|Year : 2014 | Volume
| Issue : 3 | Page : 361-368
A knowledge, attitude, and practices study regarding dental floss among dentists in India
Charu Madan1, Kapil Arora2, Vandana Srikrishna Chadha2, Bhadravathi Chaluvaiah Manjunath3, Byalakere Rudraiah Chandrashekar4, Vatchala Rani Rama Moorthy5
1 Department of Periodontics, ESIC Dental College and Hospital, Sector 15, Rohini, New Delhi, India
2 Department of Periodontics and Implantology, Manav Rachana Dental College and Hospital, Faridabad, India
3 Department of Public Health Dentistry, PGIDS, Pt. BD Sharma University of Health Sciences, Rohtak, Haryana, India
4 Department of Public Health Dentistry, People's Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
5 Department of Oral Pathology and Microbiology, Jaipur Dental College, Jaipur, Rajasthan, India
|Date of Submission||14-Oct-2013|
|Date of Acceptance||18-Nov-2013|
|Date of Web Publication||17-Jun-2014|
C 222, Second Floor, Sarvodaya Enclave, New Delhi - 110 017
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: To assess the knowledge, attitude, self-reported practices, and prescription patterns regarding dental floss amongst a select population of dentists in India. Materials and Methods: A pretested 30-item questionnaire was self-administered by authors to the dental faculty and postgraduate students in dental schools in Delhi-National Capital Region (NCR). Nine dental institutes were selected by simple random sampling procedure among 15 institutions and a total of 255 dentists were included in the study. Statistical Analysis: The data obtained were analyzed by SPSS version 18. Descriptive statistics such as frequencies were calculated and Pearson's Chi-square test was used with P value fixed at 0.05. Results: There was lack of adequate knowledge regarding dental floss, among dentists in India. 78% of the dentists responded that the routine use of dental floss was necessary for good periodontal health. Majority of the dentists cited lack of awareness, availability, and cost as the major factors affecting floss usage. Lack of training in the dental education programs may have an impact on the prescription patterns as well. 15.3% of those surveyed do not use floss at all. 63.9% of the dentists prescribed floss routinely to their patients and considered factors like education, occupation, and socioeconomic status of the patient before prescribing dental floss. Conclusion: Health education programs regarding dental floss are necessary to create awareness among the general population and adequate training at undergraduate level is also essential to increase the prescription practices. Dentists should practice recommended oral self-care and act as role models.
Keywords: Attitude, dental floss, dentists, India, knowledge, practices, survey
|How to cite this article:|
Madan C, Arora K, Chadha VS, Manjunath BC, Chandrashekar BR, Rama Moorthy VR. A knowledge, attitude, and practices study regarding dental floss among dentists in India. J Indian Soc Periodontol 2014;18:361-8
|How to cite this URL:|
Madan C, Arora K, Chadha VS, Manjunath BC, Chandrashekar BR, Rama Moorthy VR. A knowledge, attitude, and practices study regarding dental floss among dentists in India. J Indian Soc Periodontol [serial online] 2014 [cited 2020 Apr 4];18:361-8. Available from: http://www.jisponline.com/text.asp?2014/18/3/361/134578
| Introduction|| |
Periodontal diseases are one among the major chronic infections afflicting mankind at present. Even though these are preventable diseases, their prevalence is increasing in the world.  The burden of periodontal diseases is comparatively higher in developing countries.  Periodontal disease has become a major public health problem in India and the prevalence ranges from 50 to 100% in various parts of the Indian subcontinent and hence, is a matter of deep concern. 
Dental plaque or biofilm is the main etiological factor in the causation of periodontal disease and effective removal of bacterial plaque is the gold standard for its prevention. The mechanical method of plaque control is indisputably the easiest and most effective measure to prevent periodontal diseases. , It has been reported that toothbrush alone is inadequate for effective removal of dental plaque, and hence, use of other oral hygiene aids such as dental floss has been emphasized.  Even though dental floss is more effective in removal of interdental plaque than manual toothbrush alone,  the usage of dental floss as an adjunct oral hygiene aid is not encouraging throughout the world. Various reports suggest that dental floss is used only by a small part of the population on a daily basis. ,,,
It has been found that daily use of dental floss not only prevents periodontal disease but also lowers the risk of cardiovascular disease,  and hence, its importance has to be highlighted. Modification of patient's behavior regarding oral hygiene maintenance is one of the significant challenges confronting the modern dental practitioner. , Merely explaining the role of good oral hygiene in prevention of oral diseases may not result in compliance of oral hygiene instructions, but stressing the link of periodontal diseases with various systemic diseases may motivate an individual to take proper oral care. , In this context, it becomes important for dentists and auxiliary personnel to recommend the use of dental floss as well as to strive to improve the frequency of its usage by the general public, which will help in preventing periodontal diseases. ,
Since periodontal disease is one among the major public health issues in India, there is an immediate need to identify preventive strategies to reduce the burden of the disease. Dentists play an important role in suggesting effective oral hygiene aids for maintenance of good oral health, but reports suggest that the dental floss is not advised routinely to every patient in dental practice. , There is a necessity to know the factors affecting the prescription of dental floss and also to identify the barriers among the dentists in India. But since published data are unavailable, we conducted a study to assess the knowledge, attitude, self-reported practices, and prescription patterns regarding dental floss amongst a select population of dentists in India.
| Materials and methods|| |
Ethical clearance for the study was obtained from the ethics review and research board of the Manav Rachana Dental College and Hospital, Faridabad, India. The present study was a cross-sectional study in which data were collected from January to August 2010.
Since there was no standardized questionnaire, we devised a new instrument to measure it. Initially, the instrument consisted of 42 questions. A pilot study was conducted among 30 dentists to validate it, and after analyzing the data, 30 questions were finalized, which fulfilled the objective of the study. The questions were grouped into different categories and subcategories as follows.
- Eight questions assessed knowledge about dental floss
- Attitude of the dentists toward the use of dental floss was measured by a 5-point Likert scale of "agree," "strongly agree," "none," "disagree," and "strongly disagree" to indicate the degree of agreement with essentiality of dental floss, compliance in the use of dental floss, awareness in relation to dental floss, and education and dental floss
- Seven questions measured the practices being followed by the respondents themselves in the use of dental floss and their recommendation to patients.
The present study was carried out amongst the select population of dentists working as faculty in various dental schools in the National Capital Territory Region, Delhi, India.
Sample size estimation and selection of study participants
The findings of the pilot study revealed that the proportion of the dentists using dental floss was 91.1%. Using this proportion value from the pilot study, the sample size was estimated to be 252 at 95% confidence level, with a precision of 5% and a design effect of 2 using nMaster software.
The number of participants in each of these 15 dental institutions was approximated to be around 35-40. Nine out of 15 dental institutions were selected using simple random sampling.
All the faculty and postgraduate students were considered for the study. The letter of introduction explaining the rationale of study, informed consent forms, and a 30-item structured questionnaire were personally delivered to dental faculty by the authors. Since the questionnaire did not contain the name, anonymity of prospective participants was maintained, and specific instructions were given as to how to answer and return the completed forms. A total of 304 from the target respondents returned back the questionnaire, with a response rate of 85.63%. Fifty-one dentists refused to participate for personal reasons. After scrutinizing for completeness of questionnaire, incomplete forms were excluded, and thus, the final study population consisted of 106 males (average age 32.05 ± 5.91 years) and 149 females (average age 29.95 ± 5.61 years), with a total of 255 (71.83%) with an average age of 30.82 ± 5.82 years [Table 1].
Data entries and analyses of results were done using SPSS for Windows (version 18.0, SPSS, Chicago, IL, USA) statistical software package. Descriptive statistics such as frequencies were calculated and Pearson Chi-square test was used to find out the difference between variables. The P value was fixed at 0.05.
| Results|| |
The results are presented in [Table 2] and [Table 3] and [Figure 1], [Figure 2], [Figure 3] and are described below.
|Table 2: Assessment of knowledge regarding dental floss in the study population |
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|Table 3: Assessment of attitude regarding dental floss in the study population |
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Knowledge of dental floss
98% of the dentists knew that dental floss removes plaque from the interdental area. 46.7% of the dentists thought that it polishes the tooth surface as it removes the dental plaque. 27.1% of the dentists reported that it massages interdental area. More than 80% were of the opinion that dental floss reduces gingival inflammation. 78% of the dentists thought that dental floss should be customarily used along with tooth brushing every day. 74.5% of the dentists thought that toothbrushes with advanced bristle designs would remove interdental plaque similar to dental floss. 62.4% of the respondents thought that dental floss harms the interdental gingiva [Table 2],[Figure 1].
More than five correct responses were given by 66.3% of the respondents. 100% correct responses were given by only 1.6% of the participants. The trend of correct answers by the respondents is shown in Figure 1. Female dentists demonstrated better knowledge than male dentists, and MDS qualified dentists fared better when compared to BDS and PG students.
Attitude of the dentists toward dental floss
2% of the dentists strongly agreed and 20% agreed that toothbrush and toothpaste alone are not enough to remove plaque and debris. 86.3% of the dentists felt that dental floss is an essential oral hygiene aid along with the toothbrush. 78% of the dentists agreed or strongly agreed that the routine use of dental floss is necessary [Table 3].
89% dentists opined that there is a lack of patient compliance in using dental floss. 62% felt that dental floss is freely available. 62.4% of them agreed or strongly agreed that dental flossing is a time-consuming procedure. 37.71% of the dentists did not consider dental floss to be expensive.
Notably, more than 90% of the dentists thought that dental floss is not as well marketed as other oral hygiene aids in India and that there is a lack of awareness regarding dental floss among the general population. 89.8% of the respondents felt that dentists should create awareness and motivate people to use dental floss regularly.
83.1% of the dentists agreed that dental flossing should be taught at the school level. More than half of the respondents agreed that dental floss was not given adequate importance in the dental schools, and 86.6% thought that greater emphasis was required on dental floss education in the dental curriculum.
Frequency of use of dental floss
15.3% of the respondents do not floss at all, 46.3% of them floss occasionally, 22% floss once a day or more, and 9.4% floss on alternate days [Figure 2]. 28.2% of the dentists use some other interdental aid like toothpicks and interdental toothbrushes apart from dental floss.
Prescription of dental floss to the patients
63.9% of the respondents prescribe floss routinely to their patients [Figure 3]. On an average, the dentists are prescribing floss to 46% of the patients visiting their clinic. 56.7% of the dentists prescribe floss also/only in specific conditions like food impaction and fixed prosthesis. 64% of the dentists consider factors like education, occupation, and socioeconomic status of the patient before prescribing dental floss.
| Discussion|| |
The use of dental floss dates back to prehistoric times and the credit of inventing the modern dental floss goes to Levi Spear Parmly, a dentist from New Orleans, fondly referred to as the apostle of oral hygiene.  He advised flossing with a piece of silk thread to his patients in 1815, paving way for the use of modern dental floss. Since then, humble silk thread has undergone tremendous transformation in modern times. ,
Even though the use of dental floss along with regular tooth brushing has been recommended routinely for prevention of gingival diseases, , the statistics throughout the world is not encouraging, ,,, and hence, it is essential to find the knowledge, attitude, self-reported practices, and prescription patterns among dental professionals to identify deficiencies, which would be helpful to plan corrective measures. The present study was undertaken with the same objective among a select dentist population in India to identify lacunae, if any, with regard to the use and prescription of dental floss, and to our knowledge, this is the first such study to be carried out on Indian dentists.
In the present study, dentists were found lacking adequate knowledge regarding dental floss, as more than five correct responses out of eight were given by only 66.3% of the respondents. 100% correct responses were given by only 1.6% of the participants [Figure 1]. Female dentists were better informed when compared to their male counterparts, and our study had a similar outcome as that of Khami et al. 
MDS qualified dentists gave more correct answers, but still the result was not satisfactory [Table 2]. There is a lacuna in the knowledge trend, which can be attributed to the lack of training during undergraduate dental programs and failure to update the knowledge. Continuing dental education program (CDE) can be initiated with the help of professional organizations like Indian Dental Association (IDA) to increase awareness among the dentists in Delhi-National Capital Region (NCR).
In the present study, the majority of dental academicians agreed to the fact that dental floss should be used along with regular tooth brushing and that it is effective in removing interdental plaque and reducing gingival inflammation. Claydon  concluded that there was good evidence to recommend dental floss to adults for the prevention of gingival inflammation. Similarly, other researchers have shown that preventive oral health behaviors such as tooth brushing, flossing, periodic dental visits, annual prophylaxis, and combinations of the same were associated with greater tooth retention with better periodontal health. , Sambunjak et al.  conducted a systematic review and concluded that flossing in addition to tooth brushing reduces gingivitis, compared to tooth brushing alone. There is also a report that use of dental floss regularly by orthodontic patients resulted in marginally better gingival outcome than that of those who did not use dental floss at all.  Although powered toothbrushes are effective in reducing gingival inflammation and plaque than manual toothbrushes with or without floss, they cannot be recommended to everyone in India; hence, advising dental floss along with manual tooth brushing becomes essential. 
The main oral hygiene aids used in India are toothbrushes, toothpastes, and tooth powder, along with indigenous aids like neem stick, babool, charcoal, brick powder, ash, etc. , The percentage of dental floss users is significantly less when compared to toothbrush and toothpaste users. It has been reported that only 15.8% of the population in India used dental floss, which could be attributed to lack of awareness among people and prescription practices of the dentists. 
Dentists in our study strongly agreed to the fact that there was a lack of awareness regarding dental floss among the people in India, and they identified it as a major barrier and felt that dentists should play a major role in creating awareness about dental floss. There was also a general agreement for school-level training in the use of floss, enabling acceptance at an early age. Keeping in mind the low percentage or no usage of dental floss among school children, it is imperative that dentists in academic institutes should work upon conducting workshops in schools to promote the use of dental floss. ,
Cost, availability, propaganda, and prescription by dentists may play a pivotal role in the use of dental floss by the Indian population. According to a recent report, the percentage of people using toothbrush and toothpaste was significantly more when compared to toothpowder and other indigenous aids, which is a positive health behavior.  Earlier, toothbrushes and toothpastes were accessible only in urban areas; but now, due to increased awareness and commercialization, they are easily available even in rural areas where 70% of the Indian population resides.  Print and mass media also have influenced the choice of oral hygiene aids in India.  In the days ahead, dental floss may also experience a similar trend when adequate importance is given from all sectors.
A majority of the dentists also responded that dental floss is not given adequate importance in undergraduate and postgraduate dental education, and hence, this may have an effect on the prescription of dental floss to their patients. A study by Nakamura et al.  reported that dentists who were demonstrated dental flossing procedure at the dental schools by their teachers recommended dental floss more frequently among their patients, compared with those who did not see demonstrations of flossing. It is also important to educate and motivate dental students to adopt recommended oral self-care (ROSC) procedures, like flossing, themselves, as this will encourage them to advocate the same to their patients also. 
Current oral hygiene practices of dentists may also have a bearing on the prescription patterns. The percentage of Indian dentists using dental floss, as reported by Gopinath et al.,  was extremely low at 9.2%. However, our study showed that only 15.3% of the dentists did not use dental floss at all, while the rest used it once, twice, on alternate days, or occasionally. A relatively high percentage of dentists using dental floss in our study is similar to the results documented by Zadik et al .  Awareness and self-motivation among dentists in the academic institutes of Delhi-NCR seems to be optimum for this large percentage of floss users.
Further analysis in our study showed that only 22% dentists used dental floss once daily (at least), whereas Merchant et al.  and Nakamura et al.  have reported similar practices in 56.3% dentists of US and 23.4% dentists of Japan, respectively. In the present study, the percentage of female dentists using dental floss was more when compared to males, and this finding is in agreement with the findings of the study by Khami et al.,  who reported similar trend among Iranian dental school educators.
Since the daily users of dental floss among dentists in India are less, there is a high possibility that the "non daily users" may not recommend dental floss routinely to their patients. This was well supported by our results that showed 36.1% dentists in academic institutes did not prescribe dental floss routinely for interdental plaque control to patients. This is a significant barrier identified in our present study. Findings of a report highlighted that information, education, and communication (IEC) by dentists regarding good oral hygiene plays a significant role on positive health behavior among their patients.  Just prescribing dental floss is not enough; it is also essential to demonstrate correct flossing technique, as incorrect flossing may result in cervical abrasion of the teeth and angular alveolar bone loss. ,
A large number of dentists (63%) in the academic institutes in Delhi-NCR considered education, occupation, and socioeconomic status of the patient to be important while prescribing dental floss. The practice of low floss prescription could then possibly be explained by the assumption that majority of the patients visiting these institutes belong to lower socioeconomic strata. Such patients who usually hail from remote areas are not even well versed with routine tooth brushing procedures. Also, this discrimination in the prescription habits of the dentists may explain the low level of awareness regarding dental floss existing among the general population. Active measures need to be undertaken by various health agencies in India to increase the awareness regarding routine oral hygiene methods including dental flossing among the general population.
Since this survey used a self-reported questionnaire, authenticity of the responses could not be ascertained. Another limitation to our survey was the limited sample size. Since it is logistically not feasible to personally hand over the questionnaire to each dentist in their respective clinics, dentists working as faculty in the dental schools were included, but still they represent the dentists in the Delhi-NCR region. If all the dental practitioners in the region are to be included, then e-mail survey can be undertaken. Therefore, we propose that future studies be aimed with a larger sample size, which can be carried out in other geographic areas in India as well to arrive at broader conclusions. It is also worth considering the fact that the faculty and postgraduate students are exposed to the vast amount of knowledge regarding oral health as they have accessibility to scientific periodicals, carry out research, frequently discuss the recent concepts and technologies, and attend workshops and conferences, which would have impacted on the knowledge, dental flossing habits, and prescription patterns as well. On the other hand, dentists who are exclusively in private dental practice do not have access to journals and very few attend conferences and workshops to update their knowledge. This would have resulted in decreased knowledge regarding dental floss, a negative attitude, and would have affected the prescription patters as well. Still, in order to have scientific evidence, further studies may be carried out on dentists who are exclusively in private practice, which our study did not attempt.
This survey can also be extended to other healthcare professionals and the general population to understand the need and practices of dental floss.
| Conclusion|| |
To summarize, most dentists recognize dental floss as an essential oral hygiene aid and agree that its routine use is necessary. Lack of adequate knowledge among the dentists regarding dental floss has to be addressed immediately. The percentage of prescription of dental floss is also less, which can be correlated with lack of patient compliance. A large proportion of dentists agree that dental floss requires good propaganda to increase its usage. The respondents also felt that a greater emphasis is needed on dental floss education in dental schools in India as well. This may also transcend to an improved prescription of dental floss. Awareness regarding dental floss needs to be bolstered in the general population as a preventive oral healthcare behavior. Thus, increased usage of dental floss along with toothbrush may prevent periodontal diseases in the Indian population.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]