healthcare

Article
Oral Hygiene Practices and Oral Health Knowledge among
Students in Split, Croatia
Antonija Tadin 1, *,† , Renata Poljak Guberina 2,† , Josipa Domazet 1 and Lidia Gavic 1

1 Department of Restorative Dental Medicine and Endodontics, School of Medicine, University of Split,
21000 Split, Croatia; josipadomazet97@gmail.com (J.D.); lgavic@mefst.hr (L.G.)
2 Department of Prosthetic Dental Medicine, School of Medicine, University of Split, 21000 Split, Croatia;
poljak@sfzg.hr
* Correspondence: atadin@mefst.hr; Tel.: +385-98609191; Fax: +385-21557624
† These authors contributed equally to this work.

Abstract: Background: Knowledge of oral health is a fundamental prerequisite for healthy behavior,
allowing individuals to take measures to protect their overall health. This cross-sectional study
aimed to examine the knowledge of oral health as well as to assess the oral hygiene habits among
healthcare and non-healthcare students. Methods: The study was based on a questionnaire and was
conducted among 1088 students. Most of the students, 67.6% were non-healthcare students. Data
were processed by Mann–Whitney or Kruskal–Wallis one-way ANOVA test. Results: The correct
median score and interquartile range were 11 (9–13) for all surveyed students, 11 (9–12) for students
in non-healthcare programs and 13 (11–14) for students in healthcare programs. Students did not
significantly differ in the knowledge of oral health by gender (p = 0.082) but did differ by age, study
program, and year of study (p ≤ 0.001). Students whose family members work in the field of dental
medicine also showed better oral health knowledge (p ≤ 0.001). Conclusion: The results showed good





 oral health knowledge among tested university students. However, it is important to emphasize that
Citation: Tadin, A.; Poljak Guberina, students who showed better knowledge more often used additional aids to maintain oral hygiene;
R.; Domazet, J.; Gavic, L. Oral therefore, the obtained data underline the importance of students’ further education in order to better
Hygiene Practices and Oral Health understand and maintain oral health.
Knowledge among Students in Split,
Croatia. Healthcare 2022, 10, 406. Keywords: knowledge; oral health; oral hygiene; practice; students
https://doi.org/10.3390/
healthcare10020406

Academic Editors: Joseph Nissan

and Gavriel Chaushu 1. Introduction

Received: 15 January 2022

There is much more to oral health than beautiful and healthy teeth. It is fundamental
Accepted: 18 February 2022
to overall health and affects the wellbeing and quality of life of every individual [1]. Oral
Published: 21 February 2022
health affects an individual’s oral functions and social interactions, and it is closely linked
to overall health and quality of life [2–4].
Publisher’s Note: MDPI stays neutral
Oral health is an integral part of overall health, and each influences the other [3,5–7].
with regard to jurisdictional claims in
Improper diet, smoking, alcohol intake, and poor oral hygiene practices are the most
published maps and institutional affil-
significant factors influencing the occurrence of various oral diseases. Diet affects the
iations.
development of dental caries, dental erosion, periodontitis, oral cancer, and many other
diseases of the soft tissues of the oral cavity. Smoking has been linked to oral cancer,
gingival and periodontal disease, periimplantitis, tooth discoloration, halitosis, taste bud
Copyright: © 2022 by the authors.
changes, and difficulty healing wounds after surgery. High alcohol intake is associated
Licensee MDPI, Basel, Switzerland. with an increased risk of developing oral cancer or other potentially malignant disorders,
This article is an open access article periodontitis, dental caries, and xerostomia. Poor oral hygiene can lead to the development
distributed under the terms and of dental caries and periodontitis, and is also associated with heart disease, cancer, and
conditions of the Creative Commons diabetes [7–11].
Attribution (CC BY) license (https:// Many of these oral diseases are preventable through education about risk factors. Oral
creativecommons.org/licenses/by/ hygiene is a critical factor in maintaining good oral health, and subsequently is related to
4.0/). overall health and quality of life. The most effective method for preventing dental caries or

Healthcare 2022, 10, 406. https://doi.org/10.3390/healthcare10020406 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, 406 2 of 12

periodontitis is the removal of dental plaque by regular and proper mechanical cleaning of
the teeth, a key step in maintaining oral health [4,12,13].
Knowledge of oral health is a fundamental prerequisite for healthy behavior, which
allows an individual to take measures to protect their own health. Different researches have
shown links between increased knowledge of oral health and better oral hygiene and health-
related behaviors [4,14,15]. Many studies about oral hygiene practices and knowledge
have been conducted among university students in different parts of the world, but this
is the first such study conducted at the University of Split. This study aimed to examine
and compare oral health knowledge among healthcare and non-healthcare students, and
to assess their respective oral hygiene habits and students’ own self-assessments of their
oral health. The goals of the study were to determine if there is a difference in oral health
knowledge among respondents from different scientific fields, and if there is a difference in
oral hygiene habits among respondents depending on their oral health knowledge.

2. Materials and Methods

This cross-sectional survey, in the form of a questionnaire, was conducted during
February and March of 2021 at the Department of Restorative Dental Medicine and En-
dodontics of the School of Medicine, University of Split, Croatia. The study was conducted
following all ethical principles, including the Helsinki Declaration of the World Medi-
cal Association, and was approved by the Ethics Committee (Class: 003-08/21-03/0003,
No.: 2181-198-03-04-21-0012).
The online survey questionnaire, which was based on several surveys related to the
same topic, consisted of four parts and contained 43 questions [14,16–18]. The first part
included primary demographic and professional data (gender, age, study, year of study,
employment of a family member in health/dental medicine, assessment of socioeconomic
status) of respondents. The second part contained 15 closed questions related to knowledge
about oral health and its maintenance. Each correct answer in the second part was scored
with one point, and incorrect answers scored zero points, for a maximum possible score
of 15. The sum of correct answers for each respondent was taken as a measure of their
overall oral health knowledge, and was the primary result considered in the study’s
analysis. The third part consisted of 11 questions related to the oral hygiene habits of
the respondents (including frequency of brushing, use of fluoride toothpaste, duration of
brushing, toothbrush hardness, brush type, frequency of changing toothbrush, brushing
technique, use of dental floss, use of interdental brush, use of mouthwash, and tongue
washing). The fourth part consisted of three questions related to the usage of dental
services (frequency of visits to the dentist, the reason for the last visit, time since the last
visit), six questions were relative to the self-assessment of oral health (including number
of fillings, extracted teeth, number of endodontically treated teeth, bleeding gums, dental
hypersensitivity, and bad breath) and one multiple-choice question about source of oral
health information (dentist, school, family and friends, media).
Experts from various fields of dental medicine (specialists in pediatric and preventive
dentistry and specialists in endodontics and restorative dentistry) endorsed the content
of the prepared questionnaire. As a reliability test, the questionnaire was administered to
30 students (15 from healthcare and 15 from non-healthcare studies) who confirmed the
comprehensibility of the survey questionnaire. These questionnaires were not included
in the dataset of the primary study. The internal consistency of the questionnaire in the
pre-testing phase was satisfying, with a Cronbach’s alpha coefficient of 0.71.
Students of seventeen different programs completed the questionnaire: four related to
healthcare (Medicine, Dental Medicine, Pharmacy, and University Department of Health
Studies) and thirteen unrelated to healthcare (Economics, Electrical Engineering, Mechani-
cal Engineering and Naval Architecture, Philosophy, Civil Engineering, Architecture and
Geodesy, Theology, Chemistry and Technology, Kinesiology, Maritime Studies, Law, Nature
Science, Marine Studies, and Forensic Sciences) of the University of Split, Croatia. The
study included 1088 adult students of both genders from all years of study who completed
Healthcare 2022, 10, 406 3 of 12

the questionnaire. The questionnaire was designed in the form of an online survey (Google
Forms), and its link was sent to the student representatives of each program, who then
forwarded it to other colleagues. The criteria for participation were students during the
academic year 2020/2021, attending one of the programs at the University of Split, who
fully completed the questionnaire. Minor students, and those who did not fully complete
the questionnaire, were excluded from the study. The research objectives of the study
were explained to all participants at the beginning of the questionnaire. Participation was
entirely voluntary and anonymous.
The minimum required sample size (n = 377) was calculated from the total number of
students who studied at the University of Split in the academic year 2020/2021 (N = 18,026)
with a 95% confidence interval, a 5% error limit, and a response distribution of 50% (Sample
Size Calculator by Raosoft Inc., Seattle, WA, USA).
The data were analyzed by the Statistical Package for Social Sciences (SPSS, IBM Corp,
Armonk, New York, NY, USA) version 25. The Kolmogorov–Smirnov test was used to assess
the normality of the distribution of responses. Descriptive analysis calculated the frequency
and percentage of categorical data, and quantitative data were expressed as the median and
interquartile range (IQR). Statistical analysis was performed using the Mann–Whitney or
Kruskal–Wallis one-way ANOVA test. The significance level was set at p < 0.05.

3. Results
Table 1 presents the sociodemographic characteristics of the respondents; 1088 students
participated in the study, of which 869 (79.9%) were women. The mean age of the subjects
was 22.91 ± 2.62 (min 18, max 39). Most respondents (N = 352; 32.4%) attended one of the
programs in healthcare (medicine, dentistry, pharmacy, or health studies). Respondents
did not significantly differ in their knowledge of oral health by gender (p = 0.082), but did
differ by age, program, and year of study (p ≤ 0.001). Students whose family members
work in dental medicine also showed better knowledge of oral health (p ≤ 0.001).

Table 1. Demographic characteristics of students according to the average assessment of knowledge

about oral health.

Frequency Knowledge
Characteristic p
N (%) Median (IQR)
Woman 869 (79.9) 11 (9–13)
Gender 0.082
Man 219 (20.1) 11 (9–13)
18–22 500 (46.0) 11 (9–12.75) a,b
Age (years) 23–25 451 (41.5) 12 (10–14) a ≤0.001
≥25 137 (12.6) 11 (10–14) b
Biomedicine and health 352 (32.4) 13 (11–14) c,d,e,f
Social Sciences 188 (17.3) 11 (9–12) c
Field of study Technical sciences 214 (19.7) 10 (8–12) d ≤0.001
Humanities 133 (12.2) 10 (8–12) e
Natural Sciences 201 (18.5) 11 (9–13) f
1st year 285 (26.2) 11 (9–12) g,h,i
2nd year 187 (17.2) 11 (9–13) j,k,l
3rd year 199 (18.3) 11 (9–12) m,n,o
Year of study ≤0.001
4th year 150 (13.8) 12 (10–13,25) g,j,m,p
5th year 193 (17.7) 11 (10–14) h,k,n,r
6th year 74 (6.8) 14 (13–14,25) i,l,o,p,r
Family members-healthcare No 815 (74.9) 11 (9–13)
0.067
employees Yes 273 (25.1) 12 (10–13)
Healthcare 2022, 10, 406 4 of 12

Table 1. Cont.

Frequency Knowledge
Characteristic p
N (%) Median (IQR)
Family members-employees in No 998 (91.7) 11 (9–13)
0.043
dental medicine Yes 90 (8.3) 12 (10–13)
Below average 104 (9.6) 11 (9–13)
Family financial status Average 574 (52.8) 11 (9–13) q 0.013
Above average 410 (47.7) 12 (10–13) q
Data are presented as median (IQR) or as numbers (percentages). Statistical significance was examined by
Mann–Whitney or Kruskal–Wallis one-way ANOVA test. A different letter in the superscript indicates a statistical
difference between the groups (a, c, d, e, f, i, l, m, n, o, p, r p ≤ 0.001, b p = 0.030, g p = 0.012, h,j p = 0.002, k p = 0.003,
q p = 0.013). Statistical significance was set at p < 0.05.

Table 2 shows the frequency of correct and incorrect answers to the questions regarding
oral health; 13 of the 15 questions were answered correctly by most respondents; 14 (1.3%)
of the respondents did not answer any questions correctly, while 47 (4.3%) answered all
questions correctly. The median correct score was 11 (9–13) for all surveyed respondents;
11 (9–12) for respondents in non-healthcare programs, and 13 (11–14) for respondents in
healthcare programs.

Table 2. The frequency distribution (%) of students’ answers about oral health.

Question Answer N (%)

Yes 1006 (92.5)
Oral health is closely related to an individual’s general health. No 18 (1.7)
I do not know 64 (5.9)
Yes 933 (85.8)
Certain systemic diseases can manifest in the oral cavity. No 8 (0.7)
I do not know 147 (13.5)
Yes 958 (88.1)
Oral health is closely related to an individual’s quality of life. No 42 (3.9)
I do not know 88 (8.1)
Yes 854 (78.5)
The most common oral diseases are dental dental caries, periodontitis
No 25 (2.3)
and oral cancer.
I do not know 209 (19.2)
Yes 1045 (96.0)
Poor oral hygiene can lead to the development of dental caries and
No 9 (0.8)
periodontitis.
I do not know 34 (3.1)
Yes 948 (87.1)
Diet affects the development of dental caries, periodontitis and
No 33 (3.0)
oral cancer.
I do not know 107 (9.8)
Yes 898 (82.5)
Smoking is associated with the occurrence of oral cancer and
No 22 (2.0)
periodontitis.
I do not know 168 (15.4)
Yes 623 (57.3)
High alcohol intake is associated with an increased risk of developing
No 53 (4.9)
oral cancer, periodontitis and dental caries.
I do not know 412 (37.9)
Yes 851 (78.2)
The hygiene and health of deciduous teeth are just as important as
No 41 (3.8)
permanent dentition.
I do not know 196 (18.0)
Healthcare 2022, 10, 406 5 of 12

Table 2. Cont.

Question Answer N (%)

Yes 999 (91.8)
Proper oral hygiene can prevent dental caries and periodontitis. No 24 (2.2)
I do not know 65 (6.0)
Yes 660 (60.7)
Fluorides have a protective role in the development of dental caries. No 30 (2.8)
I do not know 398 (36.6)
Yes 816 (75.0)
Mouthguards can prevent sports-related injuries to the teeth and
No 21 (1.9)
soft tissues.
I do not know 251 (23.1)
Yes 287 (26.4)
A permanent tooth avulsed from the mouth due to dental trauma can
No 260 (23.9)
be returned to the oral cavity.
I do not know 541 (49.7)
Yes 662 (60.8)
Sports drinks and energy drinks can damage the tooth surface and
No 37 (3.4)
cause erosion.
I do not know 389 (35.8)
Yes 349 (32.1)
Loss of teeth due to ageing is a physiological phenomenon that is not
No 273 (25.1)
possible to prevent.
I do not know 466 (42.8)
Data are presented as whole numbers and percentages. Correct answers are italicized.

Tables 3 and 4 show oral hygiene habits among the respondents. Most respondents
brush their teeth with a toothbrush and toothpaste several times a day (85.7%), with over
60.1% of respondents using fluoride toothpaste. Interestingly, 13.6% of respondents do
not use fluoride toothpaste, 38.6% never or rarely use dental floss as an aid to maintain
oral hygiene, and 65.1% never or rarely use interdental brushes. Only 26.7% and 15.3% of
respondents use dental floss and interdental brushes daily, 59.5% of the respondents report
daily tongue washing, and only 20.9% use mouthwash daily. Most respondents change
their toothbrushes every three months. About 70% of respondents brush their teeth for
two to three minutes; only 2.5% do so for more than five minutes. Better knowledge was
shown by subjects who use dental floss two or more times a day when compared to those
who use it rarely or not at all (p = 0.018; p = 0.016). This was also the case when comparing
those who regularly use interdental toothbrushes to those who do not use them, or use
them infrequently (p = 0.038; p = 0.048). Interestingly, poorer knowledge was shown by
subjects who do not use fluoride toothpaste (p ≤ 0.001) compared to those who use them.

Table 3. Oral-hygienic habits—tooth brushing of students according to the average assessment of

knowledge about oral health.

Knowledge
Question Answer N (%) p
Median (IQR)
Rarely 2 (0.2) 12.50 (11–12.50)
Several times a month (2–3x) 43 (4.0) 11 (7–12) a
How often do you brush
Once a week 1 (0.1) 10 (10)
your teeth with a 0.010
Several times a week (2–3x) 11 (1.0) 8 (5–14)
toothbrush and toothpaste
Once a day 99 (9.1) 11 (8–13)
Several times a day 932 (85.7) 11 (9–13) a
Healthcare 2022, 10, 406 6 of 12

Table 3. Cont.

Knowledge
Question Answer N (%) p
Median (IQR)
Never 148 (13.6) 10 (7–12) b,c,d,e,f
Rarely 127 (11.7) 11 (9–12) b,g
How often do you use Several times a month (2–3x) 58 (5.3) 11 (9.75–12.75) c
Once a week 36 (3.3) 11 (9–12.75) d,h ≤0.001
fluoride toothpaste
Several times a week (2–3x) 55 (5.1) 11 (10–13) i
Once a day 117 (10.8) 11 (8.50–13) e,j
Several times a day 547 (50.3) 12 (10–14) f,g,h,i,j
Less than a minute 97 (8.9) 11 (9–13)
How long do you brush Two to three minutes 767 (70.5) 10 (8–13)
0.159
your teeth Three to five minutes 197 (18.1) 11 (9–13)
More than five minutes 27 (2.5) 11 (9–13)
Very soft “extra-soft” 161 (14.8) 12 (10–13)
Soft 334 (30.7) 12 (10–13)
Toothbrush-hardness
Medium 436 (40.1) 11 (9–13) 0.104
you use
Hard 43 (4.0) 11 (9–13)
I do not know 114 (10.5) 10 (8–12)
Manual 980 (90.1) 11 (9–13) k
The sort of toothbrush- Electrical mechanical 69 (6.3) 12 (9–14)
0.002
you use Electric sonic 32 (2.9) 13.50 (12–14) k
Electric ionic 7 (0.6) 9 (5–15)
Once a month 267 (24.5) 11 (10–13)
How often do you change Every 3 months 650 (59.7) 11 (9–13)
0.349
your toothbrush Every 6 months 138 (12.7) 11 (9–13)
Every 12 months 32 (2.9) 10 (8–12)
Horizontal 37 (3.4) 11 (9–13.50) l
What brushing technique Vertical 8 (0.7) 14 (13–14) l,m
0.002
you use Circular 214 (19.7) 12 (9.75–14) n
Combination 829 (76.1) 11 (9–13) m,n
Data are presented as median (interquartile range (IQR) or as numbers (percentages). Statistical significance
was examined by Mann-Whitney or Kruskal–Wallis one-way ANOVA test. The same letter in the superscript
indicates a statistical difference between the groups (a p = 0.015, b p = 0.032, c p = 0.029, d,m p = 0.012, e p = 0.004,
f,g,j p ≤ 0.001, h p = 0.022, i p = 0.044, k p = 0.005, l p = 0.027, n p = 0.020). Statistical significance was set at p < 0.05.

Table 4. Oral-hygienic habits–oral hygiene aids of students according to the average assessment of
knowledge about oral health.

Knowledge
Question Answer N (%) p
Median (IQR)
Never 192 (17.6) 11 (9–13) a
Rarely 229 (21.0) 11 (9–13) b
Several times a month (2–3x) 128 (11.8) 11 (10–13)
How often do you use
Once a week 82 (7.5) 11 (8.75–13) ≤0.001
dental floss
Several times a week (2–3x) 167 (15.3) 11 (8.75–13)
Once a day 187 (17.2) 11 (8.75–13)
Several times a day 103 (9.5) 12 (10–14) a,b
Never 455 (41.8) 11 (9–13) c,d
Rarely 254 (23.3) 11 (9–13)
Several times a month (2–3x) 82 (7.5) 12 (9–13)
How often do you use
Once a week 51 (4.7) 12 (10–13) 0.003
interdental brushes
Several times a week (2–3x) 79 (7.3) 12 (9–14)
Once a day 81 (7.4) 12 (10–14) c
Several times a day 86 (7.9) 12 (10–14) d
Healthcare 2022, 10, 406 7 of 12

Table 4. Cont.

Knowledge
Question Answer N (%) p
Median (IQR)
Never 248 (22.8) 11 (9–13) e
Rarely 283 (26.0) 11 (9–13)
Several times a month (2–3x) 123 (11.3) 12 (9–13)
How often do you use
Once a week 74 (6.8) 11 (10–13) 0.002
mouth rinse
Several times a week (2–3x) 132 (12.1) 12 (10–14) e
Once a day 135 (12.4) 11 (9–13)
Several times a day 93 (8.5) 12 (10–14)
Never 67 (6.2) 11 (9–13)
Rarely 154 (14.2) 11 (8–13) f
Several times a month (2–3x) 86 (7.9) 11 (10–13)
How often do you brush
Once a week 52 (4.8) 10 (9–12) 0.002
your tongue
Several times a week (2–3x) 82 (7.5) 11 (8–13)
Once a day 209 (19.2) 11 (9–13)
Several times a day 438 (40.3) 12 (10–13) f
Data are presented as median (interquartile range (IQR) and as numbers (percentages). Statistical significance
was examined by Mann–Whitney or Kruskal–Wallis one-way ANOVA test. The same letter in the superscript
indicates a statistical difference between the groups (a p = 0.016, b p = 0.018, c p = 0.038, d p = 0.048, f p = 0.023).
Statistical significance was set at p < 0.05.

Table 5 shows the frequency and reasons for using dental services, as well as self-
assessment of oral health by respondents. More than half of the respondents (55.5%) visited
their dentist within the last six months; 59.9% of respondents stated that their most recent
visit to a dentist was a regular check-up, while 32.9% stated that a problem with a tooth or
orofacial structures motivated their most recent visit. Respondents who reported the former
scored higher on oral health knowledge that those who reported the latter (p ≤ 0.001). The
average number of fillings in respondents was 4.00 ± 3.17 (min 9, max 19), the average
number of extracted teeth was 0.36 ± 0.84 (min 0, max 7), and the average number of
endodontically treated teeth was 0.61 ± 1.14 (min 0, max 8). In addition, about three-
quarters of the subjects reported experiencing bad breath, tooth hypersensitivity, and/or
bleeding from the gums.
Dentists were the most common (80.6%) source of oral health information followed by
parents (33.1%), family and friends (70.4%), media (55.9%) and school (33.7%).

Table 5. Use of dental services and self-assessment of oral health among students according to the
average assessment of knowledge about oral health.

Knowledge
Question Answer N (%) p
Median (IQR)
If necessary 470 (43.2) 10 (8.50–13)
Every 6 months 289 (26.6) 11 (9–13)
Frequency of visits to the dentist Every 12 months 211 (19.4) 11 (10–13) 0.104
Once every few years 103 (9.5) 11 (10–13)
I’m not going 15 (1.4) 11 (8–13)
Problem with tooth or orofacial
357 (32.9) 11 (9–13) a,b
structures (pain, swelling)
The reason for the last visit to the dentist Continuation of regular ≤0.001
77 (7.1) 12 (10–14) a
treatment
Regular check-ups 652 (59.8) 11 (10–13) b
Never 2 (0.2) 14 (14)
Healthcare 2022, 10, 406 8 of 12

Table 5. Cont.

Knowledge
Question Answer N (%) p
Median (IQR)
Within the last six months 604 (55.5) 12 (10–13)
Between six and 12 months 203 (18.7) 11 (9–13)
Time of last visit to the dentist More than a year ago 170 (15.6) 11 (9–13) 0.097
More than two to six years ago 109 (10.1) 10 (8–13)
Never 2 (0.2) 12 (12)
0 152 (14.0) 11 (9–13)
Number of fillings (self-assessment) 1–3 339 (31.2) 11 (9–13) 0.887
>3 597 (54.9) 11 (9–13)
0 862 (79.2) 11 (9–13)
Number of extracted teeth
1–3 211 (19.4) 11 (9–13) 0.699
(self-assessment)
>3 15 (1.4) 12 (8–14)
0 741 (68.1) 11 (9–13)
Number of endodontically treated teeth
1–3 300 (27.6) 11 (9–13.75) 0.474
(self-assessment)
>3 47 (4.3) 11 (8–13)
No 276 (25.4) 11 (9–13)
Have you ever had bleeding gums? 0.504
Yes 812 (74.6) 11 (9–13)
Have you ever smelled an unpleasant No 282 (25.9) 12 (9–13)
0.081
breath from your mouth? Yes 806 (74.1) 11 (9–13)
Have you ever felt tooth No 233 (21.4) 11 (9–13)
0.494
hypersensitivity? Yes 855 (78.6) 11 (9–13)
Data are presented as median (interquartile range (IQR) or as numbers (percentages). Statistical significance
was examined by Mann–Whitney, Kruskal–Wallis or one-way ANOVA tests. The same letter in the superscript
indicates a statistical difference between the groups (a p = 0.006, b p = 0.040). Statistical significance was set at
p < 0.05.

4. Discussion
This study aimed to assess knowledge of oral health, oral hygiene habits, and self-
assessment of oral health among students at the University of Split. Knowledge of oral
health enables the achievement of a high standard of oral health and related tissues. It is a
crucial prerequisite for responsible behavior towards one’s health.
The results of a survey of 1088 students at the University of Split found significant
differences in knowledge about oral health among respondents from different scientific
fields (p ≤ 0.001). The median response to oral health knowledge questions was 11 (9–13)
for all respondents, while it was 11 (9–12) for respondents in non-healthcare programs, com-
pared to 13 (11–14) for those in healthcare programs. Research on the student population
of Saudi Arabia has also shown that the level of knowledge about oral health is lower in
non-medical colleges than it is in medical colleges [14]. It has also been shown that a higher
level of knowledge is positively correlated with age (>22 years versus ≤22 years) [14], and
this was confirmed by this study, as we found that at the University of Split, older students
(≥23 years) show better knowledge of oral health than younger students (p ≤ 0.001).
In this study, respondents did not show a difference in knowledge depending on
gender (p = 0.082), which is consistent with results of research on postgraduate students in
India [16]. In contrast, the results of research conducted in Saudi Arabia [14] showed that
female students have significantly better knowledge, attitudes and behaviors toward their
oral health than their male counterparts. The positive oral health behaviors and attitudes
of women in the study, as mentioned earlier, could be explained by the generally greater
concern about appearance in women. For this reason, women are more likely to visit a
dentist and to educate themselves about oral health.
Periodic dental examinations are important in preventing oral diseases, educating
patients, and encouraging the maintenance of good oral hygiene [14]. Research on students
at the University of Split showed that almost half (47.7%) indicated that the socio-economic
Healthcare 2022, 10, 406 9 of 12

condition of their family was above average, according to self-assessment. A study con-
ducted in China in 2019 on a sample of 263 middle-aged respondents found a significant
link between age, low educational level, and poor oral health. This also affected oral health
knowledge, with respondents of lower socioeconomic status showing a lower level of oral
health knowledge. Poor knowledge of oral health is associated with poor oral hygiene and
a higher number of lost teeth [19]. It is known that quality of life is generally related to the
socioeconomic status, as good material conditions facilitate access to goods and services,
including oral health care [1].
The great majority of respondents correctly answered the statements “Poor oral hy-
giene can lead to the development of dental caries and periodontitis”, “oral health is closely
related to the general health of the individual”, and “proper oral hygiene can prevent dental
caries and periodontitis” (96.0%, 92.5%, and 91.8%, respectively). Research on students
from various studies in Saudi Arabia showed that most participants (94%) of both sexes
agreed that brushing their teeth prevented periodontal disease. However, a large propor-
tion of both sexes did not show an understanding of the relationship between oral disease
and systemic health problems [14]. We also found that respondents whose family members
work in dental medicine showed better knowledge of oral health (p = 0.043) than others,
which is probably due to the greater availability of information in the home environment.
We found differences in oral hygiene habits among the respondents depending on
oral health knowledge, except for duration of brushing (p < 0.159), the hardness of the
toothbrush (p < 0.104) and toothbrush replacement interval (p < 0.349). When asked
how many times a day they brush their teeth, most respondents answered that they
brush their teeth with a toothbrush and toothpaste several times a day (85.7%) for two
to three minutes (70.5%), which agrees with a survey conducted at a military college in
Bucharest, which showed that the majority of respondents (78.3%) brushed their teeth
twice a day (morning and evening), and more than half of the respondents spent three
minutes on oral hygiene [17]. In a study by Peltzer and Pengpid [18] on a sample of
19,560 undergraduate students from 27 universities in 26 countries in Asia, Africa, and
America, the results showed that 67.2% of students brush their teeth twice or more times
a day, 28.8% approximately once a day, and 4.0% never. The prevalence of brushing teeth
less than twice a day appears to be higher among students in low- and middle-income
countries than in high-income countries; e.g., 52.2% in India, 35% in Lebanon, 32% in
Turkey compared with 7.9% in Italy, or 25% in the United States. A survey of the student
population in Zagreb showed that 83% of students brush their teeth two to three times a
day, and 17% said they brush their teeth more than three times a day, all of whom were
students at the Faculty of Dentistry [20]. A similar statement was made by students from
Bjelovar, Croatia [21].
As for type of toothbrush used, the majority of our respondents (90.1%) use a hand-
held toothbrush. Similarly, a survey in Bucharest found that 77.5% of respondents used
this same type of toothbrush [17]. A study of the student population in Saudi Arabia found
that only 9.4% of women and 13% of men used electric toothbrushes [14].
More than half of our respondents (59.7%) change their toothbrush every three months,
and a relatively high percentage (24.5%) even more often once a month. Most respondents
(53.8%) of a survey of the Military College in Bucharest change their brush every three
months, and 34.3% once a month [17], while in Zagreb, 48.3% of students use the same
brush for less than three months [22].
Furthermore, dental floss is used daily by only 26.7% of our respondents, and inter-
dental brushes by only 15.3%. Students who used dental floss more often showed better
knowledge than those who did not use it or used it very rarely. In addition, students who
used interdental brushes regularly showed better knowledge than those who did not use
them. Some previous research shows that participants who brush their teeth frequently
and use dental floss have better oral health knowledge [14]; 74.8% of students in Zagreb
use additional means for maintaining oral hygiene (dental floss, interdental brushes, or
mouthwash) [22].
Healthcare 2022, 10, 406 10 of 12

When asked about the frequency of visits to the dentist, slightly less than half of
our respondents reported going to the dentist as needed (43.2%), while only 26.6% go to
the dentist every six months. Contrast this with a study from Bucharest, which found
that 35.8% underwent dental examinations twice a year, 29.1% once a year, and more
than a fifth (22.5%) visited dentists only when they have toothaches [17]. A survey of the
student population in Zagreb showed that 28% of respondents went to the dentist every
six months (most of them were dental students), and the rest of the respondents went only
as needed [20]. In a study by Peltzer et al. [18], 16.3% of students went to the dentist twice
a year, 25.6% once a year, 33.9% rarely, and 24.3% never. Our survey showed that almost a
third of respondents (32.9%) last visited a dentist due to tooth or orofacial structures (pain,
swelling). However, as many as 59.8% of respondents cited regular check-ups as a reason,
slightly higher than the European average of 50% [23].
Most respondents (73.6%) did not know how an avulsed permanent tooth from the
mouth could be returned to the oral cavity due to dental trauma. Yet this is an urgent
therapeutic procedure, performed at the accident scene, and it is very important for the
outcome of treatment, its total cost, and the consequences for the child who experienced the
accident [24]. Similar results were shown by a study where only 46.7% of medical students,
35.8% of the Faculty of Kinesiology, 22.3% of Early and Preschool Education, and 21.1% of
Teacher Education knew the same [24]. Most of the respondents had bleeding gums, bad
breath, and/or tooth hypersensitivity (74.6%, 74.1% and 78.6%).
Although oral diseases can be prevented, they tend to grow despite efforts to preserve
oral health both in Croatia and in the rest of the world [3,4]. For better prevention, the
existing levels of dental care and educational mechanisms should be harmonized and
specific mandatory measures with possible sanctions introduced [25]. Standards and
methods for promoting and achieving good oral health of children have significantly
advanced globally in the last 20–30 years [26]. In today’s population of the Republic of
Croatia, on the other hand, there is a lack of action on preventive dental care in that same
period. Given the lasting consequences of dental caries and periodontal disease, and the
costs that are then unavoidable and borne either by the state and/or the patient personally,
it is justified to ensure preventive measures at every possible level [27].
The present study showed that dentists (80.6%) are the most common source of oral
health information. These findings agree with previously published studies conducted on
school children and university students [28,29].
This study has several limitations. First, it was cross-sectional, so no causal conclu-
sions can be drawn. Second, this investigation was conducted with students at only one
University, and the involvement of others could have yielded different results. Third,
university students are not representative of young adults in general, and levels of oral
health behavior, as well as socioeconomic and health risk behavioral variables may differ in
other sectors of the population. A further limitation of the study was that all data collected
were based on self-assessment, while a dental examination could objectively assess an
individual’s oral health. In addition, the higher proportion of females and the healthcare
students in the total number of respondents suggest an overall response bias for the survey.
However, the probable reason for the better response of these students is a greater interest
in oral health and health in general.
The obtained data from this study can serve the educational institutions to understand
student knowledge better and, consequently, better promote student education through
various lectures or workshops. It is certainly recommended that the research be conducted
on student populations throughout Croatia. Furthermore, to conduct a dental examination
in parallel to objectively assess the oral cavity’s condition.

5. Conclusions
In general, the results showed good oral health knowledge among university students.
However, it is important to emphasize that healthcare students and those whose family
members work in the field of dental medicine have shown better knowledge. It was
Healthcare 2022, 10, 406 11 of 12

also confirmed that students with a higher knowledge score use oral hygiene aids more
frequently like dental floss, interdental brushes, and mouth rinses. From all the above,
it can be concluded that education on this topic is fundamental for understanding and
maintaining of oral health.

Author Contributions: Conceptualization, A.T. and L.G.; methodology, A.T., J.D. and L.G.; validation,
A.T. and L.G.; formal analysis, A.T. and L.G.; investigation, A.T., J.D. and L.G.; resources, A.T., R.P.G.,
J.D. and L.G.; data curation, A.T., R.P.G., J.D. and L.G.; writing—original draft preparation, A.T., R.P.G.,
J.D. and L.G.; writing—review and editing, A.T., R.P.G., J.D. and L.G.; visualization, A.T.; supervision,
A.T. and L.G. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Ethics Committee of School of Medicine, University of
Split, Split, Croatia (No.: 2181-198-03-04-21-0012).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data that support the findings of this study are available upon
request from the authors.
Conflicts of Interest: The authors declare no conflict of interest.

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