the visit to the dentist, it was observed that statistically significant difference with P < 0.001 was found when comparing the female children (75.3%) and male children (60.3%) who visited the dentist. Girls more frequently visited their dentist to take care of their teeth. Even though, there were more children in high socio-economic status (72%) who visited the dentist than the low socio economic status (67.5%) children. No significant difference was observed in the visit to dentist among the children who studied in government and private schools. There is statistically significant difference with P = 0.002 observed when comparing the younger age group of 10-14 years (72.6%) to the older age group of 15-16 years (56.6%) children who visited the dentist. On the broader aspect the level of knowledge score was statistically significant with P = 0.004 [Table 5].{Table 5}


In India, data on oral health behavior of children is not available; henceforth the present study intended to provide such information with regards to children aged 10 to 16 years old.

Some observations about schoolchildren's knowledge can be made. Overall, the level of oral health knowledge among the surveyed children was low.

In the present study regarding the oral hygiene habits, 58.3% of children performed the recommended practice of brushing the teeth twice a day. This is similar to that observed in some industrialized countries of east Europe, [20],[21],[22] but low when compared with western industrialized countries. [20],[21] This observation is similar to the study by Harikiran et al. (38.5%), [23] and World Health Organization (WHO) study (49%). [24] This survey found that a high percentage of the children in this study brushed their teeth twice a day although this effort was not fully organized or supported by parents, since most of them only advised and never watched their child during tooth brushing. This is in contrast to the study done in Jordanian children where majority of them brushed only once a day. [19] Brushing once preferably in the morning may indicate that such habits are difficult to change merely through mass health education. [25] Children who brushed their teeth less than once per day were meager about 2.5%, the reasons for not brushing were either that the participants had no time or it was simply forgotten. Majority of the children nearly 98% of them used tooth brush and tooth paste for cleaning their teeth. Similar results were reported by WHO (83%) and Punitha and Sivaprakasam (62.9%), in a rural population in Uttaranchal state and Kanchipuram district respectively. [24],[26] This discrepancy of using the tooth brush may be due to adoption of modern life-style by the children living in cities rather than in district. This result is not in accordance with that of the study by Mahesh Kumar et al. in Chennai, where in his study sample some of the children resorted to the use of charcoal as a medium to brush their teeth than the tooth brush. [9] This could be probably due to lack of awareness or affordability for tooth brush and paste. Majority of the children knew brushing their teeth prevents dental decay (73.5%), whereas in the study done in Pakistan reported 57% of high socio-economic school children were only aware of brushing to prevent dental problems. [27] In our study 31.1% of the children were aware that tooth brushing and flossing could be an effective tool in preventing dental problems, which is similar to a study done by Punitha and Sivaprakasam where only 14.81% of children are aware about the same fact. [26] In reality the usage of other recommended oral hygiene methods such as dental floss (0.7%) and mouthwash (0.8%) was found to be limited. This could be attributed to the dentist not encouraging them to use these devices appropriately.

The awareness of periodontal disease seems to have decreased among the children in Chennai. Most of the children were not aware about bleeding gums and the consequences of dental plaque. Only few children were aware of gingival bleeding as an indicator to periodontal diseases and tooth brushing as a valuable tool to fight against this problem. Our observation is similar to Linn, in which only few children knew periodontal disease was a disease of the gingiva and there was no evidence that they knew about plaque. [28]

According to the children's opinion the major factors that cause dental problems were sweets (81.8%) and fizzy drinks (77.7%), which is in parallel to the observations made by Al-Omiri et al. in Jordanian children who found that sweets (87.4%) and fizzy drinks (76.5%) had the same response to cause tooth decay. [19] A similar study done by Mirza et al., where he compared high and low socio-economic school children, who knew sweets (64.9%), (51.2%) and soft drinks (68.8%), (43.31%) respectively does affect the dental health. [27]

In general, the children have less understanding about major oral diseases; this may be seen in the light of fact about the regular visit to their dentist. A surprising finding in this regard was that most participants were aware of the importance of regular dental attendance. According to a study done by Zhu et al. 73.6% of the children in China knew that regular dental check-ups are necessary. [29] Similarly, 71.6% of the children in Chennai agreed with the importance of regular dental visit, but in reality only 19.1% of them practiced it. This scenario observed in Malaysian, Jordanian and Pakistani studies also. [18],[19],[27] There were 39.2% of the children who would seek dental service only when they suffered from pain. On the contrary 30.2% of them had never visited the dentist which is similar to a study by Mirza et al., where 46% reported that they never visited the dentist. [27] The drive for the last visit was due to pain in 32.4% of the children in Chennai, which is less compared with a study done by Punitha and Sivaprakasam among rural children of Kanchipuram where 58.97% of them visited the dentist since they suffered from pain. [26] This may be due to sparse knowledge among the children living in rural areas than urban region. A high proportion of the children (52.1%) reported that they did not seek dental service due to lack of toothache, probably Chennai children are highly symptom-oriented or they would try to cope with problems or control pain. The most common reason among the low socio-economic school children (47%) and even high socio-economic school children (26.5%) of Pakistan for not visiting the dentist was fear of needles. [27] This is contrary to our results in which very few children (7.9%) were scared of needles.

The children demonstrated positive attitudes toward their dentists and high awareness of the link between oral health and systemic well-being. Most of the children (71.8%) accepted the fact that the general body health is related to oral and dental diseases, which is similar to other studies done by Al-Omiri et al. on Jordanian school children and Mirza et al. on Pakistan school children. [19],[27] Studies suggest very limited oral health knowledge trickled down from the parents or through the dentist in a dental appointment to the children. [18],[19] This is similar to our study in which only 14% of the parents and 11.3% of the dentist motivated the children to seek dental treatment. On the contrary Barker and Horton in their study on pre-school children in California showed that parents played a major role in influencing their children's oral health and access to care. [30] Only 19.1% of the children in this study used dental services once in every 6 months, which is still far less than the Canadian schools where 50% of the school children used the dental service once in every 6 months. [31]

However, the data collection method may have certain limitations. It is also not known if this particular sample of 592 public school children is representative of other samples of children of similar age in Chennai. However, we believe that the sample was sufficiently large enough, including ten different schools and drawn from an economically diverse area to make the study group reasonably representative of other regions of Chennai.


The results of this study have highlighted some baseline gaps in knowledge, attitude and practice of school children. The frequency of brushing the teeth per day, the method of cleaning the teeth and decision of the treatment needed was found to be statistically significant in association to the knowledge score, whereas it was not statistically associated with gender, brushing time and duration of brushing. The knowledge score comparing the government and private school children was not significant. The females were regular in visiting the dentist when compared with the male children. Similarly, younger age group of 10-14 years was more concerned about the dental visit than the older children of 15-16 years.

Oral health education programs could be included in the school curriculum for the children to emphasis a positive attitude toward oral health. In order to positively influence and improve the oral hygiene practices among children: Community dental health carnivals, costumed characters and oral health booths and children's dental health shows could be arranged. Dental professionals should seize the opportunity to educate the public and children in order to enhance the awareness among children and impart a positive attitude toward oral health.


The authors wish to thank Dr. Eapen Thomas M.D.S, Dr. Sivakumar Nuvula M.D.S and Mr. K. Boopathi for their valuable input.


1Levine R, Stillman-Lowe C. The scientific basis of dental health education. Community Dent Health 2002;19:127.
2Petersen PE. The World Oral Health Report 2003: Continuous improvement of oral health in the 21 st century - The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003;31 Suppl 1:3-23.
3Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bull World Health Organ 2005;83:661-9.
4US General Accounting Offices. Oral Health: Dental Disease is a Chronic Problem among Low-Income Populations. Washington, DC: Report to Congressional Requesters; 2000.
5Gift HC, Reisine ST, Larach DC. The social impact of dental problems and visits. Am J Public Health 1992;82:1663-8.
6Walsh MM. Effects of school-based dental health education on knowledge, attitudes and behavior of adolescents in San Francisco. Community Dent Oral Epidemiol 1985;13:143-7.
7O'Neill HW. Opinion study comparing attitudes about dental health. J Am Dent Assoc 1984;109:910-5.
8Lang WP, Faja BW, Woolfolk MW, Glasrud PH, Frazier PJ. Elementary schoolteachers' knowledge and attitude about oral health. J Dent Res 1987;66 Spec Issue:299.
9Mahesh Kumar P, Joseph T, Varma RB, Jayanthi M. Oral health status of 5 years and 12 years school going children in Chennai city - An epidemiological study. J Indian Soc Pedod Prev Dent 2005;23:17-22.
10Holst D, Schuller A, Grytten J. Future treatment needs in children, adults and the elderly. Community Dent Oral Epidemiol 1997;25:113-8.
11Ab Murat N, Watt RG. Chief dentists' perceived strengths and weaknesses of oral health promotion activities in Malaysia. Ann Dent Univ Malaya 2006;13:1-5.
12Harn SD, Dunning DG. Using a children's dental health carnival as a primary vehicle to educate children about oral health. ASDC J Dent Child 1996;63:281-4.
13Kay EJ, Millar K, Blinkhorn AS, Atkinson JM. The prevention of dental disease: Changing your patients' behaviour. Dent Update 1991;18:245-8.
14Whittle JG, Whittle KW. Five-year-old children: Changes in their decay experience and dental health related behaviours over four years. Community Dent Health 1995;12:204-7.
15Petersen PE, Hoerup N, Poomviset N, Prommajan J, Watanapa A. Oral health status and oral health behaviour of urban and rural schoolchildren in Southern Thailand. Int Dent J 2001;51:95-102.
16Vigild M, Petersen PE, Hadi R. Oral health behaviour of 12-year-old children in Kuwait. Int J Paediatr Dent 1999;9:23-9.
17Smyth E, Caamano F, Fernández-Riveiro P. Oral health knowledge, attitudes and practice in 12-year-old schoolchildren. Med Oral Patol Oral Cir Bucal 2007;12:E614-20.
18Lian CW, Phing TS, Chat CS, Shin BC, Baharuddin LH, Jalil ZB. Oral health knowledge, attitude and practice among secondary school students in Kuching, Sarawak. Arch Orofacial Sci 2010;5:9-16.
19Al-Omiri MK, Al-Wahadni AM, Saeed KN. Oral health attitudes, knowledge, and behavior among school children in North Jordan. J Dent Educ 2006;70:179-87.
20King A, Wold B, Tudor-Smith C, Harel Y. Dietary habits, dental care and body image. In: World Health Organisation. The Health of Youth: A Cross-National Survey. Copenhagen: WHO Regional Office for Europe; 1995. p. 39-55.
21Petersen PE, Danila I, Samoila A. Oral health behavior, knowledge, and attitudes of children, mothers, and schoolteachers in Romania in 1993. Acta Odontol Scand 1995;53:363-8.
22Chen MM, Andersen RM, Barmes DE, Leclercq MH, Lyttle CS. Comparing oral health care systems: A second international collaborative study. Geneva: WHO; 1997.
23Harikiran 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.
24Oral Health Status in rural child population: Promotional & Interventional Strategies. A GOI-WHO Collaborative Programme 2006-07. Available from: 30_1453.htm. December 2012.
25Peng B, Petersen PE, Tai BJ, Yuan BY, Fan MW. Changes in oral health knowledge and behaviour 1987-95 among inhabitants of Wuhan City, PR China. Int Dent J 1997;47:142-7.
26Punitha VC, Sivaprakasam P. Oral hygiene status, knowledge, attitude and practice of oral health among rural children of Kanchipuram District. Indian J Multidiscip Dent 2011;1:115-8.
27Mirza BA, Syed A, Izhar F, Ali Khan A. Oral health attitudes, knowledge, and behavior amongst high and low socioeconomic school going children in Lahore, Pakistan. Pak Oral Dent J 2011;31:396-401.
28Linn EL. Teenagers' attitudes, knowledge, and behaviors related to oral health. J Am Dent Assoc 1976;92:946-51.
29Zhu L, Petersen PE, Wang HY, Bian JY, Zhang BX. Oral health knowledge, attitudes and behaviour of children and adolescents in China. Int Dent J 2003;53:289-98.
30Barker JC, Horton SB. An ethnographic study of Latino preschool children's oral health in rural California: Intersections among family, community, provider and regulatory sectors. BMC Oral Health 2008;8:8.
31Scott G, Brodeur JM, Olivier M, Benigeri M. Parental factors associated with regular use of dental services by second-year secondary school students in Quebec. J Can Dent Assoc 2002;68:604-8.