TYPE Original Research

PUBLISHED 02 July 2024

DOI 10.3389/fpubh.2024.1424503

Knowledge, attitude, and practice

OPEN ACCESS of patients with oral diseases
toward oral examinations: a
EDITED BY
Ammar Ahmed Siddiqui,
University of Hail, Saudi Arabia

REVIEWED BY
Mohammad Aljanakh,
cross-sectional survey study
University of Hail, Saudi Arabia
Florence Carrouel,
Université Claude Bernard Lyon 1, France
Wei Wang 1,2,3*
Farooq Ahmad Chaudhary, 1
Shanghai Engineering Research Center of Tooth Restoration and Regeneration and Tongji
Shaheed Zulfiqar Ali Bhutto Medical University Research Institute of Stomatology, Shanghai, China, 2 Department of Clinical Medical Laboratory,
(SZABMU), Pakistan Tongji University Stomatological Hospital, Shanghai, China, 3 Dental School, Tongji University,
*CORRESPONDENCE Shanghai, China
Wei Wang
chenjialuo20230605@outlook.com

RECEIVED 15May 2024

ACCEPTED 18 June 2024 Background: Properly adhering to oral hygiene and medical care is an important
PUBLISHED 02 July 2024
public health issue. Several studies examined the knowledge, attitudes, and
CITATION practices (KAP) toward oral care in various populations and generally reported
Wang W (2024) Knowledge, attitude, and
relatively sufficient knowledge but unfavorable attitudes and poor practice.
practice of patients with oral diseases toward
oral examinations: a cross-sectional survey However, no previous studies have examined the KAP toward oral examinations
study. among Chinese patients with oral diseases. This study aimed to examine the
Front. Public Health 12:1424503.
KAP toward oral examinations among patients with oral diseases in China.
doi: 10.3389/fpubh.2024.1424503

COPYRIGHT
Methods: This cross-sectional study was conducted in patients with oral
© 2024 Wang. This is an open-access article diseases who visited The Affiliated Stomatological Hospital of Tongji University
distributed under the terms of the Creative between December 2023 and February 2024. Data collection and KAP scores
Commons Attribution License (CC BY). The
use, distribution or reproduction in other
assessment were performed using a self-designed questionnaire.
forums is permitted, provided the original Results: A total of 519 valid questionnaires were included, with 292 females.
author(s) and the copyright owner(s) are
credited and that the original publication in
The mean knowledge, attitude, and practice scores were 6.42 ± 2.47 (possible
this journal is cited, in accordance with range: 0–9 points), 35.04 ± 5.68 (possible range: 10–50 points), and 16.22 ± 2.05
accepted academic practice. No use, (possible range: 4–20 points), respectively, indicating sufficient knowledge,
distribution or reproduction is permitted
which does not comply with these terms.
positive attitudes, and proactive practice. Pearson’s correlation analysis showed
that knowledge was positively correlated to attitude (r = 0.468, p < 0.001)
and practice (OR = 0.416, p < 0.001). Attitude was positively correlated to the
practice (r = 0.503, p < 0.001). Moreover, the structural equation model showed
that knowledge influenced attitude (estimate = 1.010, p < 0.001) and practice
(estimate = 0.169, p < 0.001). Attitude influenced practice (estimate = 0.122,
p < 0.001). The frequency of oral examination per year influenced knowledge
(estimate = −0.761, p < 0.001) and practice (estimate = −0.515, p < 0.001).
Expenses for oral disease per year influenced attitude (estimate = 0.537,
p < 0.001).
Conclusion: Patients with oral disease might have sufficient knowledge, positive
attitude, and proactive practice toward oral examinations. Specific knowledge
items were identified to require improvements.

KEYWORDS

knowledge, attitude, practice, oral diseases, patients, cross-sectional study

Frontiers in Public Health 01 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

Introduction questionnaires with all answers selected with the same option. This
study was approved by the Ethics Committee of Tongji University
Oral diseases encompass a wide variety of diseases and conditions, Affiliated Stomatological Hospital ([2023]-SR-36). Written informed
including odontogenic diseases (e.g., dental caries and pulpitis) (1, 2), consent was obtained by all participants before completing the
tooth fracture (3), crack, temporomandibular joint disease (4), tooth questionnaire. For the electronic survey, the informed consent
implantation (5), oral mucosal diseases (e.g., oral ulcers) (6), statement was the first step of the questionnaire; electronic consent
periodontal diseases (e.g., gingivitis) (7), maxillofacial deformities, was necessary to access the questionnaire itself.
and tumors (8, 9). Despite their vast differences in etiology, risk
factors, incidence, prevalence, and management, most of these
conditions have in common that they require an oral examination for Variables
diagnosis, examinations during management until resolution, and
regular follow-up examinations to check for recurrence and allow The basic information section included gender, age, residence,
early treatment. Gingivitis can be diagnosed by oral hygienists and can education, employment, income, marital status, smoking, oral health
be reversed by adequate oral hygiene, but the patients might need expenses, medical insurance, course of oral diseases, types of oral
guidance regarding oral hygiene. Maintaining good oral health is disease, tooth brushing frequency, tooth cleaning frequency, oral
important since periodontal diseases are risk factors for examination frequency, and history of head and neck electrotherapy.
non-communicable diseases like cardiovascular diseases, diabetes,
cancers, and adverse pregnancy outcomes, among others (10–12).
The adequate management of these conditions first requires the Data sources and measurements
patient to realize that something is wrong and seek consultation. After
that, a proper understanding of the importance of adherence to oral The questionnaire was designed based on “Prevention, Diagnosis,
examinations during the management and follow-up of the condition and Treatment of Oral Diseases.” The questionnaire was reviewed by
is also required. Indeed, several oral conditions have a high risk of experts in the field to clarify the questions (content value). A small-
recurrence after successful management. Repeated recurrences, scale pilot study (44 participants) showed a Cronbach’s α of 0.810,
especially if the recurrence is not managed early, are associated with indicating good internal consistency. The participants of the pilot
significant morbidity and treatment costs and can increase the risk of study were invited to indicate any unclear questions (face value).
mortality (e.g., cancer, of course, but also the risk of endocarditis in The final questionnaire was in Chinese and included information
patients with untreated dental abscess) (13–15). collected from four dimensions, comprising 41 items. The basic
Hence, properly adhering to oral hygiene and medical care is an information section included 16 items. The knowledge dimension
important public health issue (16). Knowledge, attitude, and practice included nine items, with 1 point awarded for a correct answer and 0
(KAP) studies are designed to provide quantitative and qualitative points for an incorrect or unclear answer (possible range: 0–9 points).
information about the gaps, misunderstandings, and misconceptions A score <5 indicated poor knowledge, and 5–9 indicated sufficient
that represent barriers to adequately implementing a specific subject knowledge. The attitude dimension included 10 items, with options
in a specific population (17, 18). Such studies are particularly useful ranging from negative to positive and scored from 1 to 5 (possible
in identifying specific points that should be addressed in educational range: 10–50 points), with a score of 10–20 indicating a negative
interventions. Several studies examined the KAP toward oral care in attitude, 21–35 indicating a neutral attitude, and >35 indicating a
various populations and generally reported relatively sufficient positive attitude. The practice dimension included five items. Items
knowledge but unfavorable attitudes and poor practice (19–24). Still, P1–P4 were scored from negative (1 point) to positive (5 points)
no previous studies have examined the KAP in relation to oral (possible range: 4–20 points), with a score of 4–8 indicating poor
examinations among Chinese patients with oral diseases. Therefore, practice, 9–15 indicating average practice, and 16–20 indicating good
this study aimed to explore the KAP toward oral examinations among practice. Item P5 was a multiple-choice question and was not scored
patients with oral diseases. but was described as a separate categorical variable.
Two research assistants, both professional interns in the field of
medical laboratory, were trained to handle recruitment and the
Materials and methods questionnaire. The research assistants contacted the patients through
the patient contact information disclosed in the hospital’s online
Study design and setting platform or communicated with the patients in person in the office
and recruited and issued questionnaires to the eligible patients. The
This cross-sectional study was conducted in patients with oral questionnaires included paper questionnaires, electronic
diseases at The Affiliated Stomatological Hospital of Tongji University questionnaires, and questionnaires pushed by the hospital platform.
between December 2023 and February 2024.

Bias
Participants
In order to ensure that the participants could correctly understand
The inclusion criterion was patients with oral diseases who visited the questionnaire content, the writing was in the form of clear and
the hospital. The exclusion criteria were (1) medical professionals, (2) concise questions, providing definitions and examples. In addition,
<18 years of age, (3) questionnaires with contradictory answers, or (4) the research assistants could provide supplementary explanations or

Frontiers in Public Health 02 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

answer participants’ questions during the questionnaire (comparison of two groups) or the Kruskal–Wallis analysis of variance
delivery process. (multiple groups) were used. Pearson’s correlation analysis was
Incomplete questionnaires and those with all KAP items answered performed to examine the correlations among KAP dimensions.
using the same option (e.g., all first options) were considered invalid. Structural equation modeling (SEM) was used to explore the path
For offline questionnaires, the participants could not go home with relationships between KAP and basic information. The SEM was
the questionnaire and bring it back later; doing so led to questionnaire based on the hypotheses that (1) knowledge influences attitude, (2)
exclusion. For online questionnaires, response time <60 s or >1,800 s knowledge influences practice, (3) attitude influences practice, (4) the
led to questionnaire exclusion. Only one questionnaire could frequency of oral examinations per year influences knowledge,
be submitted from a given IP address. attitude, and practice, (5) the course of oral diseases influences
knowledge, attitude, and practice, and (6) and the expenses for oral
diseases per year influences knowledge, attitude, and practice.
Study size Two-sided p-values <0.05 were considered statistically significant.

The sample size was estimated based on Ni’s method for

quantitative surveys, i.e., 5–10 times the number of KAP items in the Results
survey (25). The survey included 23 items. Therefore, the minimal
sample size was 115–230. This study collected 522 questionnaires, but one was excluded for
missing age information, one for contradictory answers in the pitfall
question, and one for the same answer being selected for all KAP
Quantitative variables questions. Finally, 519 valid questionnaires were included for analysis
(Figure 1). There were 56.26% of female patients, with 18–30 years of
Descriptive analysis was used to describe the demographic data of age (35.26%). The mean knowledge, attitude, and practice scores were
the study participants and their KAP scores, using means ± standard 6.42 ± 2.47 (possible range: 0–9 points), 35.04 ± 5.68 (possible range:
deviations for continuous variables and n (%) for categorical data. 10–50 points), and 16.22 ± 2.05 (possible range: 4–20 points),
Since the sample size of this paper was relatively large, based on the respectively, indicating sufficient knowledge, positive attitudes, and
central limit theorem, it was assumed that the data in this study were good practice (Table 1). Among them, 68.98% had sufficient
normally distributed. knowledge, 46.24% had a positive attitude, and 91.14% had a proactive
practice (Figure 2).
For the knowledge dimension, the highest correct rate was for
Statistical analysis item K4 (81.50%; “Before root canal treatment, patients need to
undergo clinical examinations to determine the size of the carious
SPSS 22.0 (IBM Corp., Armonk, NY, USA) was used for statistical tissue and whether the dental nerve is vital, such as blood tests and
analysis. In order to compare the differences in KAP scores among imaging examinations”), while the lowest correct rate was for item K2
study participants with different demographic characteristics, the (48.36%; “Periodontitis does not require blood tests”) (Table 2).
t-test (two-group comparisons) or ANOVA (comparisons of more Among the items in the attitude dimension, the item with the highest
than two groups) were used for continuous variables that met the proportion of positive responses was A1 (“You attach great importance
normality assumption, while the Wilcoxon–Mann–Whitney test to oral diseases, so you believe that regular oral examinations should

FIGURE 1
Participant flowchart.

Frontiers in Public Health 03 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

TABLE 1 Characteristics of the participants.

Variables n (%) Knowledge score Attitude score Practice score

Mean ± SD p Mean ± SD p Mean ± SD p
Total 519 6.42 ± 2.47 35.04 ± 5.68 16.22 ± 2.05

Gender 0.714 0.954 0.584

 Male 227 (43.74) 6.38 ± 2.59 35.02 ± 5.76 16.28 ± 1.89

 Female 292 (56.26) 6.46 ± 2.37 35.05 ± 5.62 16.18 ± 2.16

Age, years 0.148 0.289 0.263

 18–30 183 (35.26) 6.46 ± 2.31 35.48 ± 5.65 16.19 ± 1.88

 31–35 175 (33.72) 6.65 ± 2.39 35.07 ± 5.87 16.41 ± 2.10

≥36
  161 (31.02) 6.13 ± 2.70 34.51 ± 5.49 16.05 ± 2.17

Residence 0.062 0.206 0.316

 Non-urban 66 (12.72) 6.50 ± 2.46 35.16 ± 5.62 16.26 ± 2.07

 Urban 453 (87.28) 5.89 ± 2.48 34.21 ± 6.01 15.98 ± 1.87

Education 0.015 0.838 0.402

 High school/vocational 36 (6.94) 5.53 ± 2.47 35.06 ± 6.85 15.92 ± 2.23

school and below

 College/undergraduate 435 (83.82) 6.42 ± 2.49 34.99 ± 5.68 16.21 ± 2.05

 Graduate and above 48 (9.25) 7.10 ± 2.01 35.50 ± 4.75 16.52 ± 1.91

Employment 0.897 0.603 0.769

 Employed 481 (92.68) 6.42 ± 2.48 35.00 ± 5.72 16.21 ± 2.08

 Unemployment or 38 (7.32) 6.47 ± 2.26 35.50 ± 5.12 16.32 ± 1.60

others

Per capita monthly 0.049 0.143 0.056

income, Yuan

 <5,000 55 (10.60) 5.67 ± 2.29 34.60 ± 6.59 15.89 ± 2.12

 5,000–10,000 192 (36.99) 6.32 ± 2.43 34.56 ± 5.56 16.08 ± 2.13

 10,000–20,000 170 (32.76) 6.62 ± 2.48 35.06 ± 5.79 16.21 ± 1.85

 >20,000 102 (19.65) 6.71 ± 2.54 36.13 ± 5.10 16.69 ± 2.14

Marital status 0.010 0.573 0.109

 Single 136 (26.20) 5.90 ± 2.61 34.64 ± 5.55 15.90 ± 2.01

 Married 381 (73.41) 6.62 ± 2.39 35.17 ± 5.74 16.33 ± 2.05

 Divorced 2 (0.39) 5.00 ± 0.00 37.00 ± 2.83 16.50 ± 3.54

Smoking 0.242 0.005 0.005

 Never smoked 359 (69.17) 6.48 ± 2.43 34.97 ± 5.56 16.14 ± 2.12

 Former smoker 68 (13.10) 5.96 ± 2.59 33.51 ± 5.41 15.87 ± 1.87

 Current smoker 92 (17.73) 6.53 ± 2.50 36.45 ± 6.06 16.82 ± 1.80

Expenses for oral disease <0.001 <0.001 <0.001

per year, Yuan

 Less than 100 71 (13.68) 5.30 ± 3.17 31.01 ± 5.36 14.89 ± 1.91

 100–500 108 (20.81) 5.82 ± 2.42 33.98 ± 4.47 15.95 ± 2.02

 500–1,000 106 (20.42) 6.46 ± 2.40 35.39 ± 5.61 16.16 ± 1.96

 1,000–5,000 148 (28.52) 7.40 ± 1.85 37.58 ± 5.46 17.09 ± 1.80

 More than 5,000 72 (13.87) 6.74 ± 2.01 35.96 ± 5.17 16.60 ± 1.87

 Not sure 14 (2.70) 4.57 ± 2.85 29.36 ± 4.03 14.36 ± 1.86

Medical insurance - - -
(multiple choice)

(Continued)

Frontiers in Public Health 04 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

TABLE 1 (Continued)

Variables n (%) Knowledge score Attitude score Practice score

Mean ± SD p Mean ± SD p Mean ± SD p
 Urban employee basic 442 (85.16) 6.49 ± 2.49 34.93 ± 5.83 16.17 ± 2.09
medical insurance

 New rural cooperative 75 (14.45) 6.37 ± 2.27 34.72 ± 6.31 16.63 ± 1.67
medical insurance

 Urban resident basic 117 (22.54) 6.05 ± 2.40 33.94 ± 4.95 16.08 ± 1.93
medical insurance

 Retired cadre medical 10 (1.93) 6.80 ± 2.10 31.60 ± 4.27 16.70 ± 2.45
insurance

 Commercial insurance 128 (24.66) 6.94 ± 2.21 36.15 ± 6.24 16.95 ± 2.12

 No insurance 4 (0.77) 4.75 ± 2.22 33.25 ± 2.22 15.00 ± 0.82

Course of oral diseases <0.001 <0.001 <0.001

 Less than 1 year 146 (28.13) 5.71 ± 2.91 33.04 ± 5.00 15.47 ± 1.93

 1–3 years 195 (37.57) 7.02 ± 1.94 35.87 ± 5.73 16.57 ± 2.10

 3–5 years 83 (15.99) 6.75 ± 2.40 35.96 ± 6.01 16.60 ± 2.04

 More than 5 years 95 (18.30) 6.03 ± 2.44 35.60 ± 5.58 16.34 ± 1.84

Type of oral diseases 0.361 0.213 0.363

 Odontogenic diseases, 156 (30.06) 6.71 ± 2.28 35.67 ± 5.70 16.38 ± 1.77
such as dental caries,
pulpitis

 Tooth fracture/crack/ 66 (12.72) 6.15 ± 2.28 34.53 ± 5.72 15.86 ± 2.25

temporomandibular
joint disease/tooth
implantation

 Oral mucosal diseases, 105 (20.23) 6.17 ± 2.46 34.48 ± 5.38 16.08 ± 2.14
such as oral ulcers

 Periodontal disease, 187 (36.03) 6.44 ± 2.66 35.11 ± 5.81 16.31 ± 2.14
such as gingivitis

 Other, such as 5 (0.96) 5.80 ± 2.86 31.20 ± 4.02 15.60 ± 1.82

maxillofacial
deformities, tumors

Frequency of brushing 0.321 <0.001 0.005

teeth per day

 Once a day 85 (16.38) 6.27 ± 2.30 32.94 ± 5.33 15.59 ± 2.03

 Twice a day 413 (79.58) 6.41 ± 2.52 35.32 ± 5.59 16.31 ± 2.03

 Three times a day or 20 (3.85) 7.40 ± 1.85 38.15 ± 6.71 17.15 ± 2.03
more

 Do not brush teeth 1 (0.19) 6.00 35.00 16.00

Frequency of teeth cleaned <0.001 <0.001 <0.001

per year

 None 165 (31.79) 5.55 ± 2.81 32.71 ± 5.92 15.22 ± 1.99

 1–2 times 331 (63.78) 6.85 ± 2.20 36.05 ± 5.63 16.68 ± 1.95

 More than 2 times 23 (4.43) 6.61 ± 1.80 37.26 ± 3.67 16.83 ± 1.30

Frequency of oral <0.001 <0.001 <0.001

examination per year

 Once a month 20 (3.85) 6.65 ± 1.84 34.45 ± 7.13 17.35 ± 1.50

 Every 6 months 176 (33.91) 7.01 ± 2.13 36.85 ± 5.63 16.95 ± 1.87

(Continued)

Frontiers in Public Health 05 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

TABLE 1 (Continued)

Variables n (%) Knowledge score Attitude score Practice score

Mean ± SD p Mean ± SD p Mean ± SD p
 Once a year 239 (46.05) 6.49 ± 2.35 35.12 ± 5.06 16.06 ± 1.93

 Never 84 (16.18) 4.96 ± 2.99 31.15 ± 5.20 14.89 ± 2.0

Received head and neck 0.120 0.930 0.013

electrotherapy

 Yes 61 (11.75) 6.89 ± 1.93 35.10 ± 6.54 16.84 ± 1.73

 No 458 (88.25) 6.36 ± 2.53 35.03 ± 5.56 16.14 ± 2.08

FIGURE 2
Histogram of the score distribution. K: There are nine questions, with scores ranging from 0 to 5 indicating insufficient knowledge and scores ranging
from 6 to 9 indicating sufficient knowledge. A: There are 10 questions, with scores ranging from 10 to 26 indicating a negative attitude, scores ranging
from 27 to 36 indicating a neutral attitude, and scores ranging from 37 to 50 indicating a positive attitude. P: There are four questions, with scores
ranging from 4 to 13 indicating inactive practice and scores ranging from 14 to 20 indicating proactive practice.

TABLE 2 Knowledge dimension.

Items Correct, n (%)

K1. Examinations for oral diseases mainly include blood tests, oral microbiological sampling, and imaging examinations. 400 (77.07)

K2. Periodontitis does not require blood tests. 251 (48.36)

K3. Oral surgery, such as tooth extraction, generally requires blood tests, such as routine blood tests, coagulation tests, C-reactive 377 (72.64)
protein tests, and infectious disease tests.

K4. Before root canal treatment, patients must undergo clinical examinations to determine the size of the carious tissue and whether 423 (81.50)
the dental nerve is vital, such as blood tests and imaging examinations.

K5. Before treating many oral diseases, such as root canal treatment, tooth extraction, dental implantation, and teeth cleaning, it is 414 (79.77)
necessary to determine whether the patient has hypertension, diabetes, heart disease, or has undergone heart valve surgery, etc.

K6. Blood tests are generally required before root canal treatment to help doctors understand the possible causes and effects of the 422 (81.31)
disease, which helps establish the correct treatment plan.

K7. Tooth implantation is not 100% successful. In order to ensure the success rate of tooth implantation, it is recommended that 408 (78.61)
blood tests be performed before implantation to exclude some systemic diseases that may cause implantation failure.

K8. Even if there is periodontal disease before tooth implantation, it does not affect the success rate of implantation. 288 (55.49)

K9. Oral inflammations such as periodontitis, oral mucosal diseases, and peri-implantitis generally require blood tests. 351 (67.63)
For the purpose of this publication, the items were directly translated from Chinese without a formal validation and translation process.

be conducted”), while the lowest was observed for A4 (“You believe item with the highest proportion of positive responses was P3 (“You
that the treatment of oral diseases will increase the risk of infectious follow the doctor’s advice on whether to undergo blood tests or other
diseases”) (Table 3). Among the items in the practice dimension, the medical examinations”), while the lowest was P4 (“Even if there are

Frontiers in Public Health 06 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

TABLE 3 Attitude dimension.

Items Strongly agree, Agree, n (%) Neutral, n (%) Disagree, n (%) Strongly
n (%) disagree, n (%)
A1. You attach great importance to oral 193 (37.19) 248 (47.78) 69 (13.29) 8 (1.54) 1 (0.19)
diseases, so you believe that regular oral
examinations should be conducted.

A2. You feel worried and anxious about 75 (37.38) 194 (37.38) 123 (23.70) 107 (20.62) 20 (3.85)
the examination and treatment of tooth
extraction and tooth implantation.

A3. You believe that as long as you brush 24 (4.62) 102 (19.65) 124 (23.89) 213 (41.04) 56 (10.79)
your teeth frequently, oral diseases can
be improved, and frequent checkups are
unnecessary.

A4. You believe that treating oral diseases 40 (7.71) 160 (30.83) 148 (28.52) 131 (25.24) 40 (7.71)
will increase the risk of infectious diseases.

A5. You believe that oral disease 156 (30.06) 286 (55.11) 65 (12.52) 11 (2.12) 1 (0.19)
prevention is more important than
treatment, so regular examinations are
needed.

A6. You believe that blood tests are 25 (4.82) 87 (16.76) 129 (24.86) 220 (42.39) 58 (11.18)
unnecessary for diagnosing oral diseases.

A7. Due to radiation, you are unwilling to 22 (4.24) 75 (14.45) 111 (21.39) 233 (44.89) 78 (15.03)
undergo imaging examinations for oral
diseases.

A8. You believe that blood tests are 100 (19.27) 252 (48.55) 124 (23.89) 39 (7.51) 4 (0.77)
important for treating oral diseases.

A9. If you do not undergo tooth extraction 29 (5.59) 125 (24.08) 123 (23.70) 179 (34.49) 63 (12.14)
or implantation, you are unwilling to
undergo examinations.

A10. You are willing to undergo regular 120 (23.12) 259 (49.90) 104 (20.04) 34 (6.55) 2 (0.39)
oral examinations to prevent oral diseases.
For the purpose of this publication, the items were directly translated from Chinese without a formal validation and translation process.

no obvious oral symptoms, you regularly have your teeth cleaned and and good practice toward oral diseases. Knowledge influenced the
undergo blood tests or other medical examinations if necessary”) attitudes, practice, and attitude influenced practice. The frequency of
(Table 4). In addition, the main barrier to practice was the cost oral examinations per year influenced knowledge and practice.
(Figure 3). Expenses for oral disease per year influenced attitude. The findings
Pearson’s correlation analysis showed that knowledge was could help design interventions to improve oral health in general. This
positively correlated to attitude (r = 0.468, p < 0.001) and practice study identified specific knowledge items that could be improved
(OR = 0.416, p < 0.001). The attitude scores were positively correlated through educational interventions, especially regarding the need for
to the practice scores (r = 0.503, p < 0.001) (Table 5). blood tests in some oral diseases and the possible complications of
SEM showed that knowledge influenced attitudes diseases on tooth implantation. The present study showed that
(estimate = 1.010, p < 0.001) and practice (estimate = 0.169, p < 0.001). improvements in knowledge should also translate into improvements
Attitude influenced practice (estimate = 0.122, p < 0.001). The in attitudes and practice.
frequency of oral examination influenced knowledge Oral health is a major public health concern because it significantly
(estimate = −0.761, p < 0.001) and practice (estimate = −0.515, impacts healthcare expenses, quality of life, and the risk of
p < 0.001). Expenses for oral disease per year influenced attitude complications and other diseases (16, 26). For example, an untreated
(estimate = 0.537, p < 0.001) (Table 6 and Figure 4). dental abscess can cause endocarditis, or an apparently benign oral
lesion can be a developing oral cancer (13–15). Therefore, oral health
requires the individuals’ active participation, with proper hygiene
Discussion habits (brushing teeth, flossing, and looking for potential lesions),
undergoing regular teeth cleaning and dentist consultation, and
This cross-sectional study examined the KAP toward oral consulting in the presence of a problem (16, 26). The present study
examinations among Chinese patients with oral diseases. Chinese revealed good knowledge, positive attitudes, and proactive practice in
patients with oral disease have sufficient knowledge, positive attitudes, patients with oral diseases. It contrasts with several previous studies

Frontiers in Public Health 07 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

TABLE 4 Practice dimension.

Items Always, n (%) Frequently, n (%) Sometimes, n (%) Occasionally, n (%) Never, n (%)
1. You want to understand why 154 (29.67) 302 (58.19) 51 (9.83) 10 (1.93) 2 (0.39)
blood tests are necessary for the
treatment, tooth extraction, or tooth
implantation of oral diseases.

2. You want to understand which 176 (33.91) 275 (52.99) 60 (11.56) 7 (1.35) 1 (0.19)
oral diseases require blood tests or
other medical examinations.

3. You follow the doctor’s advice on 216 (41.62) 255 (49.13) 38 (7.32) 8 (1.54) 2 (0.39)
whether to undergo blood tests or
other medical examinations.

4. Even if there are no obvious oral 89 (17.15) 211 (40.66) 143 (27.55) 65 (12.52) 11 (2.12)
symptoms, you regularly have your
teeth cleaned and undergo blood
tests or other medical examinations
if necessary.
For the purpose of this publication, the items were directly translated from Chinese without a formal validation and translation process.

FIGURE 3
Barriers to medical examinations.

TABLE 5 Correlation analysis. services available, etc. In addition, these previous studies (19–24) were
performed in specific populations (e.g., nurses, patients with heart
Knowledge Attitude Practice
diseases, dental hygienists, parents, adolescents, and married couples)
Knowledge 1
and conditions (oral health, oral hygiene, and oral cancer), limiting
Attitude 0.468 (p < 0.001) 1 their scope and generalizability.
Practice 0.416 (p < 0.001) 0.503 (p < 0.001) 1 In China, an earlier study published in 2007 showed that 1,590
Chinese individuals aged >25 years had practically no knowledge
of common periodontal prevention and treatment, with only a few
that reported variable knowledge but generally negative attitudes and undergoing more or less regular oral examinations (27). A
poor practice toward oral care (19–24). Of course, adherence to oral subsequent study performed in 2012–2015 among 50,991 Chinese
health can vary widely among countries based on the socioeconomic showed that 75% of them lacked periodontal knowledge and that
status, healthcare literacy of the general population, oral health 97% did not have regular scaling (28). The present study is the

Frontiers in Public Health 08 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

TABLE 6 SEM.

Path relationships Estimate p

K ← Frequency of oral examination per −0.761 <0.001
year

K ← Course of oral diseases 0.049 0.621

A ← Expenses for oral disease per year 0.537 <0.001

A ← K 1.010 <0.001

A ← Course of oral diseases 0.526 0.010

P ← Frequency of oral examination −0.515 <0.001

P ← K 0.169 <0.001

P ← Expenses for oral disease per year 0.041 0.457

P ← A 0.122 <0.001

P ← Course of oral diseases 0.118 0.092

K5 ← K 0.094 <0.001

Frequency of oral examination per

K5 ← 0.012 0.541
year

K5 ← A −0.003 0.379

FIGURE 4
Structural equation model.

first to examine the KAP toward oral diseases among Chinese have received information about their disease and oral health in
patients with oral diseases. The high KAP is probably because all general and advice on proper oral care to prevent recurrence or
participants had been diagnosed with oral diseases and underwent the development of other diseases or sought information
treatments for their condition, in contrast with the previous by themselves.
Chinese studies that were performed in the general population. Supporting that view, the SEM analysis showed that the
Therefore, the participants in the present study are more likely to frequency of oral examination influenced knowledge and

Frontiers in Public Health 09 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

practice, suggesting that higher exposure to oral health In conclusion, Chinese patients with oral disease have sufficient
professionals increased knowledge and improved practice. The knowledge, positive attitudes, and good practice toward oral diseases.
participants are also likely to have sought information by Specific knowledge gaps and misconceptions were identified in the
themselves on the Internet or with relatives. In addition, most participants and would require improvements. Educational
participants had a college/undergraduate education and a middle interventions should be designed to improve the KAP toward dental
income. Socioeconomic factors are major determinants of KAP care further.
(29), and the present study might be biased due to the
participants’ higher socioeconomic status than the general
Chinese population. It is well known that socioeconomic status Data availability statement
is a major determinant of health literacy (29). Nevertheless, the
participants also represent the population of patients seeking oral The original contributions presented in the study are included in
care since patients with a lower socioeconomic status will often the article/supplementary material, further inquiries can be directed
not undergo proper oral care (30, 31), as also observed in China to the corresponding author.
(32, 33), Germany (34), Jordan (35), and Sweden (36). The SEM
analysis also showed that expenses for oral disease per year
influenced attitudes. Indeed, several studies showed that Ethics statement
treatment costs were a barrier to proper oral health (37, 38). In
the present study, two-thirds of the participants were ≤35 years The studies involving humans were approved by the Ethics
old. Age is a major determinant of oral health (39), with older Committee of Tongji University Affiliated Stomatological Hospital
adults showing poor oral health. The young age of the participants ([2023]-SR-36). The studies were conducted in accordance with the
in the present study could have contributed to the high KAP local legislation and institutional requirements. The participants
compared with previous studies. provided their written informed consent to participate in this study.
A large study performed in the Chinese general population in
2012–2015 revealed that 2.6% were using floss at least once a day,
2.6% were undergoing scaling at least once a year, and 6.4% would Author contributions
visit a dentist in case of gingival bleeding (28). Since then, the
Chinese government implemented policies to try to improve oral WW: Conceptualization, Data curation, Formal analysis,
health in China (40), which could also have contributed to the Investigation, Methodology, Writing – original draft, Writing – review
high KAP observed here. & editing.
Nevertheless, this study has limitations. It was performed at
a single hospital, leading to a small sample size and limited
generalizability. The participants were enrolled through Funding
convenience sampling, which could introduce bias since only the
interested individuals applied for participation. The online and The author declares that no financial support was received for the
offline participants were not compared. The questionnaire was research, authorship, and/or publication of this article.
designed by local investigators, and its content was probably
biased by the local guidelines and policies, also limiting
generalizability. In addition, the questionnaire did not undergo a Conflict of interest
formal validation process; it was not intended to be a standardized
questionnaire but a survey. The study was cross-sectional, The author declares that the research was conducted in the
preventing the analysis of cause-to-effect relationships. Although absence of any commercial or financial relationships that could
the SEM analysis provides some information about the be construed as a potential conflict of interest.
relationships among KAP dimensions and possible influencing
factors, it is a statistical method that provides an approximation,
at best. Finally, all KAP studies are at risk of the social desirability Publisher's note
bias, which entails that some participants might answer that they
do what they should do instead of what they are really doing (41, All claims expressed in this article are solely those of the authors
42). Considering the high attitude and practice scores, that bias and do not necessarily represent those of their affiliated organizations,
is probably active in the present study. In addition, KAP is or those of the publisher, the editors and the reviewers. Any product
subjective and reflects more on the intention rather than the that may be evaluated in this article, or claim that may be made by its
actual execution. manufacturer, is not guaranteed or endorsed by the publisher.

References
1. Rathee M, Sapra A. Dental caries. In: StatPearls [Internet]. Treasure Island (FL): 3. Patnana AK, Kanchan T. Tooth fracture. In:StatPearls [Internet]. Treasure Island
StatPearls Publishing. (2023). (FL): StatPearls Publishing. (2023).
2. Erazo D, Whetstone DR. Dental infections. In: StatPearls [Internet]. Treasure Island 4. Maini K, Dua A. Temporomandibular syndrome. In: StatPearls [Internet]. Treasure
(FL): StatPearls Publishing. (2023). Island (FL): StatPearls Publishing. (2023).

Frontiers in Public Health 10 frontiersin.org

Wang 10.3389/fpubh.2024.1424503

5. Gupta R, Gupta N, Weber DK. Dental implants. In: StatPearls [Internet]. Treasure 24. Zhang Y, Wong MC, Lo EC. Pathways of oral health knowledge, attitudes,
Island (FL): StatPearls Publishing. (2023). practices, and status in married couples. Community Dent Oral Epidemiol. (2016)
44:400–7. doi: 10.1111/cdoe.12228
6. Bell A, Kasi A. Oral mucositis. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing. (2023). 25. Ni P, Chen JL, Liu N. Sample size estimation for quantitative studies in nursing
research. Chinese J Nurs. (2010) 45:378–80. doi: 10.3761/j.issn.0254-1769.2010.04.037
7. Gasner NS, Schure RS. Periodontal disease. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing. (2023). 26. Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al.
Oral diseases: a global public health challenge. Lancet. (2019) 394:249–60. doi: 10.1016/
8. Watters C, Brar S, Pepper T. Oral mucosa cancer. In: StatPearls [Internet]. Treasure
S0140-6736(19)31146-8
Island (FL): StatPearls Publishing. (2023).
27. Wang QT, Wu ZF, Wu YF, Shu R, Pan YP, Xia JL. Epidemiology and preventive
9. Gonzalez M, Riera March A. Tongue cancer. In: StatPearls [Internet]. Treasure
direction of periodontology in China. J Clin Periodontol. (2007) 34:946–51. doi:
Island (FL): StatPearls Publishing. (2023).
10.1111/j.1600-051X.2007.01139.x
10. Bourgeois D, Goncalves LS, Lima-Junior JDC, Carrouel F. Editorial: the oral
28. Zhao Q, Wang SB, Xu G, Song Y, Han X, Liu Z, et al. Periodontal health: a national
microbiome is a key factor in oral and systemic health. Front Microbiol. (2022)
cross-sectional study of knowledge, attitudes and practices for the public oral health
13:855668. doi: 10.3389/fmicb.2022.855668
strategy in China. J Clin Periodontol. (2019) 46:406–19. doi: 10.1111/jcpe.13082
11. Gare J, Kanoute A, Meda N, Viennot S, Bourgeois D, Carrouel F. Periodontal
29. Svendsen MT, Bak CK, Sorensen K, Pelikan J, Riddersholm SJ, Skals RK, et al.
conditions and pathogens associated with pre-eclampsia: a scoping review. Int J Environ
Associations of health literacy with socioeconomic position, health risk behavior, and
Res Public Health. (2021) 18:7194. doi: 10.3390/ijerph18137194
health status: a large national population-based survey among Danish adults. BMC
12. Maitre Y, Mahalli R, Micheneau P, Delpierre A, Amador G, Denis F. Evidence and Public Health. (2020) 20:565. doi: 10.1186/s12889-020-08498-8
therapeutic perspectives in the relationship between the oral microbiome and
30. Oberoi SS, Sharma G, Oberoi A. A cross-sectional survey to assess the effect of
Alzheimer’s disease: a systematic review. Int J Environ Res Public Health. (2021)
socioeconomic status on the oral hygiene habits. J Indian Soc Periodontol. (2016)
18:11157. doi: 10.3390/ijerph182111157
20:531–42. doi: 10.4103/0972-124X.201629
13. Warnakulasuriya S, Kujan O, Aguirre-Urizar JM, Bagan JV, Gonzalez-Moles MA,
31. Northridge ME, Kumar A, Kaur R. Disparities in access to oral health care. Annu
Kerr AR, et al. Oral potentially malignant disorders: a consensus report from an
Rev Public Health. (2020) 41:513–35. doi: 10.1146/annurev-publhealth-040119-094318
international seminar on nomenclature and classification, convened by the WHO
Collaborating Centre for Oral Cancer. Oral Dis. (2021) 27:1862–80. doi: 10.1111/odi.13704 32. Lin HC, Wong MC, Wang ZJ, Lo EC. Oral health knowledge, attitudes, and
practices of Chinese adults. J Dent Res. (2001) 80:1466–70. doi:
14. Maymone MBC, Greer RO, Burdine LK, Dao-Cheng A, Venkatesh S, Sahitya PC,
10.1177/00220345010800051601
et al. Benign oral mucosal lesions: clinical and pathological findings. J Am Acad
Dermatol. (2019) 81:43–56. doi: 10.1016/j.jaad.2018.09.061 33. Zhu L, Petersen PE, Wang HY, Bian JY, Zhang BX. Oral health knowledge, attitudes
and behaviour of adults in China. Int Dent J. (2005) 55:231–41. doi:
15. Maymone MBC, Greer RO, Kesecker J, Sahitya PC, Burdine LK, Cheng AD, et al.
10.1111/j.1875-595x.2005.tb00321.x
Premalignant and malignant oral mucosal lesions: clinical and pathological findings. J
Am Acad Dermatol. (2019) 81:59–71. doi: 10.1016/j.jaad.2018.09.060 34. Deinzer R, Micheelis W, Granrath N, Hoffmann T. More to learn about:
periodontitis-related knowledge and its relationship with periodontal health behaviour.
16. Vozza I. Oral prevention and management of oral healthcare. Int J Environ Res
J Clin Periodontol. (2009) 36:756–64. doi: 10.1111/j.1600-051X.2009.01452.x
Public Health. (2021) 18:1970. doi: 10.3390/ijerph18041970
35. El-Qaderi SS, Quteish T'a D. Assessment of periodontal knowledge and
17. Andrade C, Menon V, Ameen S, Kumar PS. Designing and conducting knowledge,
periodontal status of an adult population in Jordan. Int J Dent Hyg. (2004) 2:132–6. doi:
attitude, and practice surveys in psychiatry: practical guidance. Indian J Psychol Med.
10.1111/j.1601-5037.2004.00080.x
(2020) 42:478–81. doi: 10.1177/0253717620946111
36. Martensson C, Soderfeldt B, Andersson P, Halling A, Renvert S. Factors behind
18. World Health Organization. Advocacy, communication and social mobilization
change in knowledge after a mass media campaign targeting periodontitis. Int J Dent
for TB control: a guide to developing knowledge, attitude and practice surveys. (2008).
Hyg. (2006) 4:8–14. doi: 10.1111/j.1601-5037.2006.00158.x
Available at: http://whqlibdoc.who.int/publications/2008/9789241596176_eng.pdf
(Accessed November 22, 2022). 37. Thompson B, Cooney P, Lawrence H, Ravaghi V, Quinonez C. The potential
oral health impact of cost barriers to dental care: findings from a Canadian
19. Lakshmi KPD, Venkatalakshmi S, Bharath C, Saravanan N, Reddy LS, Nagilla J.
population-based study. BMC Oral Health. (2014) 14:78. doi:
Correlation of knowledge, attitude, and practice with their oral health status among
10.1186/1472-6831-14-78
young adults of nursing care: a cross-sectional survey. J Pharm Bioallied Sci. (2022)
14:S82–6. doi: 10.4103/jpbs.jpbs_555_21 38. Levy BB, Goodman J, Eskander A. Oral healthcare disparities in Canada: filling in
the gaps. Can J Public Health. (2023) 114:139–45. doi: 10.17269/s41997-022-00692-y
20. Rasouli-Ghahroudi AA, Khorsand A, Yaghobee S, Rokn A, Jalali M, Masudi S,
et al. Oral health status, knowledge, attitude and practice of patients with heart disease. 39. Kassebaum NJ, Bernabe E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global
ARYA Atheroscler. (2016) 12:1–9. burden of severe periodontitis in 1990-2010: a systematic review and meta-regression.
J Dent Res. (2014) 93:1045–53. doi: 10.1177/0022034514552491
21. Coppola N, Rivieccio I, Blasi A, Ferrigno R, Baldares S, Mignogna MD, et al.
Current knowledge, attitude and practice among dental hygienists in oral cancer 40. Zhou X, Xu X, Li J, Hu D, Hu T, Yin W, et al. Oral health in China: from vision to
awareness: systematic review. Int J Dent Hyg. (2022) 20:249–61. doi: 10.1111/idh.12575 action. Int J Oral Sci. (2018) 10:1. doi: 10.1038/s41368-017-0006-6
22. Patil AN, Karkare SR, Jadhav HS, Sirikonda S, Suryawanshi VB, Patil SN. 41. Bergen N, Labonte R. “Everything is perfect, and we have no problems”: detecting
Knowledge attitude and practices of parents towards oral health maintenance among and limiting social desirability bias in qualitative research. Qual Health Res. (2020)
their children and correlation with dental caries experience-a cross-sectional study. Med 30:783–92. doi: 10.1177/1049732319889354
J Dr DY Patil Vidyapeeth. (2021) 14:40–4. doi: 10.4103/mjdrdypu.mjdrdypu_310_20
42. Latkin CA, Edwards C, Davey-Rothwell MA, Tobin KE. The relationship between
23. Lawal FB, Oke GA. Clinical and sociodemographic factors associated with oral social desirability bias and self-reports of health, substance use, and social network
health knowledge, attitude, and practices of adolescents in Nigeria. SAGE Open Med. factors among urban substance users in Baltimore, Maryland. Addict Behav. (2017)
(2020) 8:2050312120951066. doi: 10.1177/2050312120951066 73:133–6. doi: 10.1016/j.addbeh.2017.05.005

Frontiers in Public Health 11 frontiersin.org