HavinMunir
Mohammed
V year, group 12SELF- REPORTED ATTITUDE AND BEHAVIOR
TOWARD ORAL HEALTH AMONG SWEDISH
RESIDENTS AND IMMIGRANTS ADOLESCENTS.
Master’s thesis
Supervisor
Dr. Sandra Petrauskienė
⁷
FINAL MASTER‘S THESIS IS CONDUCTED AT THE DEPARTMENT
OF ORTHODONTICS
STATEMENT OF THESIS ORIGINALITY
I confirm that the submitted Final Master‘s Thesis: Havin Munir Mohammed 1. Is done by myself.
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3. I did not use any additional sources that are not listed in the Thesis, and I provide a complete list of references.
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Havin Munir Mohammed
(date) (autthor‘s full name) (signature)
CONCLUSION OF FINAL MASTER‘S THESIS ACADEMIC
SUPERVISOR
ON THE DEFENSE OF THE THESIS
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00-00-2020 Department of Orthodontics
Final Master‘s Thesis reviewer
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(full name) (signature)
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
CLINIC FOR PREVENTIVE AND PEDIATRIC DENTISTRY
SELF- REPORTED ATTIDUE AND BEHAVIOR TOWARD ORAL HEALTH AMONG SWEDISH RESIDENTS AND IMMIGRANTS ADOLESCENTS
Master’s Thesis
The thesis was done
by student ... Supervisor...
(signature) (signature)
... …... (name,surname,year,group) (degree,names , urname)
... 20…. ... 20…. (day/month) (day/month)
Kaunas, 2020
EVALUATION TABLE OF THE MASTER’S THESIS OF THE TYPE OF
SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE
Evaluation: ... Reviewer: ... (scientific degree. Name surname) Reviewing date: ...
No. MT parts MT evaluation points Compliance with MT requirements and evalutation
Yes Partially No
1 Summary (0.5 points)
Is summary informative and in compliance with the thesis content and requirements?
0.3 0.1 0
2 Are the keywords in compliance with the thesis essence? 0.2 0.1 0 3 Introduction, aim and tasks (1 point)
Are the novelty, relevance and significance of the work justified in the introduction of the thesis?
0.4 0.2 0
4 Are the problem, hypothesis, aim and tasks formed clearly and properly?
0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0 6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0 7 Were the eligibility criteria of articles for the selected
protocol determined (e.g., year, language, publication, condition, etc.)
0.4 0.2 0
8 Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) describes and is the last search day
9 Is the electronic search strategy described in suc a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the
combinations of keywords)?
0.2 0.1 0
10 Is the selection process of studies (screening, eligibility, included in systemicreview or,
ifapplicable, included in the meta-analysis) described?
0.4 0.2 0
11 Is the data extractionmethod from the articles (typesofinvestigations, participants, interventions, analysedfactors, indexes) described?
0.4 0.2 0
12 Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?
0.4 0.2 0
14 Were the principal summarymeasures (risk ratio, difference in means) stated?
0.4 0.2 0 15 Systemiza- tion and analysisof data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
0.6 0.3 0
16 Are the characteristicsof studies presented in the includedarticles, according to which the data wereextracted (e.g., studysize, follow-up period, typeof respondents) presented?
0.6 0.3 0
17 Are the evaluationsofbeneficial or harmfuloutcomes for eachstudypresented? (a) simple summary data for each intervention group; b) effectestimates and confidenceintervals)
0.4 0.2 0
18 Are the extracted and systemized data from studies presented in the tablesaccording to individual tasks?
0.6 0.3 0
19 Discussion (1.4 points)
Are the mainfindingssummarized and is theirrelevanceindicated?
0.4 0.2 0 20 Are the limitations of the
performedsystemicreviewdiscussed?
21 Does author present the interpretation of the results? 0.4 0.2 0 22 Conclusions
(0.5 points)
Do the conclusionsreflect the topic, aim and tasks of the Master’s thesis?
0.2 0.1 0 23 Are the conclusionsbased on the analysed material? 0.2 0.1 0 24 Are the conclusionsclear and laconic? 0.1 0.1 0 25 References
(1 point)
Is the references list formedaccording to the requirements?
0.4 0.2 0 26 Are the linksof the references to the text correct?
Are the literature sources cited correctly and precisely?
0.2 0.1 0
27 Is the scientificlevelofreferencessuitable for Master’s thesis?
0.2 0.1 0 28 Do the citedsources not olderthan 10 years old form
at least 70% ofsources, and the not olderthan 5 years – at least 40%?
0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presentedannexeshelp to understand the analysedtopic?
+0.2 +0.1 0 30 Practical
recommen- dations
Are the practical recommendationssuggested and aretheyrelated to the receivedresults?
+0.4 +0.2 0
31 Wereadditionalmethodsof data analysis and theirresultsused and described (sensitivityanalyses, meta-regression)?
+1 +0.5 0
32 Was meta-analysisapplied? Are the
selectedstatisticalmethodsindicated? Are the resultsofeach meta-analysispresented?
+2 +1 0
General requirements, non-compliancewithwhichreduce the numberofpoints
33 General require- ments
Is the thesisvolumesufficient (excludingannexes)? 15-20 pages (-2 points) <15p ages (-5poi nts) 34 Is the thesisvolumeincreasedartificially? -0.2 poin -1 point
s 36 Is the thesiswritten in correctlanguage, scientifically,
logically and laconically?
-0.5 point 1 point s 37 Arethereanygrammatical, style or computer
literacy-relatedmistakes?
-0.2 poin t
-1 points
38 Is text consistent, integral, and are the volumesofitsstructural parts balanced?
-0.2 point -0.5 point s 39 Amount of plagiarism in the thesis. >20% (not evaluated) 40 Is the content (namesofsections and sub- sections
and enumeration of pages) in compliancewith the thesisstructure and aims?
-0.2 point
-0.5 points
41 Are the namesof the thesis parts in compliancewith the text? Are the titlesofsections and
sub-sectionsdistinguishedlogically and correctly?
-0.2 point
-0.5 points
42 Arethereexplanationsof the key terms and abbreviations (ifneeded)?
-0.2 point
-0.5 points 43 Is the qualityof the thesistypography
(qualityofprinting, visual aids, binding) good?
-0.2 point
-0.5 points
*In total (maximum 10 points):
*Remark: the amountofcollectedpointsmayexceed 10 points.
Reviewer’s comments:
Reviewer’s name and surname: Reviewer’s signature:
TABLE OF CONTENTS
SUMMARY ... 9
INTRODUCTION ... 9
REVIEW OF LITERATURE... 13
MATERIAL AND METHODS ... 16
Subjects... 16 Questionnaire ... 16 Statistical analysis ... 17 RESULTS... 18 DISCUSSION ... 29 CONCLUSION ... 32 ACKNOWLEDGEMENT ... 32 PRACTICAL RECOMMENDATIONS ... 32 CONFLICT OF INTEREST ... 32 REFERENCES ... 33
SELF- REPORTED STUDY ATTIDUE AND BEHAVIOR TOWARD ORAL
HEALTH AMONG SWEDISH RESIDENTS AND IMMIGRANTS
ADOLESCENTS
SUMMARY
Aim: To evaluate the attitude and habits toward oral health between the Swedish residents and
Swedish immigrants’ adolescents.
Material and methods: The survey was conducted in Gårdstens School, a public school in Angered
which is a suburb in Gothenburg Municipality, Sweden.
A self-administered questionnaire was designed to evaluate the attitude and awareness of children’s oral health and enquired about demographic characteristics and dietary habits of children. The
participants were 250 adolescents. The data was analysed using SPSS, version 20. Ethical approval was obtained from the bioethics department at LSMU (No. BEC-OF-84).
Results: 56.8% of participants brushed their teeth for 2 minutes. 79.2% of children brushed their
teeth at least twice a day. 62% of participants reported using toothpaste with fluoride. 60% of children used mouthwash. A majority of children (62.4%) did not use interdental aids. Children consumed tea/coffee with sugar (70.4%), carbonated beverages (69.2%), non-carbonated beverages (71.2%), flavouredwater (84%), energy drinks (84.8%), sport drinks (85.2%) and smoothies (60.4%) mainly occasionally. Meanwhile, participants tended to have an intake of biscuits, raisins or chips (63.2%), candies (72.0%) and sweets with xylitol (59.6%) weekly.
Conclusion: Overall, participants reported a good behaviour toward oral hygiene. Swedish immigrant
adolescents had a higher sugar intake in comparison to Swedish residents.
INTRODUCTION
The dimension of oral health has been expanded by adding the concept of well being after WHO broadened the definition of health by the inclusion of social well being. Since then oral health too is considered to contribute to general well being not mere absence of disease. Daily activities like eating, talking, smiling and creative contributions to society are determinants of an individuals well being [1]. Oral health has been described as a factor of great importance for general health. At the same time, poor general health affects both oral health and the oral health-related quality of life negatively [2].
Although oral health problems are rarely life threatening they remain a major public health problem because of their burden due to high prevalence and it is now widely recognized that oral health can contribute to social, economic and psychological consequences. In other words, oral health can impact an individual’s quality of life [3].
It is now widely recognized that oral diseases can have varying impacts on people and their well being and life quality. Dental diseases cause pain, discomfort, and affect proper physical functions life chewing, talking and smiling and can influence the individual's social roles [3].
Adolescence is the period in the human life when the relationship between biological, behavioral, socioeconomic and psychological conditions have a very strong effect on caries etiology [4]. World Health Organization (WHO, 2015) defnition of adolescents is individuals that are in the age from 10 to 19 years. The American Academy of Pediatrics divides adolescence into three different stages: early adolescence 11 to 14 year old, middle adolescence 15 to 17 year old, and late adolescence 18 to 21 year old [6]. The last stage of the definition of adolescence "late adolescence" is very important regarding the oral health. In this stage, the individuals personalty, oral hygiene behaviour, diet-related choices, and motivations forms during this period [7]. The behaviours and attitudes formed during adolescence usually last into adulthood [8].
Behaviours, and more precisely within this context oral health-related behaviours, are established early in life; they usually originate from home and from the surrounding environment as children like to imitate their parents and in this way adapt many habits and behaviours from them. In everyday life, parents act as role models for their offspring, and therefore, parents own oral health-related behaviours is very important. Children are also highly dependent on their parents and carers, not only for their general physical and emotional well-being, but also to achieve good oral health care, for example, by providing
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According to the Public Health Agency, unhealthy eating habits are one of the biggest risk factors for ill-health and premature death in Sweden. The eating habits among people in Sweden have improved in many ways since 1990s, but the intake of vegetables, fruits, whole grains is still too low. At the same time, intake of sweet drinks, pastries, fat dairy is too high [12]. An important topic regarding children's eating in the last decades is associated with excess weight. The prevalence of overweight and obese children has increased from 1980s, it has turned into a global epidemic. Dietary patterns are an important factor in the development of overweight and obesity [13]. The children in the national food survey consumed about 25% of their daily energy intake from food items like soft drinks, sweets, crisps, ice cream, dessert, cakes and biscuits [14]. When it comes to dietary assessment in children, both the food intake at home and at school need to be assessed. Parents may be considered reliable reporters of children’s diet at home, but are less likely to know what their children consume outside the home [15]. This becomes especially apparent in Sweden, as children are served a public meal away from home while at school. Neither parents nor children can thus be considered to objective and reliable reporters of children’s food intake [15]. Meals served in public institutions such as schools are considered to be an important part of the task. The Swedish school meal model is unique in offering free meals to all children between 7 and 16 years of age, and students between 16-19 years of age. Since 2012, the Education Act stipulates that school lunches must be nutritious, this equal a third of the recommended daily intake of energy and nutrients. [16]. The aims of these school food policies are in a majority of cases to improve child nutrition, to teach healthy diet and lifestyle habits, and to reduce or prevent childhood obesity [17]. Since policy and provision in Sweden is universal, all children in preschool/school are reached. However, there is some evidence that older children may eat lunch outside of school premises or choose to skip lunch [18].
Migrations is a social determinant of health including oral health [19]. A higher level of dental diseases and under utilization of dental care have been reported among immigrants as compared to their native-born counterparts. In addition, while many native-native-born children see dentists for preventive purposes, immigrants receive less preventative services and more treatments for preventive purposes, Therefore, disparities in oral health among immigrants is a serious public health matter that should not be neglected [20].
Children and youth arriving from countries with limited dental care and where diets are high in sugar are at the highest risk for dental diseases [21].
Today, Sweden is a multiethnic society. In 2012 every fifth child in Sweden had a foreign background. Almost 250.000 children were born abroad or were born in Sweden of two foreign-born parents and 30% of all children in the Swedish population had some connection with a foreign country. Many foreign-born parents bring their lifestyle, including eating habits, to their new country [22].
In Sweden, inequality in health issues is a matter of great concern. Parents with foreign background bring with them different cultures and different traditions [23].
To cope with the need for a better oral health in Sweden, considerable resources began to be assigned about 50 years ago. The oral health has since then undergone a remarkable transformation. In 1974 a New Dental Act was introduced in Sweden, which made Swedish counties responsible for providing full dental service free of charge for all children and adolescents up to the age of 20 years [24]. Dental health in Swedish children and adolescents has improved continuosly and considerably over the past decades, according to both official statistics and to scientific studies [25].
A contributing factor may be that dental care has been free of charge for all children and young people in Sweden for more than half a century, making regular dental examinations a well-established routine, irrespective attending the PDS or private dental care [24]. Dental care free of charge for the individual has been extended in Region Västra Götaland [26].
Despite the reduction in the caries disease, studies show that dental caries is a considerable health problem among children and adolescents [27].
Oral health problems still remain among children and young adults. Pre-school children with a foreign background are reported to have a significantly higher prevalence of caries and cariogenic exposure than those with a Swedish background. In Sweden: few studies have focused on Swedish children and adolescents with foreign backgrounds and the data from these studies are conflicting [24]. Despite the declining prevalence, dental caries in pre-school -ages children remains a public health challenge in many countries. Healthy teeth in children depend on lifestyle factors such as promoting tooth brushing and limiting the intake of sugary snacks [28].
Although most children in Sweden attend the prevention-oriented Public Dental Service free of charge, it is obvious that inequalities in oral health still exist and have even increased when it comes to children with foreign backgrounds. The preventive programme, designed to reach all children in to the community, resulted in a general improvement in oral health among children between 1993 and 2003. However, this improvement was not as pronounced in children with foreign backgrounds. The current community preventive programme is aimed equally at all children in Sweden, but has not been able to close the gap in oral health between the children with foreign and Swedish backgrounds. On the contrary the gap has increased [29].
1 2
Hypothesis: We expect that the oral health and habits of non native Swedish citizens poorer of those who
are native citizens.
Aim: To evaluate the attitude and habits toward oral health between the Swedish residents and Swedish
immigrants’ adolescents.
Objectives:
1. To analyse the data about the oral habits among Swedish residents and Swedish immigrants adolescents.
2. To analyse the data about the dietary habits among Swedish residents and Swedish immigrants adolescents.
REVIEW OF LITERATURE
In literature, various studies have evaluated the oral health and habits of Swedish children and foreigners and it has been found that the oral health of foreigners is poorer than the oral health of the Swedish native children.
There is a strong negative relationship between socio-economic status and dental health. Despite the fact that since 1974 Sweden has a general dental care insurance [30], which gives all children and adolescents access to free dental care, this is not enough to achieve an adequate oral health status. For a long time period, children and young people in Sweden experienced very positive health trends. However, during the 1990s, differences in average general health between social groups began to increase. The health conditions for immigrants in Sweden are poorer at a group level than those for native Swedes. According to a report from the Swedish National Board of Health and Welfare [31].
The prevalence of dental caries varies in different countries [32]. During the last two decades, the prevalence has decreased significantly among children and young people in Europe and especially in Sweden. Preventive programmes based on information and instruction in oral hygiene, fluoride adminstration and sugar restrictions have contributed to the improvement in oral health . Despite the fact that oral health has improved in recent years, there are still individuals in the population with a large number of decayed teeth [29].
In a study by Kramer et al. [33], differences were found in the number of dental caries among children and adolescents in Region Västra Götaland, with a skewed distribution within age groups, genders, residental areas and in relation to individual socioeconomic status.
Almost all the young people in the Nordic countries brush their teeth at least once a day. On the other hand, the use of proximal cleaning is not so extensive. Boys generally have poorer oral hygiene habits than girls in corresponding ages.
Toothpaste with fluoride was introduced in Sweden during the later part of the 1960s and today almost all toothpaste contain fluoride. The Nordic countries have Europe's highest figures when it comes to the daily use of fluoride toothpaste [29].
Dietary habits - since the results of the Vipeholm Study were presented [42], dental health professionals have spread the information of the importance of reducing the number of sugar-containing products between meals in order to reduce the risk of caries, especially among children and adolescents [35].
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According to the National Food Adminstrations in Sweden [14], there is a steady increase in the consumption of sweets, soft ice cream, snacks and pastries. One in ten children in Sweden drink more than four decilitres of juice and soda every day and eat more than 300 grams of sweets a week.
Many studies have demonstrated apparent poorer oral health in pre-school children with a foreign background compared with native-born pre-school children [29]. Flick et al. [36] and Julihn et al. [37] found a higher caries prevalence in the permanent dentition in children and adolescents with foreign background compared with their Swedish counterparts. Other studies of older children and adolescents have not found any significant differences in caries prevalence in groups with and without a foreign background [38].
Regarding toothbrushing habits and the use of floss in children and adolescents with Swedish and foreign background, there is a conflict between the results in different studies. In one study by Ekman et al. [39], no significant differences could be found, while Dahllöf et al. [38] found that more adolescents with a Swedish background brushed their teeth twice a day or more compared with adolescents with a foreign backgrounds. When it comes to the use of fluoride, no differences between children and adolescents with and without foreign backgrounds have been found [29].
Studies have also shown that children with foreign backgrounds have poorer dietary habits and a more frequent intake of sugar-containing products between meals [29].
The level of these differences appears to depend on the degree of integration into the new society, as well as on psychosocial and cultural factors. It is also possible that immigrants have a poor knowledge of the structure and function of the health care system in the new country. They may have different expectations of care and they may lack the ability to communicate with health professionals, including oral health services [40].
Education in good oral hygiene habits is considered one of the most important strategies for caries prevention.
Irregular eating habits and a greater ingestion of sugar-containing snacks are obvious risk factor for dental caries. This has been known since the 1950s, due to the finding of the Vipeholm studies [42]. It has been shown that an increased frequency of food intake increases the risk for caries in young children. A report from the National Food Adminstration (NFA) in Sweden showed that snack consumption among children has steadily increased in recent decades. The NFA also found that the children of parents with foreign background consume more fruits and vegetables but drank less milk than their counterparts with a Swedish background [43].
Epidemiological studies from the Scandinaviann countries (Denmark, Sweden and Norway) have revelead disparities in caries between children and adolescents with and without foreign backgrounds. [45].
In the Swedish survery from 2009, 68% of persons born outside Europe stated that they had got enough information to be able to keep their teeth healthy themselves compared with 92% of those born in Sweden [46].
The oral hygiene habits differ in people depending on their socioeconomic status and cultural background. In Sweden there is a social inequality in oral health, as a majority of children that have caries come from families with a low education, low income and also from families with an immigrant background. Their oral hygiene habits are usually insufficient and their visits to the dentist are often less frequent than in children who grow up under moroe convenient social circumstances [47].
In a study that has taken place in the city of Umeå, there has been several investigations for the prevalence of caries. In these studies, a change could be seen between the years 2002 and 2007, where the occurence of caries was decreased [48]. This was coherent with a decrease in the intake of sugary snacks and an increase in tooth brushing. In a follow-up 5 years later, it was shown that the decline in caries was however limited to non-immigrant children, leaving immigrant children with a higher prevalence of caries [49]. The Swedish concept of candy being limited to Saturday could be a reason to why immigrant children might have a higher sugar consumption. This aspect as well as the lesser frequency of tooth brushing with parental assistance might partly explain the skewed distribution of caries in immigrant children compared to that of non-immigrant children [50]. It has also been observed that regardless of attempts in educating the parents with immigrant background in their children's oral hygiene, there is no improvement in their oral health. Another observed difference in the families with immigrant background is the significantly lower maintenance of dental care, even in the Nordic countries where dental care is free. This is believed to be due to a tradition where a visit to the dentist merely is made in emergenices, which makes prophylactic dental are and education more difficult [50].
It is remarkable that the knowledge of the etiology of caries has not increased during the 40-year study period despite all professional information given in schools and at dental visits [24].
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MATERIAL AND METHODS
The survey was conducted from November 2019 to January 2020 in Sweden, Gothenburg which is the second largest city in the country. The city has a population of 581,822, while the metro area has a population that exceeds 1 million residents. [14]
The study was carried out in one school called Gårdsten school. A self-administered questionnaire was distributed by one teacher to 250 students. The response rate was 100% due to the participant's high awareness and willingness to participate.
Ethical approval was obtained from the bioethics departments in Lithuanian University of Health Sciences (Reference no. BEC-OF-84).
Subjects
Participants were 250 students aged between 11 to 15 years. Gender of participants’ was grouped into three groups: girl, boy and not identifying themselves as neither boy nor girl. Family background was sorted out into the following groups: Swedish if they have born in Sweden with Swedish ethnic parents (RS, both SP); born in Sweden with a mixed ethnic background if one parent has an Swedish ethnic background and one parent does not have the Swedish ethnic background. (RS, FP+SP); immigrants if they have been born in a foreign country or born in Sweden, have risen in Sweden with two foreign born parents (RS, both FP) and immigrants if they were born and raised abroad, with foreign parents.
Questionnaire
The self-administered anonymous questionnaire was self-prepared by the investigator in English. Later it was translated in Swedish.
Questionnaire was designed to evaluate the attitude and habits toward oral health between the Swedish residents and Swedish immigrant adolescents.
The questionnaire consisted of 3 parts; the first part included questions about demographic characteristics (gender of the child and family background). The second part of the questionnaire was about the attitude and behavior of the children's oral health. The following questions asked about frequency of tooth brushing (>2 times a day, once a day, few times a week, occasionally or never), later options were regrouped into three groups: at least twice a day, once a day and rarer or never. Question
about duration of tooth brushing had the following options: up to 1 minute, 2 minutes, longer than 2 minutes. Question about type of toothpaste had these following options: toothpaste with fluoride, fluoride-free toothpaste and “I do not know". Questions about additional oral hygiene measures covered questions if they use mouthwash and interdental aids. Finally, question regarding to frequency of dental visit had the following options less than 6 months, every 6 months, once a year, in a toothache case, longer than a year or never. The part about dietary habits asked how often participants intake the following products: tea or coffee with sugar, carbonated beverages, non-carbonated beverages (juices, nectars), flavored water, energy drinks, sport drinks, smoothies, biscuits and raisins and chips, candy, sweets with xylitol. Meanwhile, frequency of intake was grouped as never, occasionally, not more than once a week, 2- 3 times a week and daily. Later these options were regrouped into 3 groups; never or occasionally, up to several times a week (weekly), and daily.
Statistical analysis
The data was analyzed using the Statistical Package for the Social Sciences (SPSS) program, version 20. To establish relationships between categorical variables, the Pearson chi-squared test (χ2) was used. The level of significance was set at P <0.05.
1 8
RESULTS
Overall, participants were girls (47.6%) boys (50.8%) and „neither boy nor girl" (1.6%). Considering the family background, participants (36%) rose in Sweden with only foreign parents prevailed, while students (14.8%) rose in Sweden with both Swedish parents were the smallest group (Table 1).
Table 1. Characteristic of participants (N=250).
Variable Total N(%)
Gender
Girl 119 (47.6)
Boy 127 (50.8)
Neither boy, nor girl 4(1.6)
Family background
Raised in Sweden with both Swedish parents 37 (14.8) Raised in Sweden with one foreign parent and one Swedish parent 53 (21.2) Raised in Sweden with only foreign parents 90 (36.0)
Raised up abroad. 70 (28.0)
Results showed that a majority (56.8%) of participants brushed their teeth for 2 minutes (Table 2). Significantly more children raised in Sweden with both foreign parents (74.4%) brushed teeth for 2 minutes than children with foreign and Swedish parent (45.3%) (p=0.001) (Table 2).
Moreover, 79.2% of children brushed their teeth at least twice a day (Table 3). Results showed that significantly more girls than "neither boy, nor girl” (86.6% vs. 25%) brushed teeth at least twice a day (p<0.001).A majority of participants (61.4%) that brush their teeth at least twice a day, brushed
teeth for 2 minutes, while a half of children (50.0%) who brushed less than daily reported brushing up to 1 minute (p=0.004) (Table 4).
Results revealed that 62% of participants reported using toothpaste with fluoride. Considering the family background, significantly children raised in Sweden with both Swedish parents (75.5%) used toothpaste with fluoride than children raised abroad (44.3%) (p=0.015) (Table 3). Furthermore, a majority of participants (67.0%) brushing teeth at least twice a day used toothpaste with fluoride, while most of children (62.5%) brushing teeth less than daily did not know the type of tooth paste (p<0.001) (Table 4).
60.0% of children used mouthwash. Subsequently, significantly more children (71.7%) raised in Sweden with one Swedish and one foreign parent used mouthwash than children raised abroad (38.6%) (p<0.001) (Table 2). Moreover, significantly more girls used mouthwash than "neither boy, nor girl” (68.1% vs. 25%) (p=0.024) (Table 3). In addition, more participants brushing teeth at least twice a day used mouthwash than children brushing teeth once a day (64.5% vs. 43.2%) (p=0.021) (Table 4).
Results showed that a majority of children (62.4%) did not use interdental aids. Although a half of children (51.3%) raised in Sweden with both Swedish parents and only 28.6% of children raised abroad reported using interdental aids, it did not differ statistically significantly (p=0.068) (Table 2).
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Table 2. Relationship between family background and children’s oral hygiene habits.
Variables Family’sbackground N(%) Total N(%) P-value
RS, both SP RS, FP+SP RS, both FP Raised abroad Duration oftoothbrushing <1 minute 9 (24.3) 14 (26.4) 7 (7.8) 24 (34.3) 54 (21.6) 0.001 2 minutes 19 (51.4) 24 (45.3) 67 (74.4) 32 (45.7) 142 (56.8) >2 minutes 9 (24.3) 15 (28.3) 16 (17.8) 14 (20.0) 54 (21.6) Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0) Typeofusedtoothpaste Withfluoride 28 (75.7) 39 (73.6) 57 (63.3) 31 (44.3) 155 (62.0) 0.015 Fluoridefree 3 (8.1) 6 (11.3) 14 (15.6) 18 (25.7) 41 (16.4) Don’tknow 6 (16.2) 8 (15.1) 19 (21.1) 21 (30.0) 54 (21.6) Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0) Usageofmouthwash Yes 26 (70.3) 38 (71.7) 59 (65.6) 27 (38.6) 150 (60.0) <0.001 No 11 (29.7) 15 (28.3) 31 (34.4) 43 (61.4) 100 (40.0) Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0)
Usageof interdental aids
Yes 19 (51.3) 24 (45.3) 31 (34.4) 20 (28.6) 94 (37.6) 0.068
No 18 (48.7) 29 (54.7) 59 (65.6) 50 (71.4) 156 (62.4)
Total N(%) 37 (100) 53 (100) 90 (100) 70 (100) 250 (100)
RS- raised in Sweden, SP- Swedish parent, FP- Foreignparent
Table 3. Relationship between gender and oral health behaviour (N=25)
Variables Gender N (%) Total N(%) P-value
Girl Boy Neither
boy, nor
girl Frequencyoftoothbrushing
At leasttwice a day 103 (86.6) 94 (74.0) 1 (25.0) 198 (79.2) <0.001
Once a day 13 (10.9) 21 (16.5) 2 (50.0) 36 (14.4)
More rare or never 3 (2.5) 12 (9.5) 1 (25.0) 16 (6.4)
Total N(%) 119 (100.0) 127 (100.0) 4 (100.0) 250 (100.0)
Usageofmouthwash
Yes 81 (68.1) 68 (53.5) 1 (25.0) 150 (60.0) 0.024
No 38 (31.9) 59 (46.5) 3 (75.0) 100 (40.0)
Total N(%) 119 (100.0) 127 (100.0) 4 (100.0) 250 (100.0)
Intake of energy drinks (Missing N=1)
Occasionally 101 (84.9) 108 (85.7) 3 (75.0) 212 (85.1) <0.001
Weekly 17 (14.3) 17 (13.5) 0 (0.0) 34 (13.7)
Daily 1 (0.8) 1 (0.8) 1 (25.0) 3 (1.2)
Total N(%) 119 (100.0) 126 (100.0) 4 (100.0) 249 (100)
Intake of sport drinks (Missing N=1)
Occasionally 105 (88.2) 106 (84,1) 2 (50.0) 213 (85.5) 0.001
Weekly 14 (11.8) 17 (13.5) 1 (25.0) 32 (12.9)
Daily 0 (0.0) 3 (2.4) 1 (25.0) 4 (1.6)
Total N(%) 119 (100.0) 126 (100.0) 4 (100.0) 249 (100.0)
Intake of smoothies (Missing N=1)
Occasionally 73 (61.3) 77 (61.1) 1 (25.0) 151 (60.6) 0.009
Weekly 42 (35.3) 49 (38.9) 2 (50.0) 93 (37.4)
Daily 4 (3.4) 0 (0.0) 1 (25.0) 5 (2.0)
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Table 4.Participants’ (N=250) behavior by their own toothbrushing.
Variables Frequencyoftoothbrushing N(%) Total N(%) P-value ≤2 times/day Once a day Less thandaily
Duration oftoothbrushing
<1 minute 38 (19.3) 8 (21.6) 8 (50.0) 54 (21.6) 0.004 2 minutes 121 (61.4) 15 (40.6) 6 (37.5) 142 (56.8)
>2 minutes 38 (19.3) 14 (37.8) 2 (12.5) 54 (21.6) Total N(%) 197 (100.0) 37 (100) 16 (100.0) 250 (100.0)
Type of used toothpaste
Withfluoride 132(67.0) 19 (51.4) 4 (25.0) 155 (62.0) <0.001 Fluoride- free 31 (15.7) 8 (21.6) 2 (12.5) 41 (16.4) Don’t know 34 (17.3) 10 (27.0) 10 (62.5) 54 (21.6) Total N(%) 197 (100.0) 37 (100.0) 16 (100.0) 250 (100) Usage of mouthwash Yes 127 (64.5) 16 (43.2) 7 (43.7) 150 (60.0) 0.021 No 70 (35.5) 21 (56.8) 9 (56.3) 100 (40.0) Total N(%) 197 (100.0) 37 (100.0) 16 (100.0) 250 (100.0)
Intake of sugared tea or coffee
Occasionally 140 (79.5) 39 (75.0) 18 (81.8) 197 (78.8) 0.036
Weekly 26 (14.8) 11 (21.2 0 (0.0) 37 (14.8)
Daily 10 (5.7) 2 (3.8) 4 (18.2) 16 (6.4)
Total N(%) 176 (100.0) 52 (100.0) 22 (100.0) 250 (100.0)
Intake of non-carbonated beverages
Occasionally 142 (79.8) 51 (82.3) 4 (40.0) 197 (78.8) 0.010
Weekly 25 (14.0) 9 (14.5) 3 (30.0) 37 (14.8)
Daily 11 (6.2) 2 (3.2) 3 (30.0) 16 (6.4)
Total N(%) 178 (100.0) 62 (100.0) 10 (100.0) 250 (100.0) Chi-square test; comparison between participants by frequency of tooth brushing
Results showed that children visit dental office mainly due to once a year (23%) or in case of pain (23%) (Figure 1).
Figure 1. Frequency of attendance of dental service among participants (N=250). (p>0.05)
Results showed that children consumed several products such as tea/coffee with sugar (70.4%), carbonated beverages (69.2%), non-carbonated beverages (71.2%), flavored water (84%), energy drinks (84.8%), sport drinks (85.2%) and smoothies (60.4%) mainly occasionally. Meanwhile, participants tended to intake biscuits, raisins or chips (63.2%), candies (72.0%) and sweets with xylitol (59.6%) weekly (Table 5).
19%
18%
23%
23%
17%
Attendance of dental service
<6 months Twice a year Once a year In case of pain >1 year
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Table 5. Participants’ consumption of various products.
Considering the gender, significantly more boys (85.7%) consumed energy drinks than 'neither boy nor girl' (75%) (p<0.001). Results showed more girls (88.2%) tended to intake sport drinks that than 'neither boy nor girl' (p=0.001). Finally, significantly more girls (61.3%) than „nor boy, neither girl“ (25.0%) drunk smoothies occasionally (p=0.009) (Table 3).
Variables Frequencyofproductsconsumption
Occasionally N(%)
Weekly N(%) Daily N(%) Total N(%)
Tea/coffeewith sugar 176 (70.4) 52 (20.8) 22 (8.8) 250 (100.0) Carbonatedbeverages 173 (69.2) 64 (25.6) 13 (5.2) 250 (100.0) Non-carbonatedbeverages 178 (71.2) 62 (24.8) 10 (4.0) 250 (100.0) Flavoredwater 210 (84.0) 35 (14.0) 5 (2.0) 250 (100.0) Energy drinks 212 (84.8) 35 (14.0) 3 (1.2) 250 (100.0) Sport drinks 213 (85.2) 33 (13.2) 3 (1.2) 250 (100.0) Smoothies 151 (60.4) 94 (37.6) 5 (2.0) 250 (100.0)
Biscuit, raisins or chips 81 (32.4) 158 (63.2) 11 (4.4) (250 (100.0)
Candy 48 (19.2) 180 (72.0) 22 (8.8) 250 (100.0)
Considering the family background, a majority (86.8%) of the children raised in Sweden, with foreign and Swedish parents had an occasionally intake of non-carbonated beverages, meanwhile significantly less children raised abroad (61.4%) occasionally consumed non-carbonated beverages (p=0.037). Significantly more children (93.3%) raised in Sweden, with both foreign parent than children (72.8%) raised abroad have used energy drinks occasionally (p=0.008). Moreover, significantly more children raised abroad consumed biscuit, raisins or chips weekly than children raised in Sweden with both foreign parents (70.0% vs. 58.9%) (p=0.002). Results showed that more participants (86.5%) raised in Sweden with Swedish parents mainly used candies weekly than children (60%) raised in Sweden with both foreign parents (p=0.0001). Significantly more children (65.7%) raised abroad consumed sweets with xylitol than participant (53.3%) raised in Sweden with foreign parents (p=0.018) (Table 6). Results showed that more children (18.2%) brushing teeth less than daily drunk sugared tea daily than children (3.8%) brushing teeth once a day (p=0.036). Furthermore, more children (79.5%) brushing teeth at least twice a day consumed non-carbonated beverages than children (40%) brushing teeth less than daily (p=0.010) (Table 4).
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Table 6. Participants’ dietary habits by the family background (N=250).
Variables Family’sbackground N(%) Total N(%) P-value
RS, both SP RS, FP+SP RS, both
FP
Raised abroad Intake of non-carbonated beverages
Occasionally 25 (67.6) 46 (86.8) 64 (71.1) 43 (61.4) 178 (71.2) 0.037
Weekly 12 (32.4) 5 (9.4) 21 (23.3) 24 (34.3) 62 (24.8)
Daily 0 (0.0) 2 (3.8) 5 (5.6) 3 (4.3) 10 (4.0)
Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0)
Intake of energy drinks
Occasionally 29 (78.4) 48 (90.6) 84 (93.3) 51 (72.8) 212 (84.8) 0.008
Weekly 8 (21.6) 5 (9.4) 5 (5.6) 17 (24.3) 35 (14.0)
Daily 0 (0.0) 0 (0.0) 1 (1.1) 2 (2.9) 3 (1.2)
Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0)
Intake of biscuits, raisins or chips
Occasionally 12 (32.4) 19 (35.8) 37 (41.1) 13 (18.6) 81 (32.4) 0.002 Weekly 25 (67.6) 31 (58.5) 53 (58.9) 49 (70.0) 158 (63.2) Daily 0 (0.0) 3 (5.7) 0 (0.0) 8 (11.4) 11 (4.4) Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0) Consumption of candies Occasionally 4 (10.8) 7 (13.2) 30 (33.3) 7 (10.0) 48 (19.2) 0.0001 Weekly 32 (86.5) 39 (73.6) 54 (60.0) 55 (78.6) 180 (72.0) Daily 1 (2.7) 7 (13.2) 6 (6.7) 8 (11.4) 22 (8.8) Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0)
Intake of sweets with xylitol
Occasionally 7 (18.9) 4 (7.5) 30 (33.3) 14 (20.0) 55 (22.0) 0.018
Weekly 23 (62.2) 32 (60.4) 48 (53.3) 46 (65.7) 149 (59.6)
Daily 7 (18.9) 17 (32.1) 12 (13.4) 10 (14.3) 46 (18.4)
Total N(%) 37 (100.0) 53 (100.0) 90 (100.0) 70 (100.0) 250 (100.0)
Analysing the relationship between duration of toothbrushing and dietary habits, results showed that more children (18.5%) brushing teeth less than drunk sugared tea or coffee daily than participants (1.8%) brushing teeth at least 2 minutes (p=0.018). Moreover, more children (20.4%) brushing their teeth <1 minute used sport drinks weekly than children (9.8%) brushing teeth for 2 minutes (p=0.016). Furthermore, more children brushing teeth at least 2 minutes consumed smoothies occasionally than adolescents brushing teeth less than 1 minute (70.4% vs. 53.7%) (p=0.013). More children (20.4%) brushing teeth less than 1 minute ate candies daily than participants (4.9%) brushing teeth 2 minutes (p=0.005). Results revealed that more children (33.3%) that brush their teeth at least 2 minutes consumed sweets with xylitol than adolescents (13.4%) brushing teeth into 2 minutes (p=0.010) (Table 7).
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Table 7.Participants’ dietary habits by duration of toothbrushing (N=250).
Variables Duration oftoothbrushing N(%) Total N(%) P-value <1 minute 2 minutes >2 minutes
Intake of sugared tea or coffee
Occasionally 31(57.4) 101(71.2) 44(81.5) 176(70.4) 0.018 Weekly 13(24.1) 30 (21.1) 9(16.7) 52(20.8)
Daily 10(18.5) 11(7.7) 1(1.8) 22(8.8) Total N(%) 54 (100.0) 142 (100.0) 54 (100.0) 250 (100.0)
Intake of sport drinks
Occasionally 40(74.1l) 128(90.2) 45(83.3) 213(85.2) 0.016 Weekly 11(20.4) 14(9.8) 8(14.8) 33(13.2) Daily 3(5.5) 0 (0.0) 1(1.9) 4(1.6) Total N(%) 54 (100.0) 142 (100.0) 54 (100.0) 250 (100.0) Intake of smoothies Occasionally 29(53.7) 84(59.2) 38(70.4) 151(60.4) 0.013 Weekly 21(38.8) 57(40.1) 16(29.6) 94(37.6) Daily 4 (7.4) 1(0.7) 0 (0.0) 5(2.0) Total N(%) 54 (100.0) 142 (100.0) 54 (100.0) 250 (100.0) Consumption of candies Occasionally 5(9.2) 33(23.3) 10(18.5) 48(19.2) 0.005 Weekly 38(70.4) 102(71.8) 40(74.1) 180(72.0) Daily 11(20.4) 7(4.9) 4(7.4) 22 (8.8) Total N(%) 54 (100.0) 142 (100.0) 54 (100.0) 250 (100.0)
Intake of sweets with xylitol
Occasionally 11(20.4) 30(21.1) 14(26.0) 55(22.0) 0.010 Weekly 34(62.9) 93(65.5) 22(40.7) 149(59.6)
Daily 9(16.7) 19(13.4) 18(33.3) 46(18.4) Total N(%) 54 (100.0) 142 (100.0) 54 (100.0) 250 (100.0)
DISCUSSION
In this current study conducted in Sweden, overall participants reported proper oral hygiene habits, such as toothbrushing at least twice a day for 2 minutes and mouthrinsing. Moreover, majority of children knew than they used toothpaste with fluoride. However, participants tended not to use interdental aid measures. Considering the dietary habits, adolescents showed a good attitude and reported consuming sugar containing products mainly occasionally or weekly.
Numerous studies have been carried out to compare the association between children's and adolescents attitude and awareness of oral health in Sweden. Only a few studies can be found which compare the ethnicities of children and the attitude and habits of the children toward oral health [23, 29, 49]. There is limited data on oral health and its determinants in the Swedish population [51]. Therefore, the main focus of this study is on the comparison of children with different ethnicities than Swedish and Swedish children and their oral hygiene and habits of the children. The results attained in this study will be compared with results from existing studies.
The results obtained from the present study shows that the recommended frequency of tooth brushing is followed as the majority of the participants brushed their teeth for 2 minutes. Similarly, a study conducted in Sweden, showed that a percentage of 51% of the adolescents brushed their teeth for two minutes or longer while 49% brush their teeth for less than 2 minutes. [59]
Results of this study showed that significantly more girls than any of the other gender groups, brushed teeth at least twice a day. Similarly, a study carried out in Lithuania found that the females brush their teeth more regularly than men [54]. Additionally, another study that was conducted in Saudi Arabia, found that more girls reported brushing their teeth than boys [55]. In a study conducted in Greece, there were similar results to the present study. The meta-analysis of data by gender, females brush their teeth more often than males. [56]. These results show a direct correlation between gender and tooth brushing habits.
In the current study, 62% of children used fluoridated toothpaste when brushing their teeth. These results are in contrast with those of a study conducted in Sweden to analyze the use of toothpaste among adolescents, which reported that in Sweden, the use of fluoride toothpaste is low, despite frequent dental care [57]. However, a study conducted in Sweden reported that fluoride toothpaste was used by 44-78% of the children [58]. Furthermore, in contrast to the present study, a study in Sweden showed that tooth brushing with fluoride toothpaste is a priority among Swedish adolescence, despite the lack of knowledge
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toothbrushing with fluoride toothpaste is significant for the prevention of caries and the population in Sweden appears to have embraced this practice to a large extent [59]. These results concur with the results of the present study that a moderate to high number of Swedish adolescents use fluoride toothpaste and are aware of its positive effect on oral health.
In the present study, overall 60% of the children reported using mouthwash. These results differ from that of a study conducted in Sweden between different age groups. The latter study results revealed that the majority reported that they did not use mouthwash. Furthermore 66% of the adolescents between the ages of 12-15 years answered that they have no usage of mouthwash, and only 24% answered that they mouth rinse with fluoride [59]. These results concur with a study conducted in Saudi Arabia, reported that 84.3% of the children answered that they do not use mouthwash [60]
In the present study, 62.4% of children did not use interdental aids. Similarly, in a study conducted in Sweden the results show that interdental aids were used less frequently among the young participants compared to participants in the age group of 31-35 years. Additionally to the latter study, 67% of the adolescents between the ages of 15-16 years reported not having any usage of interdental aid [59]
It was noted in the present study that there was occasionally an intake of products such as tea/coffee with sugar, carbonated beverages, non-carbonated beverages, flavored water, energy drinks, sport drinks and smoothies. Furthermore there was a weekly consumption of other sugar containing products such as: biscuits, raisins or chips (63.2%), candy (72.0%) and sweets with xylitol (59.6%).
In comparison to this, a study conducted in Saudi Arabia assessed the frequency of children's consumption of various cariogenic foods and found that children consumed carbonated drinks (40.6%), cake (15.8%) and sweets (14.5%) on a daily basis if not several times a day [61]. A further Swedish study revealed that high intakes of sugars and food and drink rich in added sugar in European children on both weekdays and weekends. It was shown that the intake was generally higher on weekdays and weekends [62].
The results of present study showed evidence that the energy drink intake amongst boys was higher in comparison to the other gender groups (85.7%) weekly. These results match those of a study carried out in Sweden, which showed that girls consume less sweetened drinks [63]. Additionally the results of another study from Poland showed that girls consumed fruit juices more often than boys and sweetened beverages less often. [64]. In a study conducted in India, the results revealed that males (53.4%) showed a comparatively greater tendency to have sugar sweetened products than females (47.5%). [65]. These results may show a link between gender and the consumption of sweetened drinks.
In the present study, children raised in Sweden with Swedish parents consumed candy weekly and more frequently (86.5%) than the children who are raised in Sweden with both foreign parents (60%). In comparison to these results, a 2016 study done by The Swedish Board of Agriculture, found that Sweden
has the highest candy consumption per capita in the world, about 35 pound per person per year. An average Swede eats over half a pound of candy every week. Furthermore, some researchers suggest that immigrants tend to preserve healthy eating habits such as consumption of fruits and vegetables [66]. These results, as well as the results shown in the present study show a correlation between the intake of candy and ethnicity in Sweden. However, the results regarding sweets and sugar consumption contradict previous studies conducted by Wändell et al. [66] and Irene et al. [67] which indicated that immigrants tend to have a higher intake of sugar containing food and drinks compared to the rest of the population.
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CONCLUSION
1. Children raised in Sweden with both foreign parents reported brushing teeth for 2 minutes and using mouthwash regularly. Meanwhile, children raised abroad tended to use toothpaste with fluoride and interdental aids rare than other children.
2. More adolescents raised in Sweden with Swedish parents consumed candies weekly than other children. Children raised abroad tended to consume various products such as biscuits, raisins, chips, non-carbonated beverages, energy drinks and sweets with xylitol more common than other participants.
3. This study showed that boys tended to have a higher sugar-sweetened products intake and poorer oral hygiene skills.
ACKNOWLEDGEMENT
I would like to express my sincere gratitude and appreciation to my thesis supervisor Dr. Sandra Petrauskienė of the Faculty of Odontology at the Lithuanian University of Health Sciences for the valuable guidance, continuous support, and immense knowledge. My sincere thanks also go to the principal of Gårdsten School who allowed me to conduct this research at their facility.
PRACTICAL RECOMMENDATIONS
When planning dental services for children, information on parental behaviour and attitude toward children’s oral health should be taken into consideration. Lectures for parents and children should be organized in order to emphasize the importance of oral health, oral hygiene and dietary habits. Pamphlets can be prepared with useful information as well. Since children already attend school, teachers or school staff could give short lectures about maintaining a healthy life style for children.
CONFLICT OF INTEREST
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