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Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 127-132

Influence of oral health literacy on the oral health status of school teachers in Mangalore, India

Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Mangalore, Karnataka, India

Date of Submission02-Feb-2018
Date of Acceptance03-Apr-2018
Date of Web Publication24-May-2018

Correspondence Address:
Dr. Ashwini Rao
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Light House Hill Road, Mangalore - 575 001, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_40_18

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Background: The problem of low oral health literacy (OHL) is often neglected which may lead to poor oral health outcomes and underutilization of oral care services. Objectives: The aim of this study was to determine the influence of OHL on the oral health status of school teachers in Mangalore, Karnataka. Materials and Methods: A cross-sectional survey of 260 school teachers presently working in schools at Mangalore was undertaken. Details regarding demographics, medical, and dental history, oral hygiene practices and habits, diet history, and decay promoting the potential of school teachers were obtained using face-to-face interview method. The Rapid Estimate of Adult Literacy in Dentistry-99 (REALD-99) was used to assess their OHL. An oral examination was conducted following the administration of the questionnaire at the school campus using the WHO Oral Health Assessment Form-1997. Results: The mean age of the study population was 39 ± 10.42 years. The OHL was high in the school teachers with the REALD-99 scores ranging from 45 to 95 with a mean score of 75.83 ± 9.94. There was a positive correlation between the OHL and filled teeth (FT) (r = 0.195, n = 260, P = 0.002). This study found that there was a statistically significant difference between OHL and education (F [3,256] = 9.62, P < 0.001), frequency of brushing (t[258] = −2.253, P = 0.025), and the FT (t[258] = −3.200, P = 0.002). Conclusions: Although this study indicated high OHL levels among school teachers in Mangalore, Karnataka, the magnitude of dental caries in this population was also relatively high and very few had a healthy periodontium.

Keywords: Health promotion, oral health literacy, questionnaires, school teachers

How to cite this article:
Simon AK, Rao A, Rajesh G, Shenoy R, Pai MB. Influence of oral health literacy on the oral health status of school teachers in Mangalore, India. J Indian Assoc Public Health Dent 2018;16:127-32

How to cite this URL:
Simon AK, Rao A, Rajesh G, Shenoy R, Pai MB. Influence of oral health literacy on the oral health status of school teachers in Mangalore, India. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2024 Mar 3];16:127-32. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2018/16/2/127/233074

  Introduction Top

Low health literacy has been described as “the silent health epidemic,” where there is limited ability to negotiate complex healthcare systems and understand health information.[1] A health literate person should be able to comprehend directions on prescription drug bottles, appointment cards, health brochures, doctor's directions, and consent forms.[2] Health literacy is defined by the WHO (1998) as: “The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.”[3] Underutilization of healthcare services is common in persons with low health literacy skills, who often have a higher rate of hospitalizations, high emergency room use, and ultimately poorer health outcomes.[4],[5],[6] Health literacy plays the role of a moderator between socioeconomic factors, such as race and education, health behaviors and health outcomes, partly explaining health disparities.[7],[8]

Health promotion and disease prevention approach is the most effective way to attain good oral health, and oral health literacy (OHL) should be seen in this context. OHL is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic oral health information and services needed to make appropriate health decisions.”[9] Low literacy skills are likely to impact oral health disparities, which are potential hurdles in attaining better oral health outcomes.[10] An increasing body of evidence explains how low OHL is associated with poor oral health outcomes such as dental neglect, irregular dental attendance, and worse oral health status.[10],[11],[12] In 2007, Richman et al. developed and evaluated a 99-item questionnaire called the Rapid Estimate of Adult Literacy in Dentistry-99 (REALD-99) which by the authors' own admission is simple and easy to carry out and score, and requires minimal training since lengthy evaluation tools are not practical in clinical practice.[13]

The goals of any OHL strategy would be to reduce oral health disparities and to reduce the barriers to dental care. Even though literature linking literacy to general health continues to grow, very few studies have examined the role of literacy on dental outcomes, and none has measured dental health literacy, especially among school teachers. School teachers own perceptions about health and their feeling about their own competency in health-related matters may affect the school going children.[14] The fact that school teachers are among the most important influences in the lives of school-aged children and that they can also influence their oral health decisions cannot be denied.[15] Thus, this study was contemplated to determine the influence of OHL on the oral health status of school teachers in Mangalore city in the Indian state of Karnataka.

  Materials and Methods Top

School teachers, teaching in schools of Mangalore city during the study (October 2012–January 2013) were part of this cross-sectional study.

Ethical clearance

Data collection was started after obtaining the approval from the Institutional Ethics Committee (MCODS/198/2012) and was completed over a period of 4 months (October 2012–January 2013).

Sampling methodology

Records obtained from the Block Education Office, Mangalore City, listed 170 city schools. Based on the pilot study, the mean REALD scores were 71.8, and the standard deviation was 8.02, considering 10% permissible error at 95% confidence interval, the minimum sample size was estimated to be 247. Table of random numbers was employed to select the schools, and the final sample consisted of 260 respondents from 22 schools.

Calibration of the examiner

Before conducting the survey, calibration was done to establish intraexaminer reliability for WHO Oral Health Assessment Form-1997 and the REALD-99 scores. Pronunciations from the Dorland's Illustrated Medical Dictionary [16] and Oxford Advanced Learner's Dictionary [17] were taken as the standard for calibration of REALD-99 scores. The assessment of intraexaminer reliability using the Kappa statistic showed there was almost total agreement (κ = 0.99 and κ = 0.94). The REALD-99 instrument is a prevalidated instrument for measuring OHL. However, the investigators checked the 99 items in the instrument for face and content validity by expert evaluation and group discussions among the investigators and few schoolteachers and were found to be valid.

Organizing the survey

The initial visit was made by the principal investigator to meet the Principal/School Incharge to explain about the study and to obtain permission. One day before the designated day of interview and examination, a reminder was sent to the selected school through the telephone. On the allocated day, after introduction to the principal investigator, eligible school teachers were asked to participate in the survey in a designated area within the school premises. All the subjects were provided with a patient information sheet explaining the survey procedure, and a written informed consent was obtained from them before the examination. A minimum of three visits were made to include all the willing teachers from that school. In case of teachers absent even on the third visit to the school, he/she was excluded from the study.

Information collected and methods used

The principal investigator collected the data from the respondents' using a questionnaire, REALD-99 instrument and by conducting an oral examination.

The questionnaire

Face-to-face, interview method was employed to obtain demographic details, medical history, dental history, oral hygiene practices, habits, diet history, and decay promoting potential.

Rapid estimate of adult literacy in dentistry

Respondents' read the REALD-99 instrument aloud and the principal investigator scored them based on pronunciation. Respondents were advised to only read those words for which they believe they knew the correct pronunciation. A single investigator carried out the REALD-99 assessment. In calculating overall scores for REALD-99, correct pronunciation was assigned one point and summed. REALD-99 scores have a possible range of 0 (low literacy) to 99 (high literacy).[13]

WHO basic oral health assessment form

The format was reproduced from the “Oral Health Survey – Basic Methods 4th Edition” and was printed. Clinical examination was done using natural light with the subject sitting on a chair. A trained recorder accompanied the investigator to help in recording the data.[18]

Statistical analysis

The data were coded and analyzed using the Statistical Package for the Social Sciences (SPSS, version 16.0; SPSS Inc., Chicago, IL, USA). One-way analysis of variance (ANOVA), Student's t-test (two-tailed, independent) and the Pearson product-moment correlation coefficient were used for analysis of collected data. The level of statistical significance was kept at P < 0.05.

  Results Top

The mean age of the study population was 39 ± 10.42 years. [Table 1] gives the sociodemographic characteristics of the respondents. Among the respondents, about 15.4% had never had a dental visit. All the respondents used toothbrush and toothpaste for cleaning of teeth, but 90.7% of the population did not use any other oral hygiene aids [Table 2].
Table 1: Rapid Estimate of Adult Literacy in Dentistry-99 scores and its relation to sociodemographic characteristics among study participants

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Table 2: Rapid Estimate of Adult Literacy in Dentistry-99 scores and its relation to personal habits and dietary characteristics among study participants

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The dental caries experience of the respondents was calculated from the dentition status of the WHO Oral Health Assessment Form. The mean decayed, missing, filled teeth (DMFT) among school teachers were 6.18 ± 4.35. The mean number of DMFT observed in this population were 2.84 ± 2.50, 0.95 ± 1.61, and 2.37 ± 3.44, respectively. The caries prevalence in this population was 79.2%. The prevalence of root caries was 11.5% (30). The periodontal status of the school teachers was recorded using Community Periodontal Index (CPI) and loss of attachment (LOA) scores. The analysis showed that Code 2 was the highest score for CPI, which indicated that majority (60.1%) of the school teachers had calculus deposits and with 20.7% of the school teachers presenting with the pocket formation. Bleeding on probing was a finding among 8.8% of the school teachers [Table 3]. Out of the 260 school teachers, about 1.9% had questionable fluorosis, 5.4% had very mild fluorosis, 3.1% had mild, 1.2% had moderate fluorosis, and 1.2% had severe fluorosis. The prosthetic need in the upper and lower arch was 19.8% and 28.9%, respectively.
Table 3: Rapid Estimate of Adult Literacy in Dentistry-99 scores and its relation to dental characteristics among study participants

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The OHL was high in the school teachers with the REALD-99 scores ranging from 45 to 95 with a mean score of 75.83 ± 9.94. The REALD-99 scores were distributed almost evenly between different age groups, gender, income groups and according to teaching experience. A Pearson product-moment correlation coefficient was computed to assess the relationship between the OHL levels and DMFT and caries experience. There was a statistically significant positive correlation only between the OHL and FT (r = 0.195, n = 260, P = 0.002) [Table 4].
Table 4: Correlation of Rapid Estimate of Adult Literacy in Dentistry-99 scores with dental caries experience

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Among the sociodemographic characteristics, there was a statistically significant difference between OHL and education as determined by one-way ANOVA (F (3,256) = 9.62, P < 0.001). A Tukey post hoc test revealed that the high OHL levels were statistically significant in graduates (77.91 ± 8.82, P < 0.001) and postgraduates (76.42 ± 9.30, P = 0.004) compared to high school group (69.78 ± 9.15) and also high OHL levels were statistically significant in graduates (77.91 ± 8.82, P < 0.01) and postgraduates (76.42 ± 9.30, P = 0.03) compared to diploma group (70.47 ± 14.90). There were no statistically significant difference between the high school and diploma groups (P = 0.994) and between graduate and postgraduate groups (P = 0.736) [Table 5].
Table 5: Tukey post hoc test for comparison between Rapid Estimate of Adult Literacy in Dentistry-99 scores and education

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Among the oral hygiene practices, a statistically significant difference was found between OHL and the frequency of tooth brushing as determined by an independent t-test (t(258) = −2.253, P = 0.025). No statistically significant difference was found in an independent t-test used to compare the effect of diet (t (96.64) = 1.477, P = 0.143] and frequency of changing toothbrush (t (96.64) = 1.477, P = 0.143) on OHL levels [Table 2]. Among the oral health findings, a statistically significant difference was also found between OHL and the FT as determined by an independent t-test (t(258) = −3.200, P = 0.002) [Table 3].

  Discussion Top

The present study was an attempt to assess the influence of OHL on the oral health status of school teachers in Mangalore, Karnataka. To the best of our knowledge, this was the first study to examine the association between OHL and the overall oral health status in school teachers using REALD-99. Since the participants were not recruited from a clinical environment, selection bias was avoided which is a unique asset of this study. Although recent studies have highlighted the importance of OHL, they have focused mainly on the self-reported oral health status which may not represent the actual status.[10],[12],[19],[20] High prevalence of dental caries (79.2%) was noted in this study population that was higher than the caries levels (50%–60%) reported for India by Shah.[21] The mean DMFT levels for this population was 6.18 ± 4.35 which was higher than the DMFT values 5.7 ± 4.7 as reported by Patro et al.[22] for an urban Indian population. A total of 89.6% of the study subjects in this study had one or the other periodontal diseases, these figures were comparable to the results of the study done by Singh et al. in Ludhiana, India.[23]

In chronic diseases such as dental caries and periodontal diseases, the patient compliance and comprehension play a role in the successful long-term maintenance of good oral health.[24],[25],[26] A surprising finding from this study was that dental visit, caries experience (DMFT) and periodontal status (CPI scores and LOA scores) were not found to be associated with OHL despite the fact that these factors were predictors of dental caries and periodontal disease in other populations.[24],[25],[26] All the participants reported brushing with toothpaste and toothbrush, with the majority of the population brushing twice or more daily (81.9%). This suggests previous education regarding plaque control from multiple sources which may have led to increased OHL levels among the study population.

Results from this study reveal that the REALD-99 scores ranged from 45 to 95. A study by Jones et al. found almost one-third of the subjects had low OHL (REALD-30 score <22) and reported a mean score of 23.9 (standard deviation [SD] = 1.3).[10] Lee et al. reported a mean score of 19.8 (SD = 6.4) using REALD-30.[11] Miller et al. reported a mean score of 20.7 (SD = 5.5).[19] D'Cruz and Shankar Aradhya reported that about 60.4% of the adult patients seeking oral health care in a private dental hospital in India had low health literacy level.[27]

High level of OHL (mean REALD-99 score = 75.83) among participants in the current study was significantly associated with the education level. The discrepancy of low OHL in previous studies versus the current study may be due to the very high level of education among the school teachers. The REALD 99 score was significantly associated with the FT component of DMFT. Interestingly, there was also a positive correlation between REALD 99 scores and FT component of DMFT, which may be considered as a proxy to a dental visit, although it was surprising that the dental visit component per se did not show any association with the REALD 99 scores. This may be explained by the fact that persons who required fillings may have had multiple appointments within a short time frame that might have given the opportunity to learn about oral health.

This study found an association between OHL and frequency of tooth brushing which may be attributed to the fact that those respondents are more concerned with their oral health. A minimal number of studies of respondents seeking care have been the basis for research in OHL, but the present study was community-based. The results of this study provide insights into the dimension of OHL in relation to sociodemographic characteristics, personal habits, dietary practices and dental utilization patterns. With this data, interventions can be targeted to those being at risk for low OHL and health-related knowledge, behaviors and practices can also be studied.


The cross-sectional study design was employed, and therefore no casual inferences can be made. Next, the REALD-99 instrument has been validated in English only, so our study population was limited to school teachers from English medium schools of Mangalore, Karnataka, who may have limited generalizability to school teachers in non-English medium schools, but this population is crucial to examine. It should be noted that REALD-99 is a reading recognition test and was intended only as a screening tool for basic OHL, which has some disadvantages. Another limitation of a word recognition test such as the REALD-99 is mispronunciation by the Indian population who are nonnative speakers embracing many different languages and dialects, and each of which brings different problems to English pronunciation. In addition, an objective test of fluency in the English language was not used.

Future research

The primary area will be an attempt to establish cutoff points for REALD-99 to determine the clinical relevance of score differences. Future studies can include patients in the different background including community health centers with more diversified educational levels. The effectiveness of various methods of communication aimed at increasing a subject's OHL can be undertaken. Studies to develop interventions for improving OHL and to establish a causal relationship to oral health status. In addition, studies should examine approaches that can help people to overcome barriers to health literacy.


Low OHL when recognized can alert dental care providers, so that focussed efforts can be taken to improve communication with such patients. The patient's literacy level appropriate interventions may be effective in patient compliance in dental programs. The threat of low health literacy should be acknowledged in all surveys because of the participant's difficulty in reading and comprehending informed consent forms and survey questions. Oral health informational tools comprising commonly used terminologies can improve population OHL levels.

  Conclusions Top

Although this study indicated high OHL levels among school teachers in Mangalore city, the magnitude of dental caries in this population was also relatively high, and very few had a healthy periodontium. The influence of OHL was associated with and limited to education, the frequency of brushing and the number of FT among the school teachers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rudd R, Moeykens B, Colton T. Health and literacy: A review of medical and public health literature. Annu Rev Adult Learn Lit 1998;1:1-37.  Back to cited text no. 1
Kutner M, Greenberg E, Baer J. The Health Literacy of America's Adults: results From the 2003 National Assessment of Adult Literacy; 2006. Available from: https://www.nces.ed.gov/pubs2006/2006483.pdf. [Last accessed on 2016 Aug 20].  Back to cited text no. 2
Nutbeam D. Health promotion glossary. Health Promot Int 1998;13:349-64.  Back to cited text no. 3
Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med 1998;13:791-8.  Back to cited text no. 4
Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: A systematic review of the literature. J Gen Intern Med 2004;19:1228-39.  Back to cited text no. 5
Jolly BT, Scott JL, Feied CF, Sanford SM. Functional illiteracy among emergency department patients: A preliminary study. Ann Emerg Med 1993;22:573-8.  Back to cited text no. 6
Schillinger D, Barton LR, Karter AJ, Wang F, Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes. Public Health Rep 2006;121:245-54.  Back to cited text no. 7
Paasche-Orlow MK, Wolf MS. Promoting health literacy research to reduce health disparities. J Health Commun 2010;15 Suppl 2:34-41.  Back to cited text no. 8
National Institute of Dental and Craniofacial Research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. The invisible barrier: Literacy and its relationship with oral health. A report of a workgroup sponsored by the national institute of dental and craniofacial research, National Institute of Health, U.S. Public Health Service, Department of Health and Human Services. J Public Health Dent 2005;65:174-82.  Back to cited text no. 9
Jones M, Lee JY, Rozier RG. Oral health literacy among adult patients seeking dental care. J Am Dent Assoc 2007;138:1199-208.  Back to cited text no. 10
Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE. Development of a word recognition instrument to test health literacy in dentistry: The REALD-30 – A brief communication. J Public Health Dent 2007;67:94-8.  Back to cited text no. 11
Lee JY, Divaris K, Baker AD, Rozier RG, Vann WF Jr. The relationship of oral health literacy and self-efficacy with oral health status and dental neglect. Am J Public Health 2012;102:923-9.  Back to cited text no. 12
Richman JA, Lee JY, Rozier RG, Gong DA, Pahel BT, Vann WF Jr., et al. Evaluation of a word recognition instrument to test health literacy in dentistry: The REALD-99. J Public Health Dent 2007;67:99-104.  Back to cited text no. 13
Jourdan D. Health Education in Schools. The Challenge of Teacher Training; 2011. Available from: https://www.aber.ac.uk/en/media/departmental/sell/pdf/wellbeinghealth/Health-education-in-schools.pdf. [Last accessed on 2016 Aug 20].  Back to cited text no. 14
Sekhar V, Sivsankar P, Easwaran MA, Subitha L, Bharath N, Rajeswary K, et al. Knowledge, attitude and practice of school teachers towards oral health in Pondicherry. J Clin Diagn Res 2014;8:ZC12-5.  Back to cited text no. 15
Dorland N. Dorland's Illustrated Medical Dictionary. 32nd ed. Philadelphia: Elsevier Saunders; 2012.  Back to cited text no. 16
Hornby AS. Oxford Advanced Learner's Dictionary. 7th ed. Oxford: Oxford University Press; 2010.  Back to cited text no. 17
World Health Organization. Oral Health Surveys – Basic Methods. 4th ed. Geneva: World Health Organization; 1997.  Back to cited text no. 18
Miller E, Lee JY, DeWalt DA, Vann WF Jr. Impact of caregiver literacy on children's oral health outcomes. Pediatrics 2010;126:107-14.  Back to cited text no. 19
Divaris K, Lee JY, Baker AD, Vann WF Jr. The relationship of oral health literacy with oral health-related quality of life in a multi-racial sample of low-income female caregivers. Health Qual Life Outcomes 2011;9:108.  Back to cited text no. 20
Shah N. Oral and Dental Diseases: Causes, Prevention and Treatment Strategies: Burden of Disease. New Delhi: National Commission on Macroeconomics and Health; 2005.  Back to cited text no. 21
Patro BK, Ravi Kumar B, Goswami A, Mathur VP, Nongkynrih B. Prevalence of dental caries among adults and elderly in an urban resettlement colony of New Delhi. Indian J Dent Res 2008;19:95-8.  Back to cited text no. 22
[PUBMED]  [Full text]  
Singh G, Bindra J, Soni R, Sood M. Prevalence of periodontal diseases in urban and rural areas of Ludhiana, Punjab. Indan J Community Med 2005;30:128-9.  Back to cited text no. 23
Wehmeyer MM, Corwin CL, Guthmiller JM, Lee JY. The impact of oral health literacy on periodontal health status. J Public Health Dent 2014;74:80-7.  Back to cited text no. 24
Oliveira Costa F, Miranda Cota LO, Pereira Lages EJ, Medeiros Lorentz TC, Soares Dutra Oliveira AM, Dutra Oliveira PA, et al. Progression of periodontitis in a sample of regular and irregular compliers under maintenance therapy: A 3-year follow-up study. J Periodontol 2011;82:1279-87.  Back to cited text no. 25
Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc 2010;141:527-39.  Back to cited text no. 26
D'Cruz AM, Shankar Aradhya MR. Health literacy among indian adults seeking dental care. Dent Res J (Isfahan) 2013;10:20-4.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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