Keywords
oral hygiene practice - brushing - flossing - health belief model - 18 years old -
adolescence - Norway
Introduction
Positive oral health behaviors could be understood as behaviors related to removing
dental plaque (oral hygiene, brushing/flossing), using fluoride toothpaste, adhering
to a low cariogenic diet, and regular attendance to dental service.[1]
[2] It is therefore recommended twice-a-day tooth brushing and daily interdental flossing.[3]
Adolescence (including 18 years old) is an important life period to promote favorable
oral health perceptions and behaviors. As there seems to be some stability in health
behaviors between adolescence and adulthood, which reflects lifestyles that are influenced
by both life choices and life chances,[4] it is recommended to establish favorable oral hygiene habits at this age.[5]
It is generally difficult to adopt or change certain behaviors, and there is often
discrepancy between behavior and intention.[6] By assessing young peoples’ beliefs and perceptions toward oral health, we could
possibly gain more knowledge and understanding of their oral health behavior. The
Health Belief Model (HBM) was one of the first attempts to view health within the
social context. It is a belief-based model and has been used to study a variety of
health behaviors, including oral hygiene practices.[7]
[8]
[9]
The HBM in the context of oral health suggests that a person would be more likely
to comply with recommended oral hygiene behaviors (brushing/flossing) if the person
believes that he/she is susceptible to oral diseases, that is, dental caries (perceived
susceptibility) and that dental caries has serious consequences, that is, loss of
teeth (perceived severity). A person who perceives lack of time, knowledge, or pain
to practice oral hygiene is considered as having perceived barriers to the behavior,
while if perceives that having good health as having perceived benefits from behavior.
The conviction that a person can successfully fulfill the behavior (self-efficacy).[7]
[10]
Materials and Methods
The aggregated data of municipalities in Hordaland county showed that the municipalities
that form the south district had a higher dental caries prevalence compared with the
rest of the county and Norway as well. Oral hygiene is an important factor in dental
caries experience. This study is a part of the project including other age groups
(5 primary, 12 mixed, and 18 permanent dentition age groups). The 18 years old is
a special age group in Norway as it is the starting age of payed dental public service.
Therefore, the objective of this study was to assess any differences in oral hygiene
practices (brushing/flossing) between 18 years old in the south district and the rest
of Hordaland county, and possible explanatory cognitive factors using the (HBM).
The study included 12 municipalities, with all the six municipalities from the south
district with high prevalence of dental caries as the exposure, and six municipalities
from other districts of Hordaland county with low prevalence of dental caries (control),
using a purposive sampling method based on the criteria of having the same number
of 18 years old, and with lower prevalence of dental caries experience measured as
dental caries experience (DMFT) obtained from reports of the Public Dental Health
Service (PDHS), group data). The 18 years old were contacted through a text message
to their private cellular phone for their acceptability and consenting. We used social
security numbers obtained from the participants in the questionnaire to access their
individual clinical records in (OPUS) medical record system for private and public
dental clinics used in Norway in PDHS to collect information regarding individual
dental caries experience (DMFT) and dental service utilization after written consent
(in the questionnaire from each participant). A total of 613 agreed to participate,
and 416 respondents completed the questionnaire, who were included in the analyses,
giving a response rate of 37.5%. Of these, 350 gave consent to access information
in their dental records. We obtained the approval for the study from the Norwegian
Centre for Research Data. Informed consent was obtained from all participants; the
confidentiality and safety of the information were secured in accordance with ethical
and legal principles.
Measures
The questionnaire included sociodemographic variables such as gender, country of origin,
municipality, parents’ education, and employment.
Oral Hygiene Practices and Perceived Oral Health
We asked two questions to assess brushing/flossing, “how often did you brush/floss
your teeth during the last week?.” Options were “not at all, once a week, every other
day, once a day, and twice a day.” We measured self-administered fluoride by asking,
“how frequent have you used fluoride rinse and/or tablets?” The use of the dental
service assessed by asking, “how often have you visited a dentist over the past 5
years?.” Perceived good oral health by one statement: “I have good oral health.” One
item measured fear/phobia related to dentist and syringe/needle.
The Health Believe Model Constructs
Perceived severity of dental caries by using four items: “if I were to get dental
caries, it would be very serious; if I were to get dental caries, it would hurt a
lot; if I were to get dental caries, I would lose my teeth; and if I were to get dental
caries, it would affect how I would feel in my daily life.” Perceived susceptibility
for dental caries by analyzing the statements: “it is likely that I will get dental
caries” and “within next year I will likely get dental caries.” Perceived benefits
from oral hygiene practices by using statements for each practice: “brushing at least
twice a day would prevent dental caries, my mouth feels better after I have brushed,
flossing once a day prevents dental caries, and my mouth feels better after flossing.”
Perceived barriers to oral hygiene practices by using items, respectively: “it hurts
when I brush my teeth, my gums bleed when I brush my teeth, I forget to brush my teeth
twice a day, I do not like the taste of toothpaste, it hurts when I floss, and my
gum bleeds when I floss my teeth.” Self-identity toward oral health assessed through
items: my teeth are an important part of who I am, I think of myself as a person who
takes care of my teeth, it is important for me to have good dental health, and it
is important for me to avoid cavities in my teeth” All items used a 5-point Likert’s
scale ranging from “strongly disagree to strongly agree.” Regarding internal consistency
of the scales measuring the constructs of the HBM and self-identity toward oral health,
the Cronbach Alpha’s scores were as follows for self-identity toward oral health (0.83),
perceived susceptibility to dental caries (0.88), and perceived severity of dental
caries (0.70). For perceived benefit from flossing and brushing, the scores were 0.57
and 0.59, respectively, and for perceived barriers, for flossing and brushing were
0.61 and 0.60, respectively.
Data Management and Analyses
We used Statistical Package of Social Sciences (SPSS) version 24 for data entry, management,
and analyses. Nonparametric (the Mann–Whitney U) tests was used as an alternative
to the t-test for independent samples, assessing the mean difference of the total scores of
the HBM constructs. We performed bivariate, correlation, and logistic regression analyses
to examine associations between oral hygiene behaviors, personal characteristics,
and the HBM constructs.
Results
Of the 416 respondents, 201 (48.3%) were from the south district. As presented in
([Fig. 1]) in the total sample, there were more girls than boys 262 (63%). The large majority
were born in Norway 389 (93.5%). About one-third reported that their mother or father
had higher education. The control group had more girls, mothers, and fathers with
high education compared with the south district.
Fig. 1 Percentage distribution of sociodemographic variables by the two groups.
The only significant difference between the two groups concerning oral hygiene behaviors
was in visiting the dentist at least once a year during the last 5 years (79.1 vs.
89.8%, odds ratio: 2.3, 95% confidence interval: 1.3–4.0). In addition, participants
from control group scored higher in toothbrushing, dental flossing, fluoride use,
and perceiving good oral health ([Table 1]).
Table 1
Percentages and frequency distribution of oral health behaviors by the two groups
|
Oral hygiene behavior
|
South district % (n)
|
Control municipalities % (n)
|
OR (95% CI)
|
|
Abbreviations: CI, confidence interval; OR, odds ratio.
a
p < 0.05
b
p < 0.01
c
p < 0.00
|
|
Tooth brushing
|
|
Twice a day
|
65.2 (131)
|
68.4 (147)
|
1.2 (0.8–1.7)
|
|
Dental flossing
|
|
At least once a day
|
11.4 (23)
|
16.7 (36)
|
1.6 (0.9–1.7)
|
|
Fluoride use the past 5 years
|
|
Yes
|
78.1 (157)
|
81.4 (175)
|
1.2 (0.8–1.9)
|
|
Afraid of the dentist
|
|
Yes
|
24.9 (50)
|
21.5 (46)
|
0.8 (0.52–1.3)
|
|
Afraid of syringe needles
|
|
Yes
|
37.8 (76)
|
35.8 (77)
|
0.9 (0.6–1.4)
|
|
Dental visits past 5 years
|
|
At least once a year
|
79.1 (159)
|
89.8 (193)b
|
2.3 (1.3–4.0)
|
|
Perceived oral health
|
|
Good
|
72.5 (145)
|
73.5 (158)
|
1.1 (0.68–1.6)
|
Regarding the self-identity and HBM constructs, there was a significant difference
between the two groups as the participants from the south district scored higher in
perceived susceptibility to dental caries, perceived lower benefits from oral hygiene
practices, and from flossing compared with the controls. Other nonsignificant differences
were also observed as participants from control municipalities perceived more severity
of dental caries, benefit from brushing, less barriers toward oral hygiene, brushing
and flossing, and higher oral health self-identity (
[Table 2]).
Table 2
Mean score differences of Health Belief Model constructs between the two groups
|
Variables
|
Mean (SD)
|
Difference (SE)
|
95% CI
|
|
South district
|
Control municipalities
|
|
Abbreviations: CI, confidence interval; OH, oral hygiene; SD, standard deviation;
SE, standard error.
a
p < 0.05
b
p < 0.01
c
p < 0.00
|
|
Severity
|
10.7 (0.2)
|
11.0 (0.2)
|
−0.27 (0.3)
|
−0.9 to 0.4
|
|
Susceptibility
|
6.0 (0.2)
|
5.5 (0.2)
|
0.55 (0.2)a
|
0.1 to 0.9
|
|
Benefit brushing
|
9.1 (0.1)
|
9.3 (0.1)
|
−0.24 (0.1)
|
−0.5 to 0.0
|
|
Benefit flossing
|
7.4 (0.1)
|
7.9 (0.1)
|
−0.47 (0.2)b
|
−0.8 to −0.2
|
|
Benefits OH
|
16.5 (0.2)
|
17.2 (0.2)
|
−0.72 (0.3)b
|
−1.2 to −0.2
|
|
Barriers OH
|
13.6 (0.3)
|
13.3 (0.3)
|
0.31 (0.5)
|
−0.6 to 1.2
|
|
Barriers brushing
|
8.2 (0.2)
|
7.8 (0.2)
|
0.37 (0.3)
|
−0.3 to 0.9
|
|
Barriers flossing
|
5.4 (0.2)
|
5.5 (0.2)
|
−0.06 (0.2)
|
−0.5 to 0.4
|
|
Self-efficacy
|
17.1 (0.2)
|
17.4 (0.2)
|
−0.34 (0.3)
|
−0.9 to 0.2
|
Brushing twice a day was significantly related to perceiving high susceptibility,
high benefits from brushing and oral hygiene, less barriers to oral hygiene and brushing,
beside high self-identity. Those who reported brushing less than twice a day perceived
more susceptible to dental caries, lesser benefiting from brushing, and oral hygiene
practices. They also perceived more barriers toward oral hygiene, and brushing, and
reported lesser self-identity toward oral health than those reporting brushing at
least twice a day.
Flossing was significantly related to susceptibility, benefits flossing and oral hygiene,
barriers oral hygiene and flossing, and self-identity. Those who reported flossing
less than once a day felt more susceptible to dental caries, perceived lesser benefits
from flossing and oral hygiene practices, perceived more barriers toward oral hygiene
practices and flossing, and perceived lesser self-identity to oral health ([Table 3]).
Table 3
Mean score differences of Health Belief Model constructs by brushing
|
HBM construct
|
Mean (SD) <2 times ≥2 times
|
Difference (SE)
|
95% CI
|
|
Abbreviations: CI, confidence interval; HBM, health belief model; OH, oral hygiene;
SD, standard deviation; SE, standard error.
a
p < 0.05
b
p < 0.01
c
p < 0.00
|
|
Brushing
|
|
Severity
|
10.5 (0.3)/11.1 (3.4)
|
−0.57 (0.4)
|
−1.3 0.14
|
|
Susceptibility
|
6.4 (0.2)/5.4 (2.2)
|
0.9 (0.2) ***
|
0.47 1.39
|
|
Benefit brushing
|
8.6 (0.1)/9.4 (1.2)
|
−0.8 (0.1) ***
|
−1.09 −0.52
|
|
Benefit OH
|
15.9 (0.3)/17.3 (2.3)
|
−1.5 (0.3) ***
|
−2.03 −0.95
|
|
Barriers OH
|
15.9 (0.3)/12.2 (4.2)
|
3.6 (0.5) ***
|
2.74 4.52
|
|
Barriers brushing
|
10.2 (0.3)/l6.9 (2.8)
|
3.3 (0.3) ***
|
−2.03 −0.95
|
|
Self-efficacy
|
16.0 (0.3)/17.8 (2.5)
|
−1.8 (0.3) ***
|
−2.37 −1.27
|
|
Flossing
|
|
Severity
|
10.7 (0.2)/11.7 (0.5)
|
−0.9 (0.5)
|
−1.86 0.03
|
|
Susceptibility
|
5.8 (0.1)/5.0 (0.3)
|
0.8 (0.3) *
|
0.18 1.42
|
|
Benefit flossing
|
7.4 (0.1)/9.0 (0.2)
|
−1.6 (0.3) ***
|
−2.05 −1.09
|
|
Benefit hygiene
|
16.6 (0.1)/18.5 (0.3)
|
−1.9 (0.4) ***
|
−2.65 −1.18
|
|
Benefit O Hygiene
|
13.9 (0.2)/10.3 (0.5)
|
3.6 (0.6) ***
|
2.39 4.87
|
|
Barriers O Hygiene
|
5.7 (0.1)/4.1 (0.3)
|
1.6 (0.3) ***
|
0.99 2.21
|
|
Self-efficacy
|
17.1 (0.1)/17.9 (0.4)
|
−0.8 (0.4)
|
−1.56 −0.01
|
Hierarchical logistic regression brushing practices: the results indicated that the
control variable gender in the first step, explained almost 10% of the variability
in brushing behavior (Nagelkerke R-Square = 0.097). In the second step, inclusion
of the predictor variables (visiting dentist and perceived oral health) explained
18.7% of the variability in brushing behavior (Nagelkerke R-Square = 0.187). In the
third step, inclusion of HBM constructs (perceived severity of dental caries, susceptibility
to dental caries, barriers and benefits of brushing, and self-identity oral health)
increased the explained variability in brushing behavior to 42% (Nagelkerke R-Square
= 0.42). The girls were almost three times likely to brush twice a day compared to
the boys, three HBM constructs predicted brushing twice a day. Participants who perceived
higher severity to dental caries were almost twice likely to brush twice a day (p = 0.020). Those who scored higher self-identity were more than twice likely to brush
twice a day (p = 0.006). Those who perceived high barriers to brushing had decreased odds of brushing
twice or more daily (p = 0.000; [Table 4]).
Table 4
Brushing and flossing regressed by gender and Health Belief Model constructs
|
Variable
|
B
|
p-Value
|
OR
|
95% CI
|
|
Abbreviations: CI, confidence interval; OR, odds ratio.
|
|
Brushing
|
|
Constant
|
0.8
|
0.125
|
2.14
|
|
|
Gender
|
|
Female
|
|
|
1
|
|
|
Male
|
−1.1
|
0.000
|
0.34
|
0.20–0.58
|
|
Perceived severity of dental caries
|
|
Low
|
|
|
1
|
|
|
High
|
0.6
|
0.020
|
1.86
|
1.10–3.13
|
|
Perceived susceptibility of dental caries
|
|
Low
|
|
|
1
|
|
|
High
|
−0.3
|
0.29
|
0.73
|
0.41–1.31
|
|
Perceived self-efficacy oral health
|
|
Low
|
|
|
1
|
|
|
High
|
0.8
|
0.006
|
2.14
|
1.24–3.68
|
|
Perceived benefit from brushing
|
|
Low
|
|
|
1
|
|
|
High
|
0.5
|
0.064
|
1.64
|
0.97–2.77
|
|
Perceived barriers to brushing
|
|
Low
|
|
|
1
|
|
|
High
|
−1.9
|
0.000
|
0.14
|
0.83–0.25
|
|
Flossing
|
|
Constant
|
−3.1
|
0.000
|
0.043
|
|
|
Gender
|
|
Female
|
|
|
1
|
|
|
Male
|
−1.1
|
0.007
|
0.34
|
0.18–0.75
|
|
Perceived severity of dental caries
|
|
Low
|
|
|
1
|
|
|
High
|
0.9
|
0.011
|
2.34
|
1.22–4.49
|
|
Perceived susceptibility of dental caries
|
|
Low
|
|
|
1
|
|
|
High
|
0.1
|
0.74
|
1.11
|
0.59–2.11
|
|
Perceived self-efficacy oral health
|
|
Low
|
|
|
1
|
|
|
High
|
−0.0
|
0.97
|
1.001
|
0.50–2.02
|
|
Perceived benefit from flossing
|
|
Low
|
|
|
1
|
|
|
High
|
1.01
|
0.006
|
2.8
|
1.33–5.75
|
|
Perceived barriers to flossing
|
|
Low
|
|
|
1
|
|
|
High
|
−1.5
|
0.000
|
0.23
|
0.12–0.44
|
Hierarchical logistic regression on flossing practice([Table 4]) demonstrated that in the first step (gender) explained between 6% of the variability
in flossing practices (Nagelkerke R-Square = 0.06). Adding behavioral variables in
the second step (visiting dentist and perceived oral health) explained between 10%
of the variability in flossing practices (Nagelkerke R-Square = 0.1). In step three,
the inclusion of the HBM variables (perceived severity of dental caries, susceptibility
to dental caries, barriers and benefits of flossing, and self-identity oral health)
increased the explained variability in flossing practices to between 25% (Nagelkerke
R-Square = 0.25). Gender, perceived severity, benefits from, and barriers to flossing
were the strongest predictors. Girls were almost three times likely to floss at least
once a day (p = 0.007) compared with boys. Participants with higher perception of severity of dental
caries had more than twice likelihood to floss at least once a day (p = 0.011), and those with perceived benefits from flossing had three times likelihood
to floss at least once a day (p = 0.006), and those perceived less barriers to flossing had lesser odds to floss
at least once a day (p = 0.000).
Discussion
The aim of this study was to assess and compare any differences in the oral hygiene
behaviors (brushing and flossing) between the two groups and possible correlates using
HBM.
In regard to personal characteristics, there was a slight difference between the two
groups. There were higher percentages of girls and parents with high education among
control participants. Of the total study sample, 66.8% reported brushing at least
twice a day. This is clearly less than what was reported by World Health Organization
(WHO) earlier among Norwegian girls (84%) and boys (65%), and Swedish girls (86%)
and boys (78%). In Denmark, 86% of the girls and 76% of the boys with a significant
difference between girls and boys.[11] The findings do not differ much between the Norwegian and other Nordic samples.
However, a lower proportion among the participants could indicate that late adolescence
time, a period with parent detachment where young people are increasingly becoming
more independent from their parents. This period seems thus critical to promote brushing
practice, which is essential in oral health care.[12]
[13] There was a slight difference with a higher percentage among control participants
reporting brushing twice or more per day.
In regard to flossing practice, our finding—which is 14.2% of the total study sample
reported flossing at least once a day—is slightly lower compared with the study of
Norwegian adults in 2004,[14] where 16% of their sample of Norwegian adults reported daily flossing. Among 14-year-old
Norwegian, half of the teenagers (54%) used dental floss and only 15% reported doing
so daily.[15] There was also a slight difference with a higher percentage among control participants
reporting flossing at least once a day.
These findings suggest that flossing practices compared with the recommendations seem
to be less common than brushing practices among this sample of 18-year-old participants.
Various studies, as in our study, favored girls in relation to good oral hygiene practices.[16]
[17]
[18] The fact that adolescent females tend to have better oral hygiene practices (brushing)
is in accordance the data from several countries gathered by the WHO.[19] These differences might be due to that females have higher health consciousness
and are more inclined to visiting health professionals.[20] Another reason could be that females were found to possess better knowledge and
oral health behavior-related self-efficacy.[21] Males have also been found to report more difficulties in performing oral hygiene
behaviors, while females were reported to have more in control.[22]
The only significant difference between the two groups was visiting the dental service
in the last 5 years. Participants from control group visited more frequently. Studies
supported the importance of regularly visiting the dental health service and oral
health status.[23] Some studies related self-efficacy and visiting dental service. Luzzi and Spencer
reported self-efficacy and past dental attendance were significant predictors of actual
dental attendance.[24] Both higher brushing self-efficacy and dental visiting self-efficacy were found
to be related to better brushing practices.[25]
[26] It could be an indication for the importance of dentists and dental hygienists as
professionals to provide health education and promotion of positive oral health behaviors.[26]
[27]
[28]
Relevant models from health psychology, such as HBM, seems promising to identify key
beliefs to strengthen the favorable perceptions, reducing the barriers, affecting
their attitudes, and increasing knowledge to form long-term and tailored oral health
promoting and disease preventive measurements.[29] HBM has been supported by many studies as a suitable model for predicting health
behaviors, in addition to being used in health education programs concerned with enhancing
and promoting oral health behavior.[30]
[31]
[32]
[33]
In terms of the HBM constructs, there were perceptional differences between the two
groups as participants from control perceived more susceptibility, benefits from oral
hygiene, and flossing. They also perceived higher self-efficacy, lesser barriers toward
oral hygiene, and brushing. After controlling for gender, self-efficacy toward oral
health, perceived severity of dental caries, and perceived barriers to brushing significantly
predicted brushing practice. Whereas perceived severity, barriers to, and benefits
from flossing were strong predictors of flossing practices. These factors predicted
brushing and flossing practices, respectively.
Self-efficacy toward oral health significantly predicted brushing practices in the
present study, which is in accordance with the literature. Various studies have reported
self-efficacy as the most significant factor related to oral hygiene practice. In
a study among first-year medical students, having better self-efficacy toward oral
health related with better oral health behavior.[22] A study among pregnant women as well as among children’s guardians found self-efficacy
as the only factor related to oral hygiene practice.[34]
[35] In a study among first-year medical students, having better self-efficacy toward
oral health related with better oral health behavior[24]. Increasing oral health self-efficacy should be considered as an important factor
in maintaining and promoting better oral hygiene practice. In our findings, participants
from control group had higher perceived severity than those from the south district,
in addition to its significant relation with predicting both oral hygiene practices
(brushing/flossing). The strength of perceived severity as a predictor for brushing
practices is also supported by many studies that found perceived severity significantly
predicted tooth brushing frequency. Kasmaei et al found that perceived severity plays
an important role in adapting a desirable health behavior among young adolescents,
Anagnostopoulos et al reported that perceived severity of oral diseases was related
to increased toothbrushing frequency, and Solhi et al observed the correlation between
the performance of brushing/flossing and perceived severity.[8]
[29]
[36] Increased knowledge and perceiving oral health-related problems as more severe have
been found to associate with perceiving more benefits from oral health behaviors and
less barriers to brushing.
Our results showed a significant difference in perceived benefits between the two
groups with control participants scoring higher. Perceived benefits were also significantly
related to flossing. Many studies in the literature have reported this significant
relation. Solhi et al, Charkazi et al, and Schluter et al reported a correlation between
the performance of brushing/flossing and benefits.[29]
[37]
[38] It was observed that the control participants perceived less barriers to oral hygiene
practice compared with participants from the south district. Perceived barriers were
also found as significant predictors of brushing and flossing. Studies that had used
the framework of the HBM have in general found support for perceived barriers to be
the only predictor of oral hygiene practices. For instance, among Iranian students,
perceived barriers were the only core construct that explained the oral health behavior,[39] and similarly in another study, perceived barriers were the only core construct
of the HBM that explained both flossing and brushing behaviors among Australian dental
patients.[18] Another study among Iranian female students grade four, partially supported that
perceived barriers (perceived psychological barriers) predicted oral hygiene practices.[8] Many studies reported barriers as predictors to oral hygiene practice.[40]
[41]
[42] These findings suggest that knowledge and fear appeal could possibly be used to
increase the perception of severity from oral diseases, to increase the perception
of the benefits and reduce strength of the perceived barriers. In relation to oral
health, the exact nature of the relationship between perceptions and behaviors is
complex.
Conclusion
The findings showed that the perceptional differences between the two groups might
explain the difference in oral hygiene practice (brushing/flossing). Adjusted analysis
demonstrated that self-efficacy toward oral health, perceived severity of dental caries,
and perceived barriers to brushing significantly predicted brushing practice, whereas
perceived severity, barriers to and benefits from flossing, predicted flossing. It
is therefore important that these factors are assessed in the targeted population
when planning public health campaigns. This is possibly even more important for late
adolescence. These factors might be used as driving elements in maintaining and promoting
the oral hygiene practice. The results might be used in designing health prevention
and promotion strategies to maintain better oral health for the adolescents in the
south district.
The understanding of oral health-related perceptions and self-efficacy toward oral
health, and the cognitive and psychological processes behind informed personal decisions
to adopt oral health-related behavior are important parts in the planning of interventions
and measurements directed at oral disease prevention and oral health promotion.[43] Instability in oral health perceptions from adolescence to young adulthood was related
with no recommended oral health behavior, poorer self-rated oral health, and poorer
oral health status.[44]
Limitations
All the results must be cautiously interpreted as this is an observational study with
its known limitations. One weakness to be mentioned is the DMFT data that was extracted
from the participant´s records (secondary data), which lacks standardization and calibration
of the dentists and dental hygienists that have made the registrations. Another limitation
might be self-reported information about the behaviors and HBM model constructs (information
bias). This might have had social-desirability bias and recall bias. The selection
bias is also to be considered as those who did not participate might have had different
characteristics and opinions from the actual participants. The small sample size might
have affected the level of precision and the generalizability of the study.
