Oral Health Literacy and Patient Education Practices Among Non-Dental Professionals in Chongqing, China: A Cross-Sectional Study

Introduction

Dental caries and periodontal lesions are the most prevalent oral diseases worldwide. Carious lesions can affect patients’ masticatory and speech functions and compromise patient quality of life [1]. Periodontal conditions are associated with various systemic diseases, including cardiovascular disease, liver diseases, diabetes, and rheumatoid arthritis, and pregnancy outcomes [2]. The World Health Organization (WHO) has indicated various oral conditions as significant public health issues, including dental caries, periodontal disease, oro-dental trauma, and oral cancer. Approximately 3.5 billion individuals worldwide experience pain, discomfort, and lack of function because of oral diseases [3].

The fourth National Oral Health Epidemiological Survey reported that most Chinese residents have oral diseases. The estimated prevalence rates of dental caries were 50.8%, 63.6%, 71.9%, 38.5%, 41.2%, 43.3%, 44.4%, and 98.0% in individuals who were 3, 4, 5, 12, 13, 14, 15, and 65–74 years old, respectively. Healthy periodontium was reported in only 9.1%, 5.0%, and 9.3% of residents aged 35–44, 55–64, and 65–74 years old, respectively [4]. Therefore, strategies to improve oral health in China are critical.

As a part of comprehensive general healthcare, the maintenance of oral health is critical. Healthcare professionals and other social forces in addition to dental professionals have a vital role in promoting oral healthcare and improvement to patients [5,6]. Non-dental professionals (NDPs) provide general healthcare and interact with many patients, including the elderly, children, and pregnant women. Therefore, NDPs need to have basic oral health knowledge to educate patients about oral healthcare. In some cases, NDPs frequently collaborate with dental professionals to diagnose conditions in patients and provide necessary referrals for treatment. With the wide application of the multidisciplinary cooperative medical model, a rich collaboration between NDPs and dental professionals is necessary to ensure the effective management of patients’ oral health and reduce the risk of future disease [7,8].

In this study, we aimed to assess the oral healthcare ability, awareness, and behavior of NDPs in Chongqing, China, and provide information for disseminating oral health education, improving the oral health communication abilities of NDPs, promoting inter-disciplinary collaboration, and improving oral health and general health of individuals of all ages.

Material and Methods

STUDY DESIGN AND PARTICIPANTS:

This cross-sectional study was conducted after ethics approval was obtained from the institutional research ethics committee (ref No: CQHS-REC-2019 [LSNo.67]). We focused on grade III-grade A general hospitals, as these are general hospitals that have the characteristics of multidisciplinary collaboration and serve the maximum number of patients across various regions.. From September 2022 to December 2022, three hospitals were randomly selected from 13 grade III-grade A general hospitals in the main districts of Chongqing, China. NDPs, including non-dental doctors and nurses from various departments other than dentistry, were invited to complete a self-administered questionnaire.

After considerable discussion with dental public health experts, we edited the questionnaire contents using a free professional survey e-platform “Sojump” (http://www.sojump.com). A quick response (QR) code was generated to facilitate convenient access to the final version of the questionnaire. The participants voluntarily accessed the questionnaires by scanning the QR code and completed the questionnaires anonymously. Each participant was permitted to complete the questionnaire once and submitted the questionnaire immediately after completion. A total of 406 participants completed the survey.

Prior to the formal survey, 20 representative NDPs were randomly sampled to complete the survey, and the results were analyzed to obtain statistical validity. A Cronbach’s alpha of 0.764 suggested a reliable internal consistency. The questionnaire included 3 sections. The first section asked for demographic information, such as sex, occupation, education background, positional title, and working years. The second section targeted oral health knowledge, including 11 questions on basic oral health knowledge, 13 on oral health knowledge about pregnant women or children, and 3 on acquiring oral health knowledge. The final section included 5 questions to assess respondents’ behaviors and attitudes toward spreading knowledge on oral health.

STATISTICAL ANALYSIS:

Data were statistically analyzed using SPSS software (version 21.0, IBM Corp, Armonk, NY, USA). Frequencies were calculated for categorical variables, and the chi-square test was used to compare frequencies of categorical variables between groups. A P value <0.05 was considered statistically significant.

Results

PARTICIPANTS:

Of the 406 NDPs, 40.89% were doctors and 59.11% were nurses; 68.47% were women and 31.53% were men. In terms of education, 81.77% of the participants had a bachelor’s degree or above. Regarding work experience, 124 (30.54%) had worked for 5 years or less, 96 (23.65%) had worked for 6 to 10 years, and 186 (45.81%) had worked for 11 years or longer; 20.2% had a senior title. There were statistically significant differences between the doctors and nurses in terms of sex, educational background, positional title, and working years (P<0.05; Table 1).

BASIC ORAL HEALTH KNOWLEDGE:

All participants agreed on the importance of oral health; 99.01% of participants knew that oral health affected general health, 91.13% knew the importance of regular oral health check-ups, and 88.67% were aware that smoking was a risk factor for oral cancer. Additionally, 85.71% of participants agreed that periodontal inflammation would affect the treatment of diabetes, 35.96% disagreed that “extraction can cause loosening of the adjacent tooth”, and 39.41% disagreed that “tooth loss is a natural part of aging” (Table 2).

Only 7.39% of participants answered all questions about basic oral health knowledge correctly. We observed significant differences in the correct answer rate among participants with different occupations, educational background, positional title, and working years (P<0.05). The correct answer rate was higher in the doctor’s group and in groups with a doctor degree, middle title, and 11 to 20 years of working. No significant difference was observed in terms of sex (P>0.05; Table 3).

ORAL HEALTH KNOWLEDGE REGARDING PREGNANCY AND CHILDCARE:

The rates of awareness of oral health knowledge about pregnancy and children ranged from 56.16% to 96.55%. Approximately 67.48% of participants thought that it was necessary to clean the gums before children’s teeth erupt, while 22.66% disagreed with the need for professional dental cleaning before pregnancy. Furthermore, 26.60% and 15.27% did not know the hazards of long-term lying down while drinking milk and of mouth breathing, respectively. Approximately 11.33% thought that decayed deciduous teeth did not need operative treatment. Moreover, 56.16% knew the relatively safe period of tooth treatment during pregnancy, and 57.14% thought that children’s teeth should be cleaned from the first tooth eruption (Table 4).

ACQUISITION OF ORAL HEALTH KNOWLEDGE:

Approximately 73.40% of participants were interested in oral health knowledge. Their access to oral health knowledge was mainly from the internet and dental professionals (59.11% and 58.62%, respectively). Most participants (75.86%) preferred to consult dental professionals to obtain oral health knowledge, followed by oral health training (64.53%) and internet information (44.83%) (Table 5).

BEHAVIORS AND ATTITUDES OF SPREADING KNOWLEDGE ON ORAL HEALTH:

Most participants (95.56%) agreed on intersectoral collaborations for oral healthcare. Approximately 27.09% often administered oral health education and guidance to patients, while 25.12% never provided this information. Approximately 44.33% of participants reported that their departments had oral health promotion measures. The main factors that hindered the participants from spreading oral health knowledge were a lack of knowledge (85.22%) and a busy work schedule (78.82%). Approximately 28.57% of the participants indicated that oral health education and guidance did not matter to them. When asked, “Will they carry out oral health education for patients in the future work?” 68.47% of the respondents replied positively (Table 6).

Discussion

The present study investigated the knowledge, awareness, and behavior of NDPs about oral healthcare and the ability of NPDs to implement oral health education and promote participation in oral healthcare. For this purpose, a web-based survey that focused on oral health knowledge, access, behaviors, and attitudes toward spreading oral healthcare was administered electronically to NDPs.

Oral health is an important part of overall health. Having good oral health nowadays is not only aimed at tooth health, it is a starting point for the general health and well-being of our body [9]. The prevention of oral diseases is very important, and it has become a trend to mobilize social forces to carry out oral health preventive care. NDPs are the first line of oral health care defense and interact with a large number of patients. NDPs disseminate oral health knowledge to patients and provide oral health guidance in practice, thereby contributing to the prevention of common oral diseases, including dental caries and periodontal conditions, and the promotion of general health. According to the WHO, oral diseases, tumors, and cardiovascular diseases are 3 major diseases that are significant global issues [10] and recommends a dentist-resident ratio of 1: 5000 [11]. Notably, the dentist-resident ratio in highly populated China is 1: 7768, which is far lower than the standard recommended by the WHO.

In the present study, all participants agreed with the importance of oral health. Most of the participants acknowledged the impact of oral health on general health and the necessity of regular clinical oral examinations. However, there was insufficient understanding of specific oral health knowledge. For example, 60.59% of participants did not know that tooth loss is not a natural phenomenon in the elderly. Tooth loss is an important public health concern that impacts peoples’ quality of life. Periodontal disease is common in the elderly and a leading reason for tooth loosening and loss [12,13]. Increasing evidence has shown that tooth loss can be associated with diet-related chronic diseases, such as malnutrition, obesity, cardiovascular diseases, hypertension, diabetes, and certain types of cancer [14]. The participants were not aware of the potential harm of periodontal diseases on tooth loss. Approximately 85.71% of NDPs knew about the relationship between periodontal inflammation and diabetes; this rate was higher than that reported by Dubar et al, which was 75% [15], and Xu et al, which was 48.9% [16]. There is a 2-way relationship between periodontal diseases and diabetes. The control of blood sugar has a positive effect on periodontal health, while the activity of periodontal bacteria is not conducive to the control of blood sugar [17]. Periodontal conditions are also directly associated with various other systemic diseases [2]. Dubar et al reported that 53% to 59% of general practitioners understood the influence of periodontal disease on inflammatory bowel, cardiovascular, and respiratory conditions, and only a few general practitioners considered periodontal disease as a possible risk factor for Alzheimer disease and rheumatoid arthritis [15]. Therefore, it is necessary to further strengthen the oral health–related knowledge and awareness of NDPs to improve understanding of the association of oral health with systematic health and potentially improve patient care.

If parents are negligent in the oral hygiene of their children, the children will experience dental caries soon after the emergence of teeth. Untreated dental caries can cause pain and food impaction and even influence the development of permanent teeth [18,19]. The anti-caries effect of fluoride toothpaste has been confirmed by studies [20], and fluoride toothpaste is available in various countries [21]. However, in a study by Walsh et al [18], 29.06% of respondents did not know the effect of fluoride toothpaste on preventing dental caries. Some participants (14.78%) thought that caries without pain did not need to be treated, which is not true. Pit and fissure sealants and restoration can prevent the progression of caries in select children and adolescents [22].

Smoking is not only a risk factor for lung cancer, but also for oral cancer. Notably, 88.67% of the participant group was aware of this information. Proia et al reported that changes in buccal mucosa were associated with smoking and smokeless tobacco. Tobacco-associated changes include micronuclei, bacterial adherence, genetic mutations, DNA polymorphisms, carcinogen-DNA adducts, and chromosomal abnormalities [23].

Pregnancy is associated with dental caries and periodontal disease, which can further increase the risk of systematic diseases, such as rheumatoid arthritis, atherosclerosis, and diabetes, in pregnant women. Furthermore, dental caries can affect pregnancy outcomes and increase the risk of offspring developing dental caries during the early stage of life [24]. Therefore, women who are either pregnant or expecting pregnancy should undergo oral examination and screening for dental caries for management in a timely manner [25]. Al-Habashneh et al found that 81% of physicians agreed that pregnancy increases the tendency for gingival inflammation. Approximately 50% agreed with the possible association between oral health and pregnancy outcomes, and 50% would advise patients to visit the dentist during pregnancy [26]. The results of our study group showed more optimistic results. More than 90% of participants knew the significance of oral healthcare and the management of oral diseases before and during pregnancy, 80.79% of participants believed that the oral health of women during pregnancy can affect the development of the fetus, 77.34% believed it was necessary for women to have professional dental cleaning before pregnancy, and 56.16% knew the relatively safe time to deal with teeth for pregnant women. Lyu et al reported that only a few doctors provided oral healthcare measures to pregnant patients. However, most obstetricians and gynecologists (79.17%) lacked awareness about the influence of pregnancy on the patient’s oral healthcare [27]. Ganganna et al found that the issue of dental care before pregnancy was neglected by most gynecologists; only 12% of gynecologists referred patients to the dentist before pregnancy [28].

In terms of children’s oral health, the respondents had a slightly insufficient awareness of the influence of bad oral habits on maxillofacial development in infants and children. Many participants did not know the hazards of long-term lying down while drinking milk (26.60%) and of mouth breathing (15.27%). Moreover, 42.86% of participants did not know when to start brushing a baby’s teeth. Respiratory diseases, such as rhinitis, turbinate hypertrophy, and adenoid hypertrophy, can lead to mouth-breathing respiratory tract changes and consequent deformities in craniofacial growth [29]. The pattern of craniofacial growth can be corrected by the timely treatment of respiratory conditions and by facilitating nasal respiration. When infants and young children lie down and suck a bottle for extended periods of time, the lower jaw tends to passively extend forward, which leads to the forward protrusion of the lower jaw and crossbite over time [30]. Qiong et al reported that even though 93.5% of child healthcare physicians knew that primary teeth caries should be treated as early as possible, only 39.2% were aware of the oral nursing patterns of infants, only 29.2% knew the correct breastfeeding posture, and only 36.4% received education on children’s oral health care in college [31]. NDPs should learn the relevant knowledge of children’s oral health, be attentive to potentially unhelpful habits, and provide counseling to parents for informative advice.

Oral health promotion requires healthcare providers to educate patients on the prevention of oral disease and refer them to dental professionals for the management of existing oral diseases in a timely manner. The results of the present study suggested that some NDPs lacked the necessary knowledge of oral health, which hindered them from educating patients on oral health and conducting the necessary patient referrals for collaborative treatment with dental professionals. Al Rababah et al reported that more than 90% of nurses in Riyadh, Saudi Arabia, thought that providing oral hygiene was an important element of patient care, and they acknowledged the need of updating their oral care knowledge and skills. Only 46% of participants reported the presence of a policy for oral care at their hospital unit, and 55.3% of participants indicated that patients were assessed for oral health in their department [32]. Kumar et al reported that nursing education and the implementation of proper oral hygiene measures for patients in an intensive care unit setup is an essential need [33]. Therefore, it is essential to educate NDPs to further improve oral health–related knowledge and awareness. These topics should include information on the consequences of common oral diseases, common oral healthcare measures, and oral healthcare measures for special groups.

The present survey also found that 73.40% of participants were interested in learning more about oral health knowledge. The oral health knowledge of NDPs came mainly from internet sources and oral professionals, and the consulting of dental professionals was the most common method to obtain knowledge. Only 27.09% of the participants often implemented oral health education in their clinical practice, and 44.33% of the participants’ departments had taken some measures to promote oral health. When asked about the reasons that hindered NDPs from spreading oral health knowledge to patients, 85.22% of participants stated it was due to a “lack of oral health knowledge and professionalism” and 78.82% stated it was due to busy working hours. Notably, 28.57% of participants thought that “oral health education and guidance is not their job,” indicating deficiencies in the dissemination and implementation of multidisciplinary joint services for patients. Approximately 68.47% of NDPs considered implementing oral health education in the future. Previous studies have also reported unsatisfactory trends. For example, George et al found that only 16.4% to 21.5% of obstetricians discussed the significance of oral healthcare and provided advice to pregnant women [34]. Dubar et al reported that 74.31% of general practitioners never asked their patients about their periodontal health. Most practitioners stated having insufficient knowledge of the relationship between oral and systemic diseases and hoped to complete relevant professional development courses [15]. Although the performance of spreading oral health knowledge was not ideal, 95.56% of the study participants thought it was necessary to implement oral healthcare education in collaboration with specialists in multiple disciplines. These results suggested that dental professionals should take the initiative to organize the communication and discussion with multidisciplinary doctors and promote oral health knowledge to more NDPs to increase their understanding and confidence in spreading knowledge on oral healthcare.

The strength of this study is that the research object included NDPs, who are potentially close collaborators with dental professionals in oral health knowledge dissemination. The findings of the present study are important in promoting the multi-group cooperative model of preventive oral healthcare. However, this study has some limitations. Our results are based on a self-reporting questionnaire, which can lead to information bias, whereby a participant can express either an understated or exaggerated response. Additionally, since we did not obtain information on the medical specialties of the NDPs, the number of patients seen by the NDPs, or the number of referrals to dentists, the study sample may not represent all the NDPs working in China. Therefore, further studies with an expanded sample size and validity are required to obtain comprehensive data. There is a need for multicenter studies involving larger sample sizes from diverse populations residing in different countries. Additionally, it would be interesting in future research to evaluate the knowledge of NDPs of other recently introduced preventive therapies, such as remineralizing agents, photobiomodulation, and probiotics, to expand the results of the present report [35–37].

Conclusions

The knowledge and understanding of oral healthcare among NDPs and their approach to spreading knowledge on oral health in clinical practice is not ideal. However, in this study, most NDPs were interested in oral health knowledge and agreed on the importance of intersectoral collaborations for oral healthcare. Therefore, it is imperative to strengthen the oral healthcare knowledge of NDPs and help them improve their ability to spread oral healthcare knowledge through targeted oral health education courses or training workshops, multidisciplinary discussions, and other measures. NDPs should raise their awareness of spreading oral health and strengthen their cooperation with dental professionals, to promote oral health and general health. Further research is needed to explore the best methods to achieve this goal.