Original Research Article Journal of College of Medical Sciences-Nepal, Vol-16, No 1, Jan-Mar 2020

ISSN: 2091-0657 (Print); 2091-0673 (Online) Open Access

DOI: 10.3126/jcmsn.v16i1.22630

Attitude, Behavior and Oral Health among Patients Visiting a Dental

Institution of Nepal
Sirjana Dahal,1 Prakash Poudel,2 Nirma Khadka,1 Sangita Dahal,1 Manita Acharya,1 Supriya
Shrestha,1 Manita Maharjan1
1
Department of Community and Public Health Dentistry, 2Department of Orthodontics and Dentofacial Orthopaedics,
Kathmandu Medical College-Teaching Hospital, Duwakot, Bhaktapur, Nepal.
ABSTRACT
Background: Majority of oral diseases are related to life style, which means that a behavioural change is
needed to reduce the disease. This study was conducted to assess the attitude, behaviour and oral health of
the patients visiting a dental hospital and to determine the association of oral health with age and gender.

Methods: Analytical cross-sectional study was conducted among 130 patients of age 15 years and above
who visited Kathmandu Medical College, Bhaktapur for oral health check-up. Participants were
interviewed for their attitude and behavior regarding oral health. Caries experience and periodontal
conditions were assessed. Chi square test was done to evaluate the association of age and gender with of
attitude, behavior and oral health.

Results: In this study, significantly higher number of females went to visit dentist when they noticed
bleeding gums than males (p=0.023). Tobacco was consumed more by males than females (p<0.001).
Mean DMFT was 3.85±3.035. Bleeding on probing was found in 84 (64.6%); calculus in 24 (18.5%) and
periodontal pocket of ≥4mm in 11.6%. Loss of attachment of 4 mm or more was present in 45 (34.6%)
and was significantly higher in older age group (p<0.001); in males (p=0.001); who were negligent in
visiting dentist (p=0.035); brushed by vertical method (p=0.013) for less than two minutes and more than
five minutes (p=0.015); used toothpicks or no interdental cleaning aids (p=0.009); ignored bleeding gums
(p=<.001) and who used tobacco products (p<0.001).

Conclusions: This study concluded that the attitude towards the oral health was positive among the
patients who visited Kathmandu Medical College, Bhaktapur, Nepal. The oral health behaviour was quite
unsatisfactory and needs to be improved.

Keywords: attitude; behavior; oral health.

INTRODUCTION
American Dental Association defines Oral Health In developing countries like Nepal where there is
as a functional, structural, aesthetic, physiologic inadequate focus on oral health, it is important to
and psychosocial state of well-being and is essential change the individual’s perception and behavior
to an individual’s general health and quality of life.1 towards oral health. Therefore, this study was
Improvement of oral health can be beneficial for conducted to assess the attitude, behavior and oral
overall health status of the patient.2 health of the patients visiting a dental hospital and
association of age and gender with their existing
Oral health is the standard of health of the oral and oral health.
related tissues. It enables individual to eat, speak
and socialize without active disease discomfort or METHODS
embarrassment which contributes to general An analytical cross-sectional study was conducted
well-being. There have been rapid changes in among patients who visited Kathmandu Medical
pattern of oral disease during the past decade.3 Oral College, Dental Hospital, Duwakot, Bhaktapur for
disease can be considered a public health problem oral health check-up. Convenience sampling
due to its high prevalence and significant social technique was used to select 130 patients of fifteen
impact.3 The changing way of living and the pattern years and above from September to December
of oral diseases during past few decades clearly 2018. A protocol was submitted to the institutional
denote that there is effect of lifestyle, attitude and review committee of Kathmandu Medical College
behavior on individual's oral health. Hence, and Teaching Hospital, Kathmandu, Nepal and
behavioural change is needed to reduce the disease.4 ethical clearance was obtained. Participants were

Correspondence: Dr. Sirjana Dahal, Department of Community and Public Health Dentistry, Duwakot,
Bhaktapur, Nepal. Email: sirjanadahal11@gmail.com. Phone: +977-9847279427. Article received: 2019-
02-07. Article accepted: 2020-01-23.
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 Dahal et al. Attitude, Behavior and Oral Health among Patients Visiting a Dental Institution..
informed about the study and assured that their Cohen’s kappa was used for assessing inter
participation was truly voluntary and written examiner reliability. Data were entered in
informed consent was taken. Sample size has been Microsoft Excel Sheet and analysis were done in
calculated using formula, Sample size (n)= z2pq/ Statistical Package of Social Sciences (SPSS)
e2.Where, p= prevalence of condition , q= 1-p, e= version 20. Mean, standard deviation, median,
margin of error taken as 10% (absolute error). range, percentage were calculated for descriptive
Regarding prevalence of condition, data was taken statistics. For inferential statistics, Chi-square test
from a study done in a dental hospital of Nepal was done to see the association of attitude and
(participants brushing twice daily).6 Actual Sample behaviour with oral health.
Size (n) = 3.84*65*35 /(10)2= 87.36. Adding 20%
of non-response, total sample= 104.83 ≈130 (taken). RESULTS
Inclusion criteria Out of 130 respondents, 49 (37.69%) were male
Patients visiting of Kathmandu Medical College and 81(62.31%) were female and their mean age
(≥15 years) for oral health check up and mentally was 35.95±16.23 years (median=28.50 years). The
sound patients. caries experience of the participants (DMFT) was
Exclusion criteria 3.85±3.035 (median=3). Among them, mean
Patients having any developmental disability, frail number of decayed teeth were highest (2.28±2.121)
elderly and patients under any medication affecting than filled (0.91±1.507) and missing teeth
Oral Health. (0.68±1.725). On examination of periodontal
condition using highest Community Periodontal
Participants were interviewed for their attitude and Index scored, majority of the study participants had
behaviour regarding maintenance of oral health. bleeding on probing 91(64.6%) followed by supra
Questions were taken from previously published or sub-gingival calculus 24 (18.5%) and
studies.3,6,7 Pilot study was conducted among 10% periodontal pocket of ≥4mm 15 (11.6%). Loss of
of the sample which was not included in the main attachment of 4 mm or more was present in 45
study and modifications were made in the (34.6%) of the total study population (score 1-4).
questionnaire where responses were not appropriate.
Cronbach’s alpha was used to check the internal Table 1 and 2 shows the attitude and behavior of
consistency of the questionnaire and was good males and females with regard to oral health.
(α=0.82). Mouth mirror, Shepherd’s Hook explorer Significantly higher number of females went to
and WHO probe was used for oral examination. visit dentist when they noticed bleeding on probing
Oral health was examined using DMFT for than males (p=0.023). Tobacco was consumed
assessing caries experience and Community more by males in comparison to females (p<0.001).
Periodontal Index for periodontal conditions. No significant association of age and gender was
Table 1. Attitude of study participants with regard to oral health. n=130
Total no. of Gender
Question Options P value
participants Male (n=49) Female (n=81)
Regular dental visit is Agree 114 (87.69) 42(85.7) 72(88.9)
necessary to prevent Disagree 7 (5.38) 2(4.1) 5(6.2) 0.548a
dental problems Don’t know 9 (6.92) 5(10.2) 4(4.9)
Clean, bright teeth 51 (39.23) 20(40.8) 31(38.3)
Reasons behind brushing Preventing foul smell 28 (21.53) 12(24.5) 16(19.8) 0.673a
Preventing caries, bleeding gums 51 (39.23) 17(34.7) 34(42)
Yes 107 (82.30) 42(85.7) 65(80.2)
Cleaning teeth prevents
No 11 (8.47) 4(8.2) 7(8.6) 0.686b
tooth decay
Don’t know 12 (9.23) 3(6.1) 9(11.1)
Yes 82 (63.07) 28(57.1) 54(66.7)
Oral health is related to
No 22 (16.93) 10(20.4) 12(14.8) 0.572a
systemic health
Don’t know 26 (20) 11(22.4) 15(18.5)
Dental hospital 92 (70.77) 38(77.6) 54(66.7)
Dental care should be Dental clinic 25 (19.23) 8(16.3) 17(21)
0.422b
received from General medical practitioner 2 (1.54) 1(2) 1(1.2)
Others 11 (8.46) 2(4.1) 9(11.1)
Stop brushing 18 (13.84) 12(24.5) 6(7.4)
Measures to be taken in Go to see a dentist 35 (26.92) 8(16.3) 27(33.3)
0.023a
bleeding gums Pay more attention to gums when brushing 33 (25.38) 13(26.5) 20(24.7)
Ignore bleeding 44 (33.84) 16(32.7) 28(34.6)
Don’t care if no pain 44 (33.84) 21(42.9) 23(28.4)
Measures to be taken in
Go to dentist immediately for filling 11 (8.46) 6(12.2) 5(6.2) 0.070a
tooth decay
Take pills for pain relief 75 (57.69) 22(44.9) 53(65.4)
There are harmful effects Yes 49 (37.69) 46(93.9) 3(6.1)
0.742b
of tobacco products No 81 (62.30) 74(91.4) 7(8.6)
a
Chi square test bFisher’s exact test

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 Dahal et al. Attitude, Behavior and Oral Health among Patients Visiting a Dental Institution..
Table 2. Oral health behaviour of study participants. (n=130)
No. of Gender
Question Options p value
participants Male (n=49) Female (n=81)
Only in problem 88 (67.69) 33 (67.3) 55(67.9)
Frequency of visit to dentist Once in six months 18 (13.84) 6(12.2) 12(14.8) 0.857a
Once in a year or more 24 (18.46) 10(20.4) 14(17.3)
Yes 129 (99.23) 48(98) 81(100)
Regular cleaning of teeth 0.377b
No 1 (0.77) 1(2)
Toothbrush and paste 124 (95.38) 48(98) 76(93.8)
Tooth cleaning aids/agents Toothbrush and powder 2 (1.54) 1(2) 1(1.2) 0.395b
Others 4 (3.07) 4(4.9)
Horizontal 43 (33.08) 14(28.6) 29(35.8)
Tooth brushing method Vertical 13 (10) 9(18.4) 4(4.9) 0.060a
Combined 74 (56.92) 26(53.1) 48(59.3)
Less than 2 minutes 23 (17.69) 10(20.4) 13(16)
brushing time 2 minutes 60 (46.15) 23(46.9) 37(45.7) 0.740a
More than 2 minutes 47 (36.15) 16(32.7) 31(38.3)
Dental floss 29 (22.30) 8(16.3) 21(25.9)
Interdental brush 7 (5.38) 2(4.1) 5(6.2)
Additional aids used 0.363b
Tooth pick 28 (21.53) 14(28.6) 14(17.3)
None 66 (50.76) 25(51) 41(50.6)
Oral check up 23 (17.69) 9(18.4) 14(17.3)
Scaling 38 (29.23) 17(34.7) 21(25.9)
Preventive services used in past two years 0.718a
Caries prevention measures 27 (20.77) 9(18.4) 18(22.2)
None 42 (32.30) 14(28.6) 28(34.6)
Once 41 (31.54) 14(28.6) 27(33.3)
Treatment done for gum disease in the Twice 13 (10) 7(14.3) 8(9.9)
0.139b
past year Thrice 3 (2.30) 3(6.1)
None 71 (54.61) 25(51) 46(56.8)
Yes 49 (37.69) 27(55.1) 22(44.9)
Use of tobacco products < 0.001a
No 81 (62.30) 11(13.6) 70(86.4)
a b
Chi square test Fisher’s exact test
seen with Community Periodontal Index (p=0.080 seen significantly higher in participants who were
and 0.080, respectively) and caries experience negligent in visiting dentist (p=0.035); who brushed
(p=0.810 and 0.719, respectively) (Table 3, 4). by vertical (Leonard’s) method (p=0.013); brushed
Table 3. Association of age and gender with Community Periodontal Index. (n=130)
Community Periodontal Index
Characteristics P valuea
0 (Normal) 1 (Bleeding on probing) 2(supra/sub gingival calculus ≥3(Periodontal Pocket ≥4mm)
Age
15-30 6(8.3) 51(70.8) 11(15.3) 4(5.6)
31-45 0 11(52.4) 6(28.6) 4(19.0)
0.08
46-60 0 12(60.0) 5(25.0) 3(15.0)
>60 0 10(58.8) 2(11.8) 5(29.4)
Gender
Male 0 29(59.2) 12(24.5) 8(16.3)
0.08
Female 6(7.4) 55(67.9) 12(14.8) 8(9.9)
a
Likelihood ratio

Table 4. Association of age and gender with caries less than two minutes and more than five minutes
experience. (n=130) (p=0.015); who used toothpicks or no inter dental
Caries experience cleaning aids (p=0.009); who ignored when gums
Characteristics P valuea
DMFT=0 DMFT≥1 were bleeding (p=<.001) and who used tobacco
Age Table 5. Association of age and gender with loss of
15-30 5(6.9) 67(93.1) attachment. (n=130)
31-45 2(9.5) 19(90.5) Loss of attachment
0.81
46-60 1(5.0) 19(95.0) Characteristics Score≥1 (≥ P value
>60 2(11.8) 15(88.2) Score 0 (0-3mm)
4mm)
Gender Age
Male 6(12.2) 43(87.8) 15-30 66(91.7) 6(8.3)
0.176 31-45 13(61.9) 8(4.6)
Female 4(4.9) 77(95.1) <0.001a
a b 46-60 4(20) 16(80)
Fisher’s exact test Chi square
>60 2(11.8) 15(88.2)
However, Loss of attachment was significantly Gender
Male 23(46.9) 26(53.1)
developed in older age group (p<0.001) and in Female 62(76.5) 19(23.5)
0.001b
males (p=0.001) (Table 5). Loss of attachment was a
Fisher’s exact test b
Chi square

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 Dahal et al. Attitude, Behavior and Oral Health among Patients Visiting a Dental Institution..
products (p<0.001). where only 19.6% males and 27% females did so.15
Majority of the participants in this study (92%)
DISCUSSION knew about the harmful effects of the tobacco use
Oral disease is one of the major public health whereas very few (10.9%) had idea about the
problem.8,9 To spread awareness regarding the oral ill-effects in the study conducted in Biratnagar,
health, it is necessary to know about the attitude Nepal.11 Recently, the people of Nepal may have
and behavior of the patient regarding the oral been aware of the harmful effects because of strict
health. Therefore, the present study was designed to laws adopted by Nepal,12 different awareness
assess the attitude, behavior and oral health among programs in social media and the recent change in
the patients visiting Kathmandu Medical College, packaging of tobacco products where harmful
Bhaktapur for oral health check up. effects are displayed.

The attitude and behaviour was similar among The scientific literature provides us an overview
males and females surveyed regarding oral health. regarding impact of oral health knowledge, attitude
Majority 87 (67%) of the participants generally and oral health behavior on oral diseases.2 In this
visited the dentist only in problem even when they study, males showed significantly higher loss of
sensed that it is essential to visit in every six attachment than females was associated with
months for prevention of dental problems. This tobacco consumption similar to other studies done
result is comparable to a study done among patients in a dental hospitals of Kathmandu.13,16 However, a
in Bir Hospital10 and Nursing students of Dhulikhel study showed no difference in gender for
hospital.6 This may be because people of Nepal are periodontal conditions.5 In Nepal, smoking and
not aware that regular oral health check up in every smokeless tobacco production and consumption is
six months is essential even if they do not suffer higher that may be the major cause for
from any symptoms of oral diseases. In the present periodontitis. Loss of attachment was observed
study, majority of the study population (99.2%) more in older age group (p<0.001) similar to study
cleaned their teeth regularly which is slightly higher done in a dental hospital of Nepal.5
than a study done in Biratnagar (98%); much better
than study done among construction workers of Caries experience of the study participants (DMFT)
Manglore.11, 14 In this study 100% females and 98% was 3.85±3.035 (median=3) with more of untreated
males brushed regularly which is much pleasing caries (2.28±2.121) than filled (0.91±1.507). It is
than study done among attendants in South India mainly because they visited dentist only when they
where only 88% of females and 84% males brushed have problems like pain or swelling, rather than
regularly.15 Most of the patients (95%) visiting treating in initial stage before symptoms appear.
Kathmandu Medical College were using toothbrush The caries experience is in accordance to the
and tooth paste for cleaning their teeth which is analysis of epidemiological data done in Nepal.17
better than in a study done in India where 70% of
the participants used tooth brush and tooth paste.4 This study has few limitations. Hospital based
Most of the study participants (55.5%) agreed that study has been conducted which cannot be
oral hygiene maintenance is important because it generalized to overall population of Nepal. The
prevents tooth decay. More than half of them hospital patients may have given answers that tend
(70.8%) visited dental hospitals rather than dental to overestimate their positive practices and
clinics or general medical practitioner. It is underestimate their negative habits. Temporal
disappointing to know that some of them (32%) had relationship in the associated results could not be
never received prevention service in past two years. shown due to cross-sectional nature of the study.
This could be due to decreased awareness of the
dental problems, poor attitude in seeking dental CONCLUSIONS
service, as they are more likely to visit dentist for This study concluded that the attitude towards the
emergency dental care only. oral health was positive among the patients who
visited Kathmandu Medical College, Duwakot,
Additional plaque control aids were used by almost Bhaktapur. The oral health behaviour was quite
half of the study participants including dental floss unsatisfactory and needs to be improved. Repeated
(22.3%) tooth picks (19.5%) which is better than oral health awareness programs including oral
the study conducted in China where 4% used dental health education and motivation in hospitals as well
floss and 36% used tooth picks.7 Most of the as community would help further develop their
subjects (70%) would visit a dentist for bleeding attitude and behaviour.
gums and decayed tooth. More than half of the
male participants (55.1%) and 44.9% of females Conflict of Interest: None
had used tobacco products in their life time either in
smoking or smokeless form which is much higher
than the study done among attendants in India

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 Dahal et al. Attitude, Behavior and Oral Health among Patients Visiting a Dental Institution..
REFERENCES Health. 2006 Jun;34(67_suppl):139-46.
1. American Dental Association House of 10. Bhadra M. The knowledge, attitude and oral
Delegates. ADA Policy: Definition of Oral health behavior of adults attending Bir Hospital
Health. A American Dental Association; 2014 Dental Department. 2003.
(cited in 2018 July 24).Available from https:// 11. Dali M, Laleet R. A Study on Oral Health
www.ada.org/en/about-the-ada/ada-positions- Knowledge, Attitude and Practice among
policies-and-statements/ada-policy-definition-of Population of Siswani Jahada VDC in
-oral-health. Biratnagar City, Nepal-A Questionnaire Survey.
2. Bhattarai R, Khanal S, Rao GN, Shrestha S. Asian Pac J Health Sci. 2014.1:51-6.
Oral health related knowledge, attitude and 12. Ministry of Health and Population. Tobacco
practice among nursing students of Kathmandu Product Control and Regulatory Directive.
–a pilot study. Journal of College of Medical Government of Nepal. 2014 (cited in February
Sciences-Nepal. 2016.12(4):160-8. 1, 2018). Available from https://
3. Scaglia P, Niknamdeh A. Assessment of current www.tobaccocontrollaws.org/files/live/Nepal/
oral health knowledge attitude and oral hygiene Nepal%20%20TP%20Regs%202014.pdf.
practices among 12-year old school children 13. Gupta S, Maharjan A, Dhami B, Amgain P,
and patients attending the dental facility at Vezo Katwal S, Adhikari B, Shukla A. Status of
Hospital in the rural village of Andavadoaka, Tobacco Smoking and Diabetes with
Madagascar. Malmö University. 2017;15:1-24. Periodontal Disease. Journal of the Nepal
4. Kaira LS, Srivastava V, Giri P, Chopra D. Oral Medical Association. 2018 Sep 1;56(213).
Health-Related Knowledge, Attitude and 14. Bipina P, Kadam M, Mohammed N, Jain A.
Practice among Nursing Students of Rohilkhand Awareness and Asssessment of Oral Hygeine
Medical College and Hospital. J Orofac Res. and Periodontal Status among the Construction
2012 Jan 25;2(1):20-3. Workers in Aj Hospital Campus, Mangalore.
5. Rajkarnikar J, Acharya J. Prevalence and International Journal of Current Research and
severity of periodontal diseases among Review. 2015 May 1;7(9):36.
Nepalese adults-a hospital based study. Journal 15. Warad L, Pulayath CV, Baby M, Ismail SP.
of College of Medical Sciences-Nepal. 2014;10 Assessment of Oral Health Knowledge, Dental
(1):11-6. 7. Caries and Periodontal Status among
6. Humagain M, Tamrakar M. Oral health related Attendants of Degree Colleges in South India.
knowledge, attitude and practice among nursing Int J Oral Care Res. 2018;6(1):24-29.
students of Dhulikhel hospital: A study. J Nepal 16. Pradhan S, Bhat MK. Assessment of
Dent Assoc. 2010:11(2):117-12. periodontal status of rural nepalese population
7. Zhu L, Petersen PE, Wang HY, Bian JY, Zhang using the community periodontal index. J Nepal
BX. Oral health knowledge, attitudes and Dent Assoc. 2009;10:97-104.
behavior of adults in China. Int Dent J. 2005 17. Van Palenstein Helderman W, Groeneveld A,
Aug;55(4):231-41. Truin GJ, Shrestha BK, Bajracharya M,
8. Dumitrescu AL. Periodontal Disease–A Public Stringer R. Analysis of epidemiological data on
Health Problem. Frontiers in public health. oral diseases in Nepal and the need for a
2016 Jan 8;3:278. nationa oral health survey. International dental
9. Ekman A. Chapter 5.10: major public health journal. 1998 Feb;48(1):56-61.
problems—dental health. Scand J Public
Citation: Dahal S, Poudel P, Khadka N, Dahal S, Acharya M, Shrestha S, Maharjan M. Attitude, Behavior
and Oral Health among Patients Visiting a Dental Institution of Nepal. JCMS Nepal. 2020; 16(1):44-8.

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