|Year : 2015 | Volume
| Issue : 1 | Page : 52-57
Assessment of oral health attitudes and behavior among undergraduate dental students using Hiroshima University Dental Behavioral Inventory HU-DBI
Swathi Vangipuram, R Rekha, G Radha, SK Pallavi
Department of Public Health Dentistry, VS Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||19-Mar-2015|
Dr. Swathi Vangipuram
Department of Public Health Dentistry, VS Dental College and Hospital, KR Road, V.V. Puram, Bengaluru - 560 004, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Dental students are the future leaders in oral health care and are expected to be teachers of oral hygiene as well as role models of self-care regimens for their patients. Objective: The objective was to assess self-reported oral health attitude and behavior among undergraduate dental students and to analyze variations between gender and level of education. Materials and Methods: A self-administered questionnaire based on the Hiroshima University-Dental Behavioural Inventory (HU-DBI) was distributed among 270 undergraduate students which consisted of 20 dichotomous responses (yes-no). Data were analyzed using the analysis of variance and statistical significance was set at P < 0.05. Results: Females had better oral health attitude and behavior toward visiting the dentist and oral hygiene practices, mean HU-DBI score of 8.8 (P < 0.05). Furthermore, the preclinical students (1 st , 2 nd years) had better oral health attitude and behavior especially towards gingival health, oral hygiene practices and visiting the dentist (P < 0.05). Conclusion: Among dental students, the overall attitude of oral health was good, even though there were deficits in a few areas. The oral health attitudes and behavior were better among female's dental students and were not improved with increasing levels of education. Better comprehensive dental education with exposure to dental health and prevention is suggested to improve dental students' oral health attitudes and behavior.
Keywords: Dental students, Hiroshima University-Dental Behavioural Inventory, oral attitudes, oral health behavior
|How to cite this article:|
Vangipuram S, Rekha R, Radha G, Pallavi S K. Assessment of oral health attitudes and behavior among undergraduate dental students using Hiroshima University Dental Behavioral Inventory HU-DBI. J Indian Assoc Public Health Dent 2015;13:52-7
|How to cite this URL:|
Vangipuram S, Rekha R, Radha G, Pallavi S K. Assessment of oral health attitudes and behavior among undergraduate dental students using Hiroshima University Dental Behavioral Inventory HU-DBI. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Oct 1];13:52-7. Available from: http://www.jiaphd.org/text.asp?2015/13/1/52/153587
| Introduction|| |
The behavior of oral health providers and their attitudes toward their own oral health reflect their understanding of the importance of preventive dental procedures and improving the oral health of their patients.  Dental students, the future oral health professionals, play an important role in educating and promoting public oral health.  Dental students' oral health attitudes reflect their understanding of the importance of disease prevention and their commitment to improving their patients' oral health. Dental students, in general, have been found to have a positive attitude toward oral health, but their own oral health behavior must improve if they are to serve as positive models for their patients, families, and friends. 
Dental health is a highly individualized concept, the perception of which is very much affected by an individual's culture and socioeconomic status. The attitude of people toward their own teeth and the attitude of dentist's who provide dental care play an important role in determining the oral health condition of the population.  Researchers have found that the oral health attitudes and behavior of dental students differed in the preclinical and clinical years.  Furthermore, the oral health attitude and behavior of dental students were found to vary between countries and cultures.  Although there are lot of published data related to the motivation of patients to follow an effective oral health care program, few studies have dealt with attitude and behavior of dental students in motivating patients. 
The dental education system in India accepts candidates from various socioeconomic backgrounds who become eligible to study dentistry based on their score in state entrance exams. The dental curriculum in India comprises 4 years, divided into two parts: Preclinical (year 1 and 2) and clinical years (years 3 and 4 and internship). Indian dental students are only introduced to the preventive aspects of oral health in the latter half; henceforth their level of dental education can affect oral health behavior. Moreover, males and females have different physiological and psychological behavior, so it is possible that their oral health behavior might be different too. 
There is no universally accepted or recommended index or inventory to measure dental attitude and behavior. The data that have been collected on the attitude and behavioral aspects were derived from a series of independent questionnaire. The Hiroshima University-Dental Behavioural Inventory (HU-DBI), developed by Kawamura, has been used to examine the oral health-related attitudes and behaviors of dental students.  Oral health attitudes and behavior of dental students were frequently evaluated with this scale in several countries. 
Study carried out to assess dental attitudes and behavior among dental students in Jordan reported that the oral health attitude and behavior in Jordan were poor.  Study comparing Japanese and Finnish dental students reported that the Japanese dental students in their final year appeared to have better oral health behavior, as estimated by the HU-DBI than their Finish peers did. ,, Dagli et al. among undergraduate dental students in Rajasthan, found that overall attitude and behavior was poorer and did not differ among different years of study. ,
However, there are insufficient data, on oral health attitude and behavior among dental students in Bangalore, India. Hence, the purpose of this study was to assess the self-reported oral health attitudes and behavior among undergraduate dental students and to analyze variations between gender and level of education.
| Materials and Methods|| |
The data were collected in academic year 2013-2014 during the month of September from V.S Dental College and Hospital, Bangalore after obtaining permission from the ethical review board of institution and informed consent was obtained from students. Undergraduate dental students and students who gave consent to participate and present on the day of study were included in the study.
The students' oral health attitudes and behavior were assessed using the English format of the HU-DBI questionnaire. HU-DBI questionnaire developed by Kawamura,  consists of 20 items in a dichotomous response format (agree/disagree) [Table 1]. One score is given for each "agree" response to items 4, 9, 11, 12, 16, and 19, and one score is given for each "disagree" response to items 2, 6, 8, 10, 14, and 15. Maximum possible score is 12, and the minimum score is 0. The higher the score is the better the oral health attitude and behavior. ,
A self-administered questionnaire based on the HU-DBI was distributed among 270 students from 1 st year to final year dental and interns of V.S dental college and hospital. Students from all academic years were invited to complete the questionnaire in their classrooms after lectures. Participation in the study was voluntary. All participants were provided with a questionnaire and were given a full explanation of the study. Each participant had taken a time of 7-15 min to fill the questionnaire. The score of each item which relates to oral health attitude and behavior in the HU-DBI was analyzed and then a mean score was calculated.
Data were analyzed by IBM SPSS Statistics for Windows, Version 19.0.(IBM Corp., Armonk, NY). A statistical model was developed for analysis of variance with HU-DBI scores as the dependent variable and level of dental education, sex and age as an independent variable. The level of significance was set at P < 0.05.
| Results|| |
Of the 320 undergraduate dental students, 270 completed the questionnaire, yielding a response rate of 84.3%. Distribution of study participants based on years of study and mean age [Table 2]. Majority of students were from 1 st year and 2 nd year B.D.S and mean age range among study participants was from 18.4 to 23.4 years. Majority of study participants were females with 72.2%, and most of the students were from upper middle class (67.03%) [Table 3].
|Table 2: Distribution of study participants based on years of study and mean age |
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|Table 3: Distribution of study participants based on gender and socioeconomic status |
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On the comparison of the mean HU-DBI scores among various years of dental education, the 1 st year B.D.S students had a highest mean score of 8.4 followed by interns with mean score of 7.68 [Table 4]. Preclinical students had a high mean score of 8.04 which was statistically significant compared to clinical students (P - 0.042) and female students having high mean score of 8.8 when compared to males (P - 0.032) [Table 5]. No significant difference was observed among the different age groups [Table 6].
|Table 4: Mean scores of HU-DBI questionnaire among various years of dental education |
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|Table 5: Mean scores of HU-DBI questionnaire among preclinical and clinical students |
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[Table 7] represents the distribution of the responses to the 20 items, based on the level of dental education. About 58.1% of dental students agreed with the statement. I don't worry much about visiting the dentist (item 1). Bleeding gums (item 2) were reported in 12.5% of the participants and worry about color of teeth (item 3) was reported by 71.1%. About 58.1% answered that it was impossible to prevent gum disease with only tooth brushing (item 14), and 49.2% reported that they postponed going to the dentist until they had a toothache. A greater proportion of preclinical than clinical students said they thought that they could not avoid having false teeth in old age (item 6, P < 0.01) and that their teeth were getting worse despite daily brushing. About 68.1% of the students agreed with the statement "I brush my teeth carefully" (item 9). A higher response of agreement for item 12 checking the teeth in the mirror after brushing (83.3%) In addition, compared with clinical students, a greater proportion of preclinical than clinical students reporting believing it impossible to prevent gum disease by tooth brushing alone (item 14, P < 0.021) and did not feel that they brushed well unless they used strong strokes (item 18, P < 0.003).
|Table 7: Responses obtained for each questionnaire based on years of study |
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| Discussion|| |
An important task of oral health professionals is to instill in their patients the correct oral habits to prevent oral diseases. The first step in establishing a habit is to provide relevant knowledge to the patients and to raise their awareness of how to prevent oral diseases. High awareness of self-oral health in a dental student may have a direct impact on his attitude for patient education and may help to create oral awareness in the general population. 
In this study, gender had a significant relationship with HU-DBI scores. Females had better attitude and behavior regarding visiting the dentist and oral hygiene and health. Researchers have found that females engage in better oral hygiene behavior, possess a greater interest in oral health and perceive their own oral health to be better than do males.  These results agree in general with the results of Ostberg et al.  and Fukai et al.,  who found female dental students had better oral health attitudes and took better care of their teeth than their male colleagues.
In the present study among dental students, age was not a significant factor affecting attitude and behavior. The result is in accordance with previous studies involving Greek, Japanese, Finnish, and Chinese dental students. , But contrary to study conducted by Dagli et al. among Rajasthan dental students in which results were statistically significant only for age and HU-DBI. 
The present study identified significant differences in oral health attitudes and behavior between students from different years of dental study. It was found that the overall mean HU-DBI score of the preclinical students was significantly higher than that of clinical students. This is contrary to finding reported by Dagli et al.  and Neeraja et al.  who found clinical students having higher mean HU-DBI score than the preclinical students. The finding in the presented study can be attributed to more enthusiastic and esthetic concerned younger generation students. However, the overall mean HU-DBI score among dental students in this study was higher than reported from studies performed in other countries. 
The socioeconomic status had no significant effect on mean HU-DBI score. About 71.1% of the dental students were concerned about the color of their teeth compared to 67% of Jordanian dental students.  Only 12.5% of dental students had bleeding gums which was a higher proportion than found among Australian dental students (6%) and a lower proportion than found among Finnish (45%) and Japanese (25%) dental students. , This showed that the students in this study paid good attention to their oral hygiene maintenance and were also very much concerned about esthetics.
Most of the clinical students stated that they used a disclosing solution to see how clean their teeth were. This might be due to the fact that students take the periodontics lecture relating to the use of disclosing solution in the 3 rd year, but their clinical training starts in the final year. Interestingly, bleeding gums after tooth brushing were more frequently observed among clinical than preclinical students. Accordingly, self-care practice aids for improving oral health should be introduced in both preclinical and clinical years, and the importance of preventive oral health behaviors should be strongly emphasized.
Less than one-third of the respondents had never been professionally instructed on how to brush their teeth, and half of the participants indicated that they would postpone going to the dentist until they had a toothache. Thus, it is necessary for oral health professionals to recognize the significant and importance of preventive activities to make their patients aware. Thus, an organized intervention leading toward an improved dental status by increasing the population's knowledge, attitude, and behavior can be achieved.
Preclinical dental students were more concerned about the color of their teeth and bad breath than clinical students, a finding also reported by Dumitrescu et al.  About 68% of dental students put off going to the dentist until they had a toothache. Similar frequencies were seen among dental students in Japan (56%), Hong Kong (67%), Korea (65%), and China (64%).
Overall, the knowledge among the dental students in this study was good although they had deficits in few areas, like the proper force and technique of brushing and the use of disclosing solutions to identify deposits on the teeth. Oral health education needs to be provided in these areas.
The results of the study showed that dental student's oral health behaviors and attitudes did not improve with increasing level of dental education. The study provides valuable baseline information that will allow comparison of dental student's oral health awareness in various schools curricula.
The limitations of the study were, this study was conducted in only one dental college, limiting the generalizability of the results. Data were not derived longitudinally but rather cross-sectionally, thus observed changes cannot with certainty be attributed. Although our subjects comprised students who belonged to all socioeconomic strata, as India is still a developing country, the relatively small group tested could be a limitation in the study. A further study involving a larger group might reveal stronger relations than those reported.
The study should be conducted in various dental colleges with a representative sample of male and female dental students of various levels of dental education. Further studies are needed to evaluate the relationships among the caries experience, gingival health, and self-reported oral health behaviors and attitudes between students at different academic levels.
Comprehensive programs aiming to promote students' dental hygiene practices and preventive oral health knowledge and should start from the beginning of dental training.
| Conclusion|| |
In this study, the overall knowledge of oral health behaviors among the dental students was good, even though there were deficits in their knowledge in few areas. The oral health attitude and behavior of dental students did not improve with increasing level of dental education with preclinical students having better oral health attitude and behavior than clinical students. Females had more positive dental health attitudes and behaviors.
| References|| |
Barrieshi-Nusair K, Alomari Q, Said K. Dental health attitudes and behaviour among dental students in Jordan. Community Dent Health 2006;23:147-51.
Gallagher EB, Moody PM. Dentists and the oral health behavior of patients: A sociological perspective. J Behav Med 1981;4:283-95.
Khami MR, Virtanen JI, Jafarian M, Murtomaa H. Prevention-oriented practice of Iranian senior dental students. Eur J Dent Educ 2007;11:48-53.
Davis P. Social Context of Dentistry. Long wood publishing group.London.1980. p. 21-27
Sharda AJ, Shetty S. A comparative study of oral health knowledge, attitude and behaviour of first and final year dental students of Udaipur city, Rajasthan, India. Int J Dent Hyg 2008;6:347-53.
Kawamura M. Dental behavioral science. The relationship between perceptions of oral health and oral status in adults. Hiroshima Daigaku Shigaku Zasshi 1988;20:273-86.
Al-Omari QD, Hamasha AA. Gender-specifi c oral health attitudes and behavior among dental students in Jordan. J Contemp Dent Pract 2005;6:107-14.
Kawamura M, Iwamoto Y, Wright FA. A comparison of self-reported dental health attitudes and behavior between selected Japanese and Australian students. J Dent Educ 1997;61:354-60.
Kawamura M, Honkala E, Widstrom E, Komabayashi T. Cross- cultural differences of self-reported oral health behavior in Japanese and Finnish dental students. Int Dent J 2000;50:46-50.
Dagli RJ, Tadakamadla S, Dhanni C, Duraiswamy P, Kulkarni S. Self reported dental health attitude and behavior of dental students in India. J Oral Sci 2008;50:267-72.
Kawabata K, Kawamura M, Miyagi M, Aoyama H, Iwamoto Y. The dental health behaviour of university students and test-retest reliability of the HU-DBI in Japanese. J Dent Health 1990;40:474-5.
Kawamura M, Kawabata K, Sasahara H, Fukuda S, Iwamoto Y. Dental behavioral science: Part IX. Bilinguals' responses to the dentalbehavioral inventory (HU-DBI) written in English and in Japanese. J Hiroshima Univ Dent Soc 1992;22:198-204.
Ostberg AL, Halling A, Lindblad U. Gender differences in knowledge, attitude, behavior and perceived oral health among adolescents. Acta Odontol Scand 1999;57:231-6.
Fukai K, Takaesu Y, Maki Y. Gender differences in oral health behavior and general health habits in an adult population. Bull Tokyo Dent Coll 1999;40:187-93.
Jaramillo JA, Jaramillo F, Kador I, Masuoka D, Tong L, Ahn C, et al
. A comparative study of oral health attitudes and behavior using the Hiroshima University-Dental Behavioral Inventory (HU-DBI) between dental and civil engineering students in Colombia. J Oral Sci 2013;55:23-8.
Neeraja R, Kayalvizhi G, Sangeetha P. Oral health attitudes and behavior among a group of dental students in Bangalore, India. Eur J Dent 2011;5:163-7.
Dumitrescu AL, Kawamura M, Sasahara H. An assessment of oral self-care among Romanian dental students using the Hiroshima University - Dental Behavioural Inventory. Oral Health Prev Dent 2007;5:95-100.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]