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Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 97-102

Oral health knowledge and practices: their influence on oral health status of auxiliary health workers in health centers of Mangalore, India

1 Department of Public Health Dentistry, Sri Balaji Dental College and Hospital, Moinabad, Ranga Reddy, Telangana, India
2 Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India

Date of Submission04-Sep-2018
Date of Acceptance02-Apr-2019
Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. Mallikarjun Sajjanshetty
Department of Public Health Dentistry, Sri Balaji Dental College and Hospital, Yenkapally, Moinabad, Ranga Reddy, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_173_18

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Background: Disparity exists in the availability of dental care services in rural India as compared to urban setup. Majority of dental offices are set in urban areas, with little access to rural population, driving people to primary health centers for all health needs. In situations like these, auxiliary health workers can be delegated with the duties of oral health education to the masses provided they possess adequate information/knowledge regarding oral healthcare and practices. Aim: The aim of this study is to assess the influence of oral health knowledge (OHK) and oral health practices on the oral health status among auxiliary health workers in the health centers of Mangalore. Material and Methods: A cross-sectional study was carried out among the auxiliary health workers in Mangalore. OHK and practices were analyzed using a pretested, screening questionnaire. Oral health status was analyzed using the WHO Oral Health Assessment Form-1997. Data were analyzed using the Statistical Package for the Social Sciences software, version 16.0 (SPSS Inc., Chicago, IL, USA). Chi-square test and binary logistic regression test were employed. P < 0.05 was considered statistically significant. Results: Majority (72.8%) of the auxiliary workers had good OHK and followed recommended dental practices. Better OHK was associated with better oral health, namely lesser decayed teeth and more filled teeth (P < 0.05). Better OHK correlated negatively with missing teeth among participants (P < 0.05). Visiting a dentist in previous 6 months, brushing twice a day, and changing brush every 3 months were the important predictors of improved oral health (P < 0.05). Conclusion: Better OHK and practices can significantly impact the oral health status of auxiliary health workers in Mangalore. It also projects the impact that it can have on the oral health of rural population as auxiliary health workers are the first line of information for the underprivileged masses. Dedicated oral health programs to educate/train auxiliary workers in health centers can form an alternative approach to reach rural population.

Keywords: Hospital auxiliaries, oral health, rural health center

How to cite this article:
Sajjanshetty M, Rao A, Gururaghavendran R, Shenoy R, Mithun Pai B H. Oral health knowledge and practices: their influence on oral health status of auxiliary health workers in health centers of Mangalore, India. J Indian Assoc Public Health Dent 2019;17:97-102

How to cite this URL:
Sajjanshetty M, Rao A, Gururaghavendran R, Shenoy R, Mithun Pai B H. Oral health knowledge and practices: their influence on oral health status of auxiliary health workers in health centers of Mangalore, India. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2024 Mar 3];17:97-102. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2019/17/2/97/260868

  Introduction Top

India, the largest democracy and second-most populated country, has majority of its population residing in villages.[1] Health infrastructure in these villages comprise the primary health centers (PHCs) which form the cornerstones of health care.[2] There are nearly 25,000 health centers functioning in the country established by the Government of India under the National Rural Health Mission,[3] which provide health care to this underprivileged population. However, the lack of access in these remote areas forms a major obstacle to the delivery of quality health-care services.[4]

Infrastructure for dental health care (although deficient) is growing rapidly with nearly 1.2 lakh dentists working across the country.[5] However, the demand and supply ratio of dentists is misleading with an overall reported dentist to population ratio of 1:10,000, which does not hold true to the situation in rural setup where the actual dentist-to-population ratio is 1:250,000.[1] This problem ensues because <5% of the graduating dentists enter the government sector that reaches the indigent rural population,[5] creating a great deal of scarcity in dental healthcare facilities in the PHCs that render health care to rural population.[6] Above all, there exists neither national-level program nor policy to address oral health problems of this population, leaving many underserved groups with no access to oral health care.

Oral health is a state of being free from chronic oral disease, tooth decay, and other diseases and disorders that affect the oral cavity.[7] Oral diseases are among the most common diseases of human society, which take up a lot of family time and expenditure.[8] They are unambiguously related to oral health practices followed, knowledge of oral health, and health-seeking behavior.[9] A decline in dental diseases with improvements in oral hygiene practices has also been noted earlier.[10] Despite all the evidence on efficiency of dental practices, there still exists a great burden of oral diseases in India,[11] which can logically be explained by the lack of dental facilities,[12] inequality in access to care,[13] asymmetrical distribution of workforce,[5] and deficiency of services provided in the rural areas where majority of the population resides.

Although good oral health practices and knowledge regarding oral health are associated with better oral health status among a varied group of population [14],[15],[16] and vice versa,[17] there exists no literature on the knowledge and practices of oral health among auxiliary health workers working in the PHCs, namely, auxiliary nursing midwife, general nursing midwifery, accredited social health activist, and others who educate the underprivileged population on matters of hygiene, health, prevention, and health promotion including oral care practices. Since there is availability of only these auxiliary health workers as the source of any kind of health information for rural population, this study aimed to assess their knowledge to derive a conclusion where necessary programs intending to train this population can be advocated which shall enable them to educate the rural community about different aspects of oral health and its maintenance. Hence, the present study focused to assess the oral health knowledge (OHK) and practices and evaluate its influence on the oral health status of auxiliary health workers in Mangalore.

  Material and Methods Top

The present study employed a cross-sectional study design. It was conducted among auxiliary health workers in the PHCs of Mangalore, Karnataka. List of all the PHCs in Mangalore was obtained from the District Health Officer, Mangalore. All the PHCs of Mangalore were included in the study.

A pilot survey was conducted among 20 auxiliary health workers in Mangalore before the main study. Sample size of a minimum of 120 study participants was calculated according to the findings of the pilot study using G Power software (version 3.1.2, Denmark) with effect size of 0.5, 95% confidence interval, and at 80% power of the study. A total of 173 participants were screened for the present study. Pretesting of the questionnaire was done to assess the content validity of the questionnaire, by asking the experts in the field of research to provide feedback on how well each question measures the construct in question. Convergent validity and divergent validity for each item were determined by first comparing answers to another question measuring the same concept and then by measuring this answer to the participant's response to a question that asks for the exact opposite answer.

Ethical clearance was obtained from the Institutional Ethics Committee (IEC), Mangalore (Ref No: MCODS/198/2011), and informed consent was obtained from each participant before administration of the questionnaire and oral examination.

An inclusion criterion for the present study was auxiliary health workers in PHCs of Mangalore. Participants not willing to give written informed consent were excluded from the study. Data collection was completed over a period of 6 months.

The questionnaire was translated to the local language (Kannada) by the first translator and back translated to English language by a second translator. The final version of the questionnaire in Kannada was then finalized by the investigators and the two translators.[18] Before the commencement of the main study, the questionnaires were administered to the study participants who were not included in the main study. The questionnaire was validated with 20 auxiliary health workers before administration after obtaining approval from the IEC. The questionnaire was given to five subject experts who assessed the comprehensibility, relevance, and appropriateness of the questionnaire.[19] Reliability of the questionnaire was assessed by employing Cronbach's alpha. Calibration of the examiner was done to establish interexaminer reliability, which was assessed by employing the Kappa statistic. Based on the pilot study, Kappa statistic was found to be 0.82, which suggests good agreement.

Information on demographics, medical and dental history, dietary practices, lifestyle habits, and oral health practices was collected using an interview schedule; a pretested and validated, close-ended, self-administered questionnaire was used to assess the OHK of the participants, and oral examination was conducted to determine their oral health status. The number of correct answers provided constituted their OHK score. Clinical oral examination was done using the WHO Oral Health Assessment Form-1997.[20]

Clinical examination was carried out in the premises of health centers, which was done in natural lighting conditions in the PHC settings with the participant sitting comfortably on a chair with a head rest.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences, Version 16.0 (SPSS Inc., Chicago, IL, USA). The Chi-square test was used to assess the relationship between OHK, oral health practices, and oral health status among auxiliary health workers in Mangalore. Pearson's correlation coefficient was conducted to assess the correlation among OHK and oral health status. Binary logistic regression was performed to assess the predictors of poor oral health status among the participants. Using this method, variables which showed a statistically significant difference at the 95% level (P < 0.05) were selected.

  Results Top

A total of 173 auxiliary health workers working in 23 health centers participated in this study. Majority of the participants were females, followed mixed dietary habits with a mean age of 42.2 ± 9.9 years. Work experience of the study population ranged from 1 to 27 years, and majority of the participants were free from systemic illnesses. Sociodemographic characteristic distribution is presented in [Table 1]. Almost all the participants used toothbrush and toothpaste; other oral hygiene practices and dental visit characteristics are presented in [Table 2].
Table 1: Sociodemographic characteristics (n=173)

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Table 2: Oral hygiene practice and dental visit characteristics of study participants (n=173)

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OHK for each individual was calculated by the number of correct answers they provided (maximum = 17, minimum = 0). The scores for OHK among the present study participants ranged from 7 to 17, with a mean of 13.05 ± 2.26 and median of 14.0. Participants scoring 10 or below were categorized as having poor OHK, and those who scored 11 or more were labeled as possessing good OHK. Majority of the participants (n = 126 [72.8%]) had good OHK, and remaining participants (n = 47, [27.2%]) had poor OHK.

Mean decayed missing filled teeth (DMFT) among the study population was 4.93 ± 4.5 and the caries prevalence was 67.1%. Mean number of teeth with decayed, missing, and filled component was 2.16 ± 2.30, 1.2 ± 2.1, and 1.64 ± 2.8, respectively. Calculus deposits were recorded in majority of the participants (60.7%) and bleeding on probing was elicited among 17.9% of the participants. 75% of the study population showed no loss of attachment (LoA), while 22.5% showed a LoA of 4–5 mm, and the rest (2.4%) showed 6–8 mm LoA.

It was found that participants with good OHK showed significantly lesser decayed teeth (DT) (P < 0.05) and more number of filled teeth (FT) (P < 0.05). However, OHK showed no statistically significant association with caries experience (DMFT), missing teeth (MT), periodontal condition community periodontal index (CPI), and LoA (P > 0.05) [Table 3]. A statistically significant negative correlation was noted between OHK and MT (P < 0.05). Negative correlations were also observed between OHK and DT, FT, DMFT, CPI, and LoA which, however, showed no statistical significance (P > 0.05) [Table 4].
Table 3: Association of oral health knowledge and oral health status

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Table 4: Correlation of oral health knowledge with oral health status

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Participants brushing twice or more revealed significantly lower LoA (P < 0.05), while no association was observed between brushing frequency and caries experience (DMFT) and periodontal status (CPI) (P > 0.05). Changing toothbrush more frequently associated with better periodontal condition (CPI) (P < 0.05); however, frequent changing of toothbrush did not affect other oral health criteria (P > 0.05). Previous dental visit was associated with higher caries experience (P < 0.05), MT (P < 0.001), and FT (P < 0.001). Use of oral hygiene aids showed no association with oral health status (P > 0.05) [Table 5].
Table 5: Association of oral health practices and oral health status

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Binary logistic regression analysis showed that “female gender” and “visit to a dentist in the past 6 months” were associated with lesser caries experience (P < 0.05). Increase in age had a negative impact on the periodontal condition (P < 0.05), and participants who changed their toothbrush every 3 months had better periodontal condition (P < 0.05). Age had a negative impact on the LoA (P < 0.05), and brushing twice a day or more had beneficial effect on LoA (P < 0.05). Participants brushing only once a day had higher LoA scores as compared to those who brushed twice a day or more (P < 0.05) [Table 6].
Table 6: Binary logistic regression analysis

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  Discussion Top

Owing to paucity in the literature regarding OHK, practices, and oral health status among auxiliary health workers in India, the present study stands to be a prototype to these studies, indicating possibilities of further research. However, comparison has been facilitated with the studies conducted on population groups with similar training and expertise as the present study population.

Majority of the participants followed recommended oral hygiene practices such as brushing twice a day,[21] similar to previous studies,[22],[23] while dissimilar findings were reported by Al-Ansari et al.[10] Recommended frequency of changing toothbrush (American Dental Association)[24] was also practiced by more than half the respondents, a finding superior to those in a study by Kaira et al.[23] Other oral hygiene aids were used by a meager percentage of the participants reflecting their lack of awareness, as compared to an earlier study.[23] These practice behaviors among the study population could well be explained by the fact that neither there exists training or education about oral care in the curriculum of the auxiliary health workers nor they are trained in such aspects before they get recruited.

Nearly 1/4th of the auxiliary health workers in this study reported no previous dental visit which was contrary to the findings of Kaira et al.,[23] where almost all the participants reported visiting a dentist sometime. However, Udoye [25] reported much poorer findings, where more than half respondents reported not a single dental visit in their life. Nearly half of the participants reported a dental visit more than a year ago reflecting a negligible consideration to the periodic dental visit; similar findings were also reported by Frenkel et al.[26] Dental visit patterns in the past 1 year were satisfactory and in line with those of Al-Ansari et al.[10] and Kaira et al.[23] Dental visits among the participants mostly culminated in restorative and curative are with lesser emphasis on preventive care, unlike that of Kaira et al.,[23] indicating minimal importance to preventive practices among the study participants.

Majority of the respondents in the present study had a good knowledge of oral health similar to the ones reported by Walid et al.[27] and Hajizamani Abolghasem et al.[28] Findings, refusing the present study, were also observed in the literature as reported by Preston et al.,[29] Mohanty and Parkash,[30] Simons et al.,[31] Young et al.,[32] and Howard [33] where the knowledge of majority of the care home staff and auxiliaries was found to be poor. Periodontal status of the participants was poor and in line with the poor dental visit characteristics, similar to the reports from Sharda and Shetty.[34] Although literature was scarce for comparison of this aspect of the oral health of the auxiliaries, it is generally believed that auxiliaries, particularly those in health care, have better oral habits compared to those in nonhealth care fields, thereby preventing the development of more terminal conditions of orofacial complex.[35]

Dental caries prevalence was high among the participants and highlighted the need for the dental care required among them, similar to the health workers in Ambala;[36] however, comparatively lesser prevalence of dental caries was reported by Sharda and Shetty.[16] The present study reported the dominance of DT among total DMFT score, indicating a high rate of unmet treatment needs. This observation can be explained by the evidence from earlier studies that majority of the patients visit a dentist only in case of pain.[37],[38],[39] Female gender, absence of a medical condition, age, and increasing work experience determined better OHK of the participants, similar to the results obtained by Chiba et al.[40] and Lian et al.[41] Female participants were more inclined toward utilizing dental care, as expressed by the increased number of FT; previously, a study by Camargo et al.[42] also reported similar finding. Better OHK predicted better oral health with increased number of restored teeth and lesser DT, although it showed no predictable improvement in periodontal status. Similar findings were also observed earlier,[16],[36] which explains the importance of OHK in health-seeking behavior of the population.

In a developing country like India, people encounter various obstacles associated with access of dental services and majority of the population usually resort to health centers for all health needs, including complaints pertaining to oral health. The auxiliary health workers are in a position to access this population and create awareness of oral health at a grass-root level. Hence, it becomes obligatory that these health workers are provided with adequate information regarding oral health so as to motivate the patients regarding oral health care utilization and maintenance and also refer the patient to dental care professional in need. There is a need for policymakers to include oral health practices as a part of training for auxiliary health workers so that they can act as a source of information to rural population and develop positive attitude toward dental practices and utilization of dental care among them.


Introduction of training program to make the health-care workers aware of dental and oral hygiene practices can help improve dissemination of knowledge among rural population in a better way. However, being a questionnaire study, recommendations/extrapolation from this study can be limited to health centers of Mangalore.

Avenues of future research

Further studies are recommended in this area of research to find out the efficiency of training programs on the oral health practices of healthcare workers as well as the rural population.


We would like to thank Dr. Vijayendranath Nayak, Post Graduate in Oral Medicine and Radiology, AJ Institute of Dental Sciences, Mangalore, for technical and logistic support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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