Scientific rationale for study: The oral cavity is the mirror of the body, so oral hygiene is necessary for maintaining oral and general health. Toothbrush acts as a tool in maintaining oral hygiene. In modern days, however, everyone is directed toward using toothbrush and disposing it without proper care. Hence, this study was undertaken with an aim to assess the knowledge, perceptions, and behaviors of oral health-care professionals who can educate better about toothbrush contamination and disinfection to the society.
Principal findings: Education improves knowledge; similarly, when participants were compared, faculty had greater awareness as compared with others in following sterilization protocol.
Practical implications: Prevention is better than cure. INTRODUCTION
Oral health is necessary for an individual's well-being and is integral to good general health. The most common oral hygiene aid used to improve the oral health of an individual is toothbrush.[
] Toothbrushing plays an important role in personal oral hygiene and plaque control. Toothbrushes may act as reservoirs for several diseases as there are chances of cross 1 contamination intra- and extraorally causing oral and systemic diseases including septicemia and gastrointestinal, cardiovascular, respiratory, and renal problems. Bacteria and viruses build upon toothbrushes after usage and remain viable for 1 week.[ ] 2
Well-known literature is there for toothbrushing methods but not about toothbrush disinfection. Taji and Rogers reported that toothbrushes stored in bathrooms are heavily contaminated with enteric bacteria dispersed by aerosols.[
] Hence, there is a need for disinfection of toothbrushes before usage. The American Dental Association (ADA) recommends disinfection of toothbrush maintenance for heavily risk patients rather than healthy.[ 3 ] There are different disinfection methods for sterilizing toothbrushes such as ultraviolet sanitizers, chemical agents, microwave irradiation, and dishwashing. Among these, chlorhexidine (CHX) was proved to be more effective in destroying microbial species.[ 4 5 6 ] 7
As prevention is always better than cure, modern dentistry emphases on preventive programs such as toothbrushes and dental floss instruments which are used for maintaining oral cleanliness. Hence, toothbrushes' storage,
contamination, and disinfection is an important perspective in preventing oral and systemic diseases. Although methods for toothbrushing are described in the literature, procedures for maintaining the cleanliness of toothbrushes are rarely discussed.
professionals prevent dental and promote oral health in the society. They are the role models for educating, motivating, and integrating preventing procedures in the daily life of the people. Hence, it is essential to assess the perception of these professionals with regarding to the storage, contamination, and disinfection. As there are few studies conducted on dental students in the literature based on this concept, this study was undertaken with an aim to assess the knowledge, perceptions, and practices about toothbrush storage, contamination, and disinfection among dental students and faculty in Andhra Pradesh, South India. MATERIALS AND METHODS
A cross-sectional questionnaire study was conducted among faculty members, postgraduates, and interns in Andhra Pradesh between the months of February and March 2018.
Source of data
The data were collected through a primary, closed-ended, structured, self-administered questionnaire.
All faculty members, postgraduates, and interns of the selected postgraduate institutions were included in the study.
All the faculty, postgraduates, and interns from these selected postgraduate institutions with the essential qualification of BDS and MDS, who were present on the particular day of investigation, and who gave informed consent were included in the study.
Ethical clearance and informed consent
Ethical clearance was obtained from the institutional review boards (ECR/804/Inst/AP/2016). Before the start of the survey, permission to conduct the study was obtained from principals of the selected postgraduate dental institutions in Andhra Pradesh. The purpose of the study was explained to the study participants and informed consent was obtained from them during the study.
A pilot study was conducted among sixty faculty members, postgraduates, and interns of one of the dental institutions of Andhra Pradesh to assess the reliability of the questionnaire by using test–retest design. It was given to the same faculty members, postgraduates, and interns twice after 1-week duration. Reliability was assessed for the questionnaire. The Cohen's kappa value was computed as 0.8734* which indicated nearly perfect agreement among examiners. The sample size was assessed using the formula
N = z 2 pq/ d 2. Considering the prevalence of knowledge as 40%, 95% confidence level, and 80% power, and allowable error d = 4.75. Hence, a sample size of 425.53 was obtained, which was rounded off to 450 to ensure equal distribution of 150 participants in each group. Sampling
A list of a total of 17 dental colleges was obtained from the website of Dr. NTR University of Health Sciences (
. From this list, nine dental colleges in total from Telangana, Krishna, and Kadapa regions were selected by simple random sampling and 450 study samples (faculty members, postgraduates, and interns) were included in the study. http://www.ntruhs.ac.in) Collection of data
Data were collected using a pretested, self-administered structured questionnaire in their respective institutions. The questionnaire was divided into three parts; the first part was related to demographic details which include age, gender, qualification, department, designation and teaching experience, and oral hygiene practices. The second part consisted of questions about
perceptions regarding toothbrush storage, and the third part is knowledge, perceptions, and practices regarding toothbrush storage, contamination, and disinfection. The questionnaire was distributed to all the study participants who were present on the day of the investigation of selected postgraduate institutions and collected back on the same day. Statistical analysis
The collected data were analyzed using the Statistical Package of Social Sciences 22 version statistical package (IBM SPSS Statistics, Chicago). Descriptive statistics were performed to analyze the influence of age, gender, and professional title on knowledge scores pertaining to toothbrush storage and disinfection using analysis of variance, Student's
t-test, and Chi-square tests. P < 0.05 was considered statistically significant. RESULTS
Of 450 study participants, 150 were faculty, 150 were postgraduates, and 150 were interns. The mean age of the study participants was 27.95 + 6.3 years, among them 63.3% were female and 36.7% were male [
Table 1]. Table 1:
Demographic parameters of the study population
When a question was asked regarding the necessity of sterilization protocol, most of the dental
professionals, i.e., interns, postgraduates, and faculty reported that it was very much essential for maintaining oral health. When questions were asked regarding oral hygiene practices, it was found that most of the study participants were brushing twice a day except interns who were doing it once a day and prebrushing mouthwash was not used by all the dental professionals, and moreover, fluoridated dentifrice was used by most of the participants. When a question was asked regarding the frequency of using a new toothbrush, most of the study participants (interns and postgraduates) mentioned that they used to change it once in 3 months, but faculty gave a response that after observing wear and flare of bristles, they used to change their toothbrushes [ Table 2]. Table 2:
Distribution of participants based on
perceptions for toothbrush storage and disinfection
Perceptions regarding toothbrush storage were assessed in the second part of the questionnaire; study participants (56%) reported that they used to store their toothbrushes in an open environment outside the bathroom, separately not in contact with other family members. Seventy-eight percent of them reported that contact between toothbrushes is an important issue for bacterial contamination, but most (63%) of them used to share their toothpaste with family members and friends [ Table 2].
professionals (52%) reported that they only make suggestions to the patients regarding the change of toothbrushes but not about storage [ Table 2].
Knowledge and behaviors of dental
professionals regarding disinfection were assessed in the third part of the questionnaire. When questions were asked about the disinfection of toothbrushes, most (67%) of them were aware of that but were not acclimatized in doing that regularly. When the question was asked regarding the necessity of disinfection, they told them it was very much essential and everybody should do that before using it [ Table 2].
There were statistically significant differences between the three groups regarding the frequency of brushing and change of toothbrush, storage of toothbrush, and knowledge on toothbrush
contamination and disinfection P value is (0.01*,0.01*,0.01*,0.04*,0.01*) respectively [ Table 3]. Table 3:
Association between groups based on knowledge regarding toothbrush storage and disinfection practices
A highly statistically significant difference was observed regarding the type of toothpaste, reason behind change of toothbrush, contact between toothbrushes during storage, and sharing of toothpaste with family members or friends
P value is (<0.001**). The practices related to the disinfection of toothbrush and patient advice regarding storage and disinfection were also highly significant between the three groups [ Table 3]. DISCUSSION
Oral health behavior of a person is very important for oral disease prevention and is determined by the brushing habits, toothbrush storage and disinfection procedure, interdental space cleaning, and regular dental visits. The present study highlights that faculty and postgraduates are having better knowledge perception on toothbrush storage,
contamination, and disinfection. Hence, oral health professionals have prioritized toothbrush as oral hygiene aid to promote dental health.
The present study assessed the knowledge,
perceptions regarding toothbrush storage, contamination, and disinfection among dental postgraduates, interns, and faculty. Not many studies have been done in this regard. Therefore, comparisons were made wherever possible. The current study included 450 study participants, comprising postgraduates, interns, and faculty with nearly equal distribution from three dental colleges.
In the present study, about 50% of the study participants (faculty and postgraduates) brushed their teeth twice per day, whereas interns brushed their teeth once a day, whereas in a study reported by Peker
et al., 87% of dentists brushed their teeth twice a day or more.[ ] This relatively high percentage compared to previous reports might be because the study was carried out at a university, and all of the surveyed dentists had at least a postgraduate education. This indicates that education contributes to improved knowledge, and as the level of education increases, there is an improvement in the level of oral health awareness, attitude, and behavior. 2
In the present study, about 77% of the study participants were using fluoridated toothpaste suggesting that dental
professionals are updating their knowledge as new oral health management strategies are identified.
The ADA recommends that toothbrushes be replaced every 3–4 months, or sooner if the bristles appear worn or splayed.[
] However, this recommendation is based on the loss of mechanical efficiency, not on bacterial 5 contamination of the toothbrush. In this study, most participants declared that toothbrushes should be replaced once every 3 months, consistent with the recommendations of the ADA. Similarly, in a study reported by Peker et al., dentists replaced their toothbrushes once in 3 months, and additionally, 72% of them advised their patients about the frequency of changing their toothbrushes.[ ] 2
In this study, the surveyed dentists stored their toothbrushes in open places in a toothbrush holder separately from toothbrushes of other individuals/family members, but they shared their toothpaste with other individuals/family members. Contradictory to this finding, a study reported by Peker
et al.[ ] reported that the study participants stored their toothbrushes in closed containers to avoid external 2 contamination. However, if toothbrushes are stored in closed spaces, millions of microorganisms and enteric bacteria can contaminate the brushes through aerosols from the bathroom Moreover, if toothbrushes and toothpastes are shared also act as a source of cross contamination. However, external environment and contact with other toothbrushes were cited as the most common source of contamination by majority of postgraduates and interns, respectively in another study.[ ] 8
A significant association was found between the dentist's title and knowledge about toothbrush disinfection. It may be that dentists with more educational background have a greater awareness of toothbrush disinfection, or that they pay special attention to the issue or to research related to toothbrush disinfection.[
In the current study, more than half of them felt that it is necessary to disinfect toothbrush, but more than half of the study participants in this study did not follow that which is a clear indicator of inadequate knowledge or its practical application in daily life. According to previous literature, CHX was proved to be an effective disinfectant in eliminating microorganisms.[
] 7 Limitations
Further studies are required for assessing knowledge, attitudes, and
perceptions of oral health-care professionals regarding toothbrush contamination, storage, and disinfection. So that preventive measures could be undertaken to improve the oral health of the public.
As budding dentists, more attention should be paid by the postgraduates and interns in practicing appropriate toothbrush disinfection methods and also advise their patients as a part of oral hygiene instructions.
Despite the ADA's recommendation that high-risk patients disinfect their used toothbrushes, disinfection should be recommended for everyone in daily life as prevention of disease is always better than curative regimens.[
] 5 CONCLUSION
The findings of the study conclude that there were varied opinions regarding the toothbrush
contamination and disinfection among faculty, postgraduates, and interns which might be attributed to the difference in academic knowledge, exposure to a wide range of information, and clinical experience over the years between the groups. Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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