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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 14-21

Oral health status and use of sugary products among adolescents in urban and rural schools in Al-Ahsa, Saudi Arabia

1 Student College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia
2 Teaching Assistant Department of Periodontology, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia
3 General Dental Practitioner, Al-Ahsa, Saudi Arabia
4 PhD Candidate Department of Dental Public Health, University of Finland, Finland
5 Professor Department of Periodontology, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia
6 Professor Department of Dental Public Health, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia

Date of Submission27-Apr-2020
Date of Decision01-Aug-2020
Date of Acceptance27-Sep-2020
Date of Web Publication17-Apr-2021

Correspondence Address:
Syed Akhtar Hussain Bokhari
Department of Preventive Dental Sciences, College of Dentistry, King Faisal University, Al-Ahsa
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_30_20

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Introduction: Diet of an individual plays a remarkable role in maintaining health. Urbanization has had a great impact on the food habits of the society with the balance shifting to sweetened and refined food consumption. Dietary habits also has remarkable contribution to dental and overall health status. Aim: This study was designed to evaluate oral health awareness, practices, status, and the use of sugary products among urban and rural high school adolescents of Al-Ahsa, Saudi Arabia.
Materials and methods: A cross-sectional mixed study was conducted using questionnaire and clinical examination among two female and two male urban and rural schools. Information on oral health awareness, practices, and use of sugar products were obtained using a self-reported structured questionnaire. Oral health status was assessed using decayed, missing, and filled teeth (DMFT) index, gingival index, Angle's classification at University dental clinics. The Chi-square test and t-test were performed using SPSS.
Results and Discussion: Ninety-seven urban and one hundred and twenty-eight rural students with a median age of 17 years for males and 16 years for females completed the study. Eighty-five percent urban and 86% rural students demonstrated oral health awareness and practices, showing significant level for rural females (54%, P = 0.002) and urban females (72%, P = 0.006). Ninety-four percent urban and 89% of rural students used sugary products with a significant level for rural females (P = 0.001) for carbonated drinks only. Eighty-six percent of students had decayed, 22% missing and 38% filled teeth. Mean DMFT was 7.0 ± 4.7. Ninety-five (95%) participants showed mild-to-moderate gingivitis, 35% malocclusion, 11% other oral pathologies. Rural and urban difference for oral health parameters was significant only for filled teeth (P = 0.001) for urban and missing teeth (P = 0.019) among 15 years old for rural adolescents.
Conclusion: This study demonstrates a good level of oral health awareness, but poor oral health status among both urban and rural students with an insignificant difference for most of the parameters studied.

Keywords: Adolescents, oral health knowledge, rural, schools, sugar products, urban

How to cite this article:
Alwabari MA, Alquraini AM, Albakheet AS, Alsaljah RS, Alkuhl H, Ashraf J, Alotaibi AR, Hussain Bokhari SA. Oral health status and use of sugary products among adolescents in urban and rural schools in Al-Ahsa, Saudi Arabia. Saudi J Oral Sci 2021;8:14-21

How to cite this URL:
Alwabari MA, Alquraini AM, Albakheet AS, Alsaljah RS, Alkuhl H, Ashraf J, Alotaibi AR, Hussain Bokhari SA. Oral health status and use of sugary products among adolescents in urban and rural schools in Al-Ahsa, Saudi Arabia. Saudi J Oral Sci [serial online] 2021 [cited 2023 Mar 22];8:14-21. Available from: https://www.saudijos.org/text.asp?2021/8/1/14/313925

  Introduction Top

Globally prevalent oral diseases have serious health and economic burden and greatly reduce the quality of life of the affected people.[1] Worsening of oral health is frequently attributed to many risk factors that include poor dietary and oral hygiene habits[2] and these factors result from a lack of awareness and knowledge.[3] Oral health knowledge is an essential prerequisite for health-related practices.[4]

Marked changes in the lifestyle of young Saudi people, such as an increase in consumption of sweetened beverages, low frequency of regular tooth-brushing, and higher smoking, are reported, and this may have public health implications.[5] Consequently, dietary habits and lifestyle of young Saudi are not up to the mark and that is considered as a health risk behavior.[6]

Studies reporting the oral health status of the Saudi population have shown an overall caries prevalence of 99% for deciduous and permanent dentition and 100% prevalence of gingival diseases among children.[7] Gingival inflammation, a recognized risk factor for periodontitis, occurs mostly in adolescence and is associated with poor oral hygiene practices[8] and socioeconomic status.[9] The prevalence of tooth loss in Saudi adolescents is reported high as compared to adolescents of other countries.[10] Malocclusion prevalence is also noted high in 12 –15–year–old Saudi adolescents.[11]

Individuals, in adolescence age adopt habits that are passed onward in adulthood. Little information is available regarding the oral health awareness, practices, and use of sugar products among adolescents of the Al-Ahsa region. Therefore this research was aimed to evaluate oral health status, awareness, practice associated sociodemographic, and dietary factors among high school students of urban and rural areas of the Al-Ahsa region.

  Materials and methods Top

This cross-sectional mixed study was conducted using questionnaire and clinical examination of high school students at University dental complex, Al-Ahsa, Saudi Arabia, during February 2019. Male and female students from randomly selected high schools were invited to participate in the study after having formal consent from students and school authority. Ethical approval of the study was obtained from the College Research Review Committee vide letter # KFU/CoD/R/002/2018. The study sample was selected using the two-stage sampling technique. Open Epi was used to calculate sample size with the power of study as 80, confidence interval of 0.95% and with an α error of 0.05%. In the first stage, data of male and female schools both in urban and rural areas was obtained from the education department. There are 33 male and 37 female urban high schools and 24 male and 20 female rural high schools in the Al-Ahsa region of Saudi Arabia. At the second stage, two male and two female schools were randomly selected, one from each urban and rural locality. From the selected schools, 490 students (245 males and 245 females) were randomly recruited for the study. All students were brought to KFU dental complex on the day fixed for each school.

At the KFU dental complex, all students were asked to fill a close-ended questionnaire related to their personal, general health, oral health awareness and practices, and use of sugary products. The questions were validated by running a pilot study. Personal information included the age, gender, education level, school, height and weight, family size, level of father and mother education, father and/or mother income. General health questions were about physical disability, systemic disease, and smoking habits. Regarding oral health awareness, students were asked about (1) importance of oral health, (2) oral rinsing after meals, (3) tooth cleaning frequency, 4) visiting a dentist, and reason of visit. Questions about sugar products included (a) use of sweets/candies, (b) carbonated drinks, (c) cakes and cookies, (d) ice cream and alike, (e) juices, (f) chocolates, and (g) fruits.

Later on, all students were requested for an oral examination for the status of decayed, missing and filled teeth (DMFT), dental trauma, gingivitis measured by the gingival index, malocclusion measured by Angle classification, and soft tissue pathologies. Two dentists and three BDS students, who were calibrated with the principal investigator (SAHB) for the study variables, carried out the examination. The level of inter-examiner agreement was 79.3%–88.4% and intra-examiners agreement was 81.7-87.0%, and the level was measured by using the Kappa test.

Statistical Package for Social Sciences (SPSS®) Version 23.0 was used for data analysis. Categorical variables were analyzed using the Chi-square test and continuous variables using t-test. The level of significance was set at P < 0.050.

  Results Top

General characteristics

Ninety-seven urban (47 males, 50 females) and 128 rural (46 males, 82 females) high school students participated and completed the study questionnaire with a median age of 17 years (males 17 years, females 16 years). One hundred eighty-six students (70 urban and 116 rural) accepted the oral examination. Fifty-one percent of urban and 27% of rural were students from the 3rd grade of high school. Majority (>60%) of the study participants had 5–8 family members. Greater than or equal to forty-six percent of the participants' fathers were government employees and majority (≥70%) of the mothers were unemployed in both urban and rural students. Majority (≥80%) of students did not disclose their income status. Age, educational level, father and mother educational level showed significant differences between urban and rural participants [Figure 1].
Figure 1: General characteristics of study participants

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Oral health awareness and practices

Ninety-three percent of females and 90% of males agreed that oral health is important. One hundred and thirty-six participants (50% urban and 69% rural) rinsed their mouths after each meal; however, the difference between genders and urban-rural was insignificant. One hundred and seventy-eight (79%) students claimed that they brush their teeth and it was significant for females (P = 0.006) among genders, and rural females were significantly better in this practice (P = 0.002) compared to urban females. More females (41%) use toothbrush twice daily as compared to males (36%). Urban males were significantly higher (P = 0.001) for once-daily brushing. Fifty percent of both urban and rural students never or occasionally visited the dentist, 28% visited every 3 months or more. Forty-two percent visited the dental clinic for dental decay, 9% for gum disease, and 66% for other treatments (orthodontic and prosthetic etc.,). The frequency of visits to dentists was higher among females [Table 1].
Table 1: Oral health awareness among study participants, n (%)

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Use of sugar products

More than 53% of participants use sugary products. Rural females were significantly (P = 0.001) noticeable in the use of carbonated drinks and fruits (P = 0.020). Of all students, 92% consume chocolates, 53% carbonates drinks, 88% cake and cookies, 91% ice cream, 88% juices, and 92% use fruits at least 1–2 times in a month. An equal number of urban and rural females use candies on a daily basis, whereas more rural females (21%) use candies 2–4 times weekly as compared to urban females (8%). Twenty-nine percent and 17% female students drink carbonated drinks 2–4 times a week. 52%, 38%, 26%, 38%, 42%, and 66% of students, respectively, use chocolates, carbonated drinks, cake and cookies, ice cream, juices, and fruits every-day or 2–4 times a week [Table 2].
Table 2: Sugar consumption among study participants, n (%)

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Oral health status

Eighty-six percent (86%) students had decayed, 22% missing and 38% filled teeth. Mean DMFT was 7.0 ± 4.7. Mild or moderate gingivitis was shown by 95% of participants, 35% showed malocclusion, and 11% other oral pathologies. Rural and urban difference for oral health parameters was significant only for teeth with fillings (P = 0.001) and missing teeth (P = 0.019) among 15 years old. Only 1% of the participants have experienced dental trauma [Table 3].
Table 3: Oral health status (n [%]/[mean±standard deviation]) among study participants

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Regression analysis

Multinomial logistic regression analysis was applied to see any difference in consumption of sugar products between urban and rural adolescents. Location (urban/rural) was kept as predictor variable and outcome variables were carbonated drinks, cakes and cookies, juices, ice cream, fruits, chocolate candies. No significant difference was observed for any of the above variables except ice cream (P = 0.034) between urban and rural adolescents. Linear regression was used using DMFT as dependent variable and no significant difference was noted between urban and rural samples. Ordinal logistic regression with gingival index as dependent variable and inclusion of mother education and importance of oral health in the model, both location, gender and importance of oral health were highly significantly associated with gingival index score. Binary Probit regression was applied with presence of decayed teeth (yes/no) as dependent variable. Location (urban) was significantly (P ≤ 0.001) associated with the presence of decayed teeth.

  Discussion Top

Oral health knowledge is considered as an essential prerequisite for health-related behavior and better oral health is associated with increased knowledge.[4],[12] In Saudi Arabia, many studies have evaluated oral health awareness and practices, use of sugar products or dietary habits and oral health status.[13],[14],[15] A Study conducted in another Arab country has also reported these parameters among adolescents.[12]

This study observed the status and difference of oral health awareness, practices, and use of sugary products between urban and rural high school adolescents of Al-Ahsa region in Saudi Arabia. This study may be the first one from this region that has assessed the above-mentioned aim. An incredible access to information through social media and internet technology have made it easy for all communities (urban and rural) to utilize modern dietary products and avail facility of medical and dental services. Gender differences are observed in oral health behaviors that are associated with various factors of knowledge, attitude, education level, socioeconomic status, lifestyle, and stress.[13] By conducting this study, we have tried to comprehend the school adolescents' behavior with respect to use of sugary products and oral health knowledge.

Because of westernization and diversification in food consumption patterns;[14] Saudi adolescents' dietary habits are characterized by low intake of milk, fruit and vegetables and high intake of fast food, sweets, chocolates and sugary beverages[15] and such dietary habits are augmenting the incidence of dental caries, gingivitis, and periodontitis leading to tooth loss.[16]

In this study, 92% of study adolescents are consuming using chocolates/candies, 91% ice cream, 82% cake and cookies, 88% use sweetened juices, however use of carbonated drinks was not so high (53%). This high consumption of sugary drinks ranks Saudi Arabia at 9th level worldwide in the use of soda drinks and 51% of 12–13 year olds use it in daily fluid intakes, sugar sweetened carbonated drinks are prominent in 14–16 years old males.[17]

In this study, 90% of the investigated adolescents considered that oral health is important, more than 50% of them rinse mouth after meals, 79% brush teeth daily with higher percentage in females, 50% never or occasionally visited dentists and this is consistent with another study,[16] in that study 89% of 15–24 years old sample never visited dentist for routine checkup and 43% visited for a complaint only.

Oral health status of adolescents of this study sample showed DMFT as 7.00 DT as the highest component, with 7.40 in urban males and 7.22 in rural males, whiles urban and rural females had low DT as 4.38 and 6.20, respectively. This study showed no gender difference in dental caries status while another study has reported a significant difference.[18]

Prevalence of dental caries at national level among Saudi Arabian children is assessed to be 80%[13] that is close to our finding of 86%. A meta-analysis[19] has indicated a high prevalence of dental caries in every age group in different parts of KSA. A review paper[20] on prevalence of dental caries in Saudi Arabia showed 70% permanent dentition with mean DMFT score of 3.5; that is lower as compared to our study.

Very few studies have reported an overview of oral health diseases and associated risk factors from Eastern region of KSA. A previous study[21] conducted in this region observed only dental caries and their relation to dental knowledge and dietary habits in primary school male children. This study has reported decayed teeth prevalence as 68.9%, 24.5% of the study sample brush teeth twice per day. 44.6% of children used Miswak, as an additional method of dental cleaning. In another study from Eastern province of KSA, 14–19 years aged adolescents showed mean tooth loss as 0.83 ± 1.18 for all subjects. Boys lost more teeth than girls did and this status was significantly linked with sweet consumption, smoking, and oral hygiene practices of tooth brushing, dental flossing and dental visits,[10] while in this study, we have noted a low mean tooth loss (0.35 ± 0.79) and boys too had low mean tooth loss. However, another study from Eastern Saudi Arabia has demonstrated low prevalence of dental caries in primary and permanent teeth as compared to other researchers reported from different cities of KSA.[22]

Findings of this study are also comparable with that of a most recent study[4] that has reported 82.3% of the schoolchildren were aware that good oral health is important for general health. More than half (58.8%) took sweets daily compared to 12% of our study participants. Most of children (69.6%) visited a dentist for pain, in our study most subjects visited dental clinic because of dental problem. Majority (66.9%) of the children were not brushing teeth daily in comparison to our study where 79% brushed teeth. Reported from a study[23] from Qatar on students aged 12–14 years, only 25.8% showed high level of oral health knowledge. 67% students, aged 10–18 years, from Riyadh reported brushing daily and difference between genders was significant, 50% reported dental visits during last 6 months[24] in comparison to our study students, we have not observed any gender difference and daily brushing habit that was 44% and dental visit was 66%.

In a study in Jeddah,[25] females brushed and flossed their teeth more than males; however, miswak use was higher in males. The dentist visit was mainly due to dental pain. In our study, the use of miswak was very low. With respect to oral health knowledge, DMFT status and attitudes related to the use of sweets in our study participants are comparable to a descriptive study from Jazan, Saudi Arabia. However, caries prevalence was high (91.3%), knowledge was generally good, both girls and boys had poor attitudes to sweet foods and sweet foods/beverages were frequently used by most (>90%) comparing with this study (>53%).[26]

Alghamdi and Almahdy[27] reported DMFT prevalence 54.1% in 14–16 years old children of 12 intermediate boys' schools of Riyadh. DMFT was lower with high SES status. The prevalence of dental caries among the study population was found to be 72.9%. There is a high prevalence of dental caries among students aged 15–17 years in Abha, Saudi Arabia.[28] DMFT prevalence of this study is comparable with an Indian study,[29] that showed 91% DMFT prevalence in 11–15 years old students. It has been expressed in a review on studies conducted during 1992–2016 on 6 –year–old children from Gulf Cooperation Council countries that DMFT score was 2.57 and prevalence was 64.7%.[30] In comparison with findings from the regional country, the mean DMFT index value in this study was much higher in the same age group.[31]

Mild gingival inflammation was 47%, moderate 45%, with urban males (25%), rural males (29%) and rural females (32%). Urban females showed much less gingivitis (4%) in our study. Among 13–15 years males from Dammam and Khobar, 38% brushed their teeth twice daily, 82.8% consumed sugary drinks, and 68.3% sugary foods. In a study by Kukletova M et al, Czech children had 43% mild and 19.5% moderate .gingivitis [32] whereas among Nigerian school children, 20.4% were found to have moderate/severe gingivitis.[33] In a 4-year longitudinal cohort study conducted among children from Bengbu, Anhui province, China, prospective association between consumption pattern of sugar-sweetened beverages and childhood periodontal health was assessed. It was observed in this study that children with higher sugar-sweetened beverages consumption during the transition period from childhood to adolescence were under higher risk for periodontal diseases.[34]A similar study among adolescents in publics schools in São Luís, Brazil also substantiates that periodontal diseases are associated with added sugar consumption.[35] More the less, the present study also found association of gingivitis and sugar intake. [32],[33],[34],[35],[36],[37],[38]

Findings of this study related to dental malocclusion correspond with those of another recent study[11] that demonstrated Class I relation as 71.2%, Class II relation as 23%, and Class III as 5.8%. Class I canine relationships was 68%, Class II bilateral and unilateral was 18.8% and 8%, respectively, while bilateral Class III and unilateral 4% and 1.2%, respectively. Angle's Class I on the right side was 56%, of left side 53%; Class II on the right side was 11%, on the left side was 14.5%; Class III on the right side was 25% and on the left side was 20.5%. Anterior maxillary crowding was 11.3% and mandibular crowding was 23.2%. Both maxillary and mandibular crowding was higher in male adolescents as well rural had more crowding. The prevalence of dental trauma in 12–14year-old boys was reported to be 34%.[39]In a systematic review on Traumatic Dental Injuries (TDI) , it was found that all 25% of children and adolescents between the age of 7 to 19 years of age had a TDI of permanent dentition.[40] whereas, in our study, dental trauma due to any reason was 4% in males and 2% in female students. In a study,[13] 18–19 years old females had greater knowledge, a more positive attitude, a healthier lifestyle, and a higher level of oral health behaviors than males. In light of this study, regular oral health activities at schools should be planned and executed with a mutual collaboration of health and education departments.

  Conclusion Top

In summary, this study does not to show differences in most of the study variables among genders and rural-urban groups, however behaviors and practices of female students concerning oral health were better that is consistent with other studies. The strength of the study is that we used appropriate sampling strategy to include all male/female students from public schools randomly. The study is limited by the facts: a) it was a cross sectional study, b) oral health awareness information were self-reported, c) many female students refused oral examination. On the basis of these limitations, generalizability of results is compromised. Therefore, the authors have planned to conduct another study with large sample size and motivate the female participants for their oral examination in order to obtain a comparable oral health status and other variables among the school adolescents of Al-Ahsa region.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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