Knowledge, attitudes, and practices of school teachers toward oral health - A cross-sectional study

INTRODUCTION

Oral hygiene and dental care are two major essentials in everyone’s busy schedule. Millions of people are risking their oral health by failing to give themselves the proper care and attention they need. People may be affected by dental issues at any age. Hence, it is essential that oral hygiene awareness should be properly given to the individual at the earliest as possible.^[1]

In 1995, the World Health Organization launched a Global School Health Initiative, highlighting the importance of schools in delivering health education to students. It has been observed that numerous educators in schools offer insufficient or incorrect details concerning oral health to their pupils.^[2] Educating school children on oral health helps in developing healthy oral habits at a very early age itself. Children spend a considerable amount of time in school, especially during the age when their habits are being formed.^[1] Schools provide an effective platform for promoting oral health because they reach over 1 billion children worldwide. Hence, school teachers can play an important role in providing appropriate education on oral health and care to their students. It is now established that school teachers have an internationally recognized potential role in school-based dental education, and considerable importance has, therefore, been attributed to their dental knowledge.^[3]

One of the major disadvantages of using school teachers in dental health education is that the teachers may be poorly aware of oral health, the teachers may be insufficiently trained on the aspects of oral healthcare, which prevents the teachers from participating in teaching the children effectively. In order to educate their students about the positive aspects of dental healthcare, the teachers themselves need a good knowledge, attitude, and practice towards oral hygiene.^[4]

Under the National Oral Health Programme (NOHP) of India, school teachers play a crucial role in promoting oral health among children. Their contributions can be categorized into key areas: Health education and awareness, where they deliver oral hygiene lessons; role modeling, by setting examples through their own habits; screening and early identification of dental issues; behavior change agents, encouraging students to adopt healthy routines; support for school health programmes, by assisting in camps and distributing materials; and sustainability and follow-up, ensuring ongoing reinforcement of oral health messages. Implementation research supports this model, showing its effectiveness and the need for continued training and integration into school systems.^[5-7] The present survey was done to assess the knowledge, attitude, and practices of oral health in school teachers of Trivandrum, Kerala.

MATERIALS AND METHODS

The study began after acquiring approval from the Institutional Review Board of Noorul Islam Institute of Medical Science and Research Foundation (NIMS/IEC/2023/04/06). This cross-sectional study was conducted for six months from December 2022 to June 2023. The study will include school teachers of various schools in Trivandrum city. Five Government and five private schools will be selected randomly. With permission of the principal of the school, the researchers will meet the teachers at school and explain the dental health questionnaire to them, which will then be distributed and later collected after 30 min. Individuals who participate in the study will be provided with a written informed consent form. A pre-validated questionnaire containing 23 questions will be used to gather information on knowledge, attitudes, and practices regarding oral health. Each person was allowed to give their responses only once. They were given both verbal and written information regarding the purpose of the data being collected.

Sample size was estimated using the formula:

N = Population size (450)

e = Margin of error (absolute precision [D] = 5% [0.05])

p = Percentage value (expected proportion of respondents)-30%

z_ἀ at 95% confidence interval (CI) = 1.96

Final sample = 300 (Minimum required sample)

The final sample necessary for a CI of 95% was found to be 300.

Sample selection was done based on the inclusion criteria; individuals consenting to participate in the study, school teachers of various schools in Trivandrum city, and individuals who are fluent in reading, writing, and understanding English. Those who were unwilling to participate were not included in the study. Data will be entered into Microsoft Excel sheets. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 22.0 (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp) and level of significance was set at P < 0.05. Descriptive statistics was performed to assess the proportion of each category of the respective groups. Inferential statistics was done using the Chi-square test for proportion. RStudio was used for the data visualization.

RESULTS

The present study, among 300 school teachers, to evaluate their knowledge, attitudes, and practices (KAP) concerning oral health has revealed several important findings. Almost all teachers (98.2–100%) were able to pinpoint that oral health was related to general health. However, a small number of government school teachers (3.92%) were still unaware of such a link. A great majority of survey respondents – 81.68% from government educational institutions and 84.02% from those in the private sector – correctly indicated irregular brushing, frequent consumption of sugary foods, and infrequent dental visits as the main causes of dental problems. Equally, 81.6% of all the educators realized that good habits such as avoiding sweets, brushing well, rinsing after meals, and having regular checkups can certainly prevent oral diseases.

Most of the teachers knew that their toothpaste was infused with a fluorine compound. Still, on the other hand, many of them, though, were unsure – 30.5% of government and 23% of private school teachers. The teachers were especially found to have a very limited knowledge about dental floss, as more than half of them were not aware of the good it does (51.2% government, 60.4% private) [Figure 1].

Close

Figure 1:

Comparison of oral hygiene knowledge awareness among government and private school teachers in Kerala.

Export to PPT

A very high proportion (over 98%) concurred that good oral health was a personal responsibility. The majority of them admitted that it was after the pain got unbearable that they finally visited the dentist (93.9% government, 87.6% private), while an equal number (87% government, 89.9% private) recognized that regular dental checkups are vital to the proper care of oral health [Figure 2].

Close

Figure 2:

Comparison of oral hygiene attitudes among government and private school teachers in Kerala.

Export to PPT

Nearly all participants said that they used a toothbrush and toothpaste (98.5% government, 98.2% private), and a majority stated that they brushed twice a day (71% government, 89.4% private). Brushing styles were not the same among the teachers, with many of them using both horizontal and vertical strokes (64.9% government, 79.9% private). However, a very large number of educators revealed that they were not in compliance with this recommendation and that they were not changing toothbrushes every 3 months (57.3% government, 60.4% private). Just a small number (29.8% government, 30.8% private) used the amount of toothpaste that was recommended, which is about a pea size. Moreover, a lot of teachers did not know the right way to put toothpaste on the brush (43.5% government, 36.9% private). Mouth rinsing (94.7% government, 100% private) and tongue cleaning (89.3% government, 93.5% private) were the most common habits and also the most important after meals [Figure 3].

Close

Figure 3:

Comparison of oral hygiene practices among government and private school teachers in Kerala.

Export to PPT

DISCUSSION

The present study, aimed at assessing knowledge, attitude, and practices of oral health in school teachers of Trivandrum, Kerala, revealed several interesting findings that can be correlated with existing literature. Our finding that over 95% of participants recognized the connection between oral health and general health is notably higher than reported in studies from Kuwait and Nepal,^[8,9] contrasting with lower percentages reported by Alshemari and Alkandari^[9] in Kuwait and Singh et al.,^[10] in Nepal. The high proportion of teachers in our study who recognized the preventative role of diet, brushing, rinsing, and checkups also stands out, exceeding findings from studies in Tamil Nadu^[11] and Bhopal,^[12] suggesting a potentially greater understanding of preventive measures among Trivandrum teachers.

However, the study also revealed a significant gap in knowledge regarding dental floss, with over half of the participants unaware of its use and benefits. This aligns with findings from studies in Mumbai^[1] and Davangere^[3] reinforcing the need for targeted interventions to educate teachers about the importance of flossing. Regarding dental visits, the high proportion of teachers in our study who had visited a dentist for treatment contrasts with findings from Karachi, Pakistan.^[13] The primary reason for dental visits in our study was pain, followed by decay and filling, which aligns with findings from Kurnool, Andhra Pradesh^[14] and underscores the trend in developing nations for pain to be the primary motivator for dental visits. This contrasts with studies in Davangere^[3] and Dharamshala,^[15] where caries was the most prevalent reason.

Concerning oral hygiene practices, the near-universal use of toothbrush and toothpaste in our study mirrors findings from Lucknow, UP.^[16] The large proportion of participants brushing twice daily is also consistent with studies in Mumbai and Pondicherry. While our study found that about half of the teachers changed their toothbrush every 3 months, similar to findings in Pondicherry,^[17] this practice differs somewhat from studies in Mumbai^[1] and Puducherry.^[17] The current study is notable as perhaps the first to examine oral health KAP among school teachers in Trivandrum.

The generalisability of this study appears promising, supported by consistent findings from similar studies conducted across multiple Indian states and the presence of a uniform education system nationwide. Central government initiatives such as the NOHP and Ayushman Bharat further provide a standardized framework conducive to scaling such interventions. However, several factors may limit broader applicability. These include regional disparities such as language barriers, poor student-to-teacher ratios, infrastructural gaps, variations in local policies, and differences in teacher workload and motivation. Methodological limitations also exist, including a relatively small sample size, restricted geographical coverage, potential self-reporting bias, and challenges in obtaining permissions from educational institutions. To enhance the robustness and applicability of findings, future research should focus on larger and more diverse samples and include structured educational interventions. Despite these limitations, the study offers meaningful insights – highlighting that while knowledge and attitudes toward oral health among teachers are generally positive, actual practices, particularly in areas such as flossing and regular toothbrush replacement, require significant improvement.

Implementation research under the NOHP of India has shown that school teachers, when equipped with structured training and educational tools, can effectively promote oral health among students. Studies from states such as Tamil Nadu, Kerala, Rajasthan, and Gujarat reported significant improvements in children’s oral hygiene knowledge and habits when teachers conducted regular sessions using interactive materials. “Train-the-Trainer” models proved especially effective in empowering teachers to deliver oral health education, though challenges such as time constraints, limited resources, and lack of follow-up were commonly noted.^[11,18-21]

CONCLUSION

Many teachers already demonstrate strong awareness of oral health, research highlights gaps in their practical implementation, underscoring the need for continuous support, refresher training, and integration into broader school health frameworks. By empowering teachers as role models who reinforce healthy habits through daily routines and practical demonstrations, NOHP can foster sustainable, community-wide improvements in oral health.