Self-rated oral health status, oral health service utilization, and oral hygiene practices among adult Nigerians

Oral health is an important tool for achieving good general health [1]. Oral diseases and disorders often result in physical discomfort, pain, infection and sometimes tooth loss [2]. They also frequently cause difficulty in chewing; swallowing; speaking, and can disrupt sleep and productivity [1, 2]. Consequently, oral diseases and disorders not only affect the victim’s life as well as their social networks, the community at large and productivity of the citizens at the national level [2–4].

The promotion of good oral hygiene at the population level is advocated and supported by the World Health Organisation (WHO) and the International Federation of Dentists (FDI) [5–8]. The adoption of preventive strategies both at the individual and population level helps reduce the negative impact of oral diseases including improving quality of life. One critical tool identified for achieving good oral health is the institution of effective and efficient oral hygiene practices [1, 5, 9]. The value of good oral hygiene practices has increased over the years.

Research indicates that the removal of bacteria plaque is essential for the prevention of the two most prevalent dental conditions namely dental caries and periodontal disease [5, 9]. To achieve and maintain good oral hygiene, and prevent dental caries regular tooth brushing using fluoride containing toothpaste at least twice a day is recommended. [8] The use of dental floss for cleaning of interproximal surfaces is also crucial for effective plaque removal [7, 8].

In Nigeria, information on oral health service utilization patterns and common oral hygiene practices among adult Nigerians is sparse. Most of the available information is from research localized to south west Nigeria or to specific sub-populations such as pregnant women and school going children [10–12]. Research reports have consistently confirmed that a large proportion (more than 70%) of adult Nigerians have periodontal disease [11, 13], a condition strongly associated with oral hygiene status. Although in the last two decades reports using the decayed, missing and filled teeth (DMFT) index, show a low dental caries prevalence of 10% to 20%, dental caries remain a public health concern because most carious lesions remain untreated [10–13]. Reports also indicate poor awareness of oral health, irregular tooth brushing and generally poor oral hygiene among Nigerians [10, 13]. Other data indicates that very few Nigerians (less than 20%) visit a dentist regularly [10–12]. This may be related to the inadequate number and poor geographical distribution of oral health care providers countrywide; factors which do not favor adequate access to oral health care services [10, 12].

Elsewhere evidence shows that oral health care utilization patterns and oral hygiene habits are influenced by socio-demographic characteristics [2, 3]. Persons with higher education and a higher social economic status have been reported to exhibit better oral hygiene habits and oral health utilization habits [2, 3, 14–16]. However, the effect of socio-demographic characteristics on oral health service utilization in Nigeria is not documented. To our knowledge this is the first national survey conducted to assess the oral health service utilization pattern and oral hygiene practices of adult Nigerians.

This survey was conducted before the introduction of the national oral health policy in Nigeria [12] with an overall goal to provide veritable information for the implementation, monitoring and evaluation of the proposed national oral health policy. The study also aimed at determining the association between socioeconomic status, educational status, ethnic groups and geopolitical zones in Nigeria with the prevalence of oral health service utilization and pattern of oral hygiene practices among adults in Nigeria.

This is the first national study to be conducted on oral health care service utilization and oral hygiene practices among adult Nigerians resident in the different geopolitical regions. Most of the earlier studies have been localized to specific regions in the country or have targeted specific populations such as pregnant women or school children [19–22]. Our results reveal that adult Nigerians view their oral health status positively but have poor regular oral health utilization habits and oral hygiene habits. A good number of the participants do not clean twice their teeth daily (52.0%) or brush for at least two minutes each time (39.7%).

A good proportion (58.3%) of the study participants viewed their oral health status as good or very good. This perception may explain the apathy displayed towards oral health service utilization as just over a quarter of the participants had ever visited a dentist. Anecdotal reports suggest that Nigerians generally associate not visiting a health facility with good health and similarly not visiting a dentist with good oral health. Therefore, it is common to visit the dentist only when they have symptoms that have not responded to home therapies. Furthermore, there is a tendency for adults to initially seek the attention of alternative health care practitioners before visiting a health facility. This in our view may explain the low utilization rates recorded. However, it is worth noting that the fact that oral health services are not readily available in all communities may limit the utilization of oral health services by most Nigerians [10–12].

We recorded a higher percentage (26.4%) of previous dental visits in this study than has been reported previously [23]. Differences in the results obtained may be because the earlier study was conducted at household level and was restricted to one town in south west Nigeria. However, oral health service utilization rates in our study were lower than previously reported in other countries [24–26]. A pattern of not visiting the dentist regularly has been reported among various groups in Nigeria [11–13, 18, 19, 21, 22] indicating a need to actively promote the utilization of dental services in the country as part of a strategy for achieving good overall health. One suggested approach for achieving increased utilization of dental services is the institution of national guidelines regarding dental visits e.g. integration of oral health into other essential medical services such as antenatal and postnatal care, as well as services for medically compromised persons and the elderly.

We also observed that age group, educational status and occupational status were associated with utilization of dental services, a finding reported in other countries [27, 28]. The fact that older persons reported significantly more previous dental visits than younger persons was not surprising. Older persons tend to have more dental problems [2, 27, 28], since most of the reported visits were sequel to the onset of dental symptoms it can inferred that the visits were made by older persons. As expected, more educated persons and more skilled workers also reported higher prevalence of previous dental visits than those with less education and those in less skilled professions. However gender and geo-political zone were not related to previous dental visits.

Majority of the participants reported using toothbrushes for cleaning. Generally, a higher proportion of older persons utilized other tools especially the chewing stick for cleaning. This finding may be an indication of a shift towards the use of modern tools such as the toothbrush among Nigerian adults. Persons in the younger age groups may have been influenced by information obtained from school and the media as they had received more education and more were engaged in skilled professions. In addition, there were more younger persons in some geo-political zones that in others. This was confirmed by the statistically significant effect of the sex, educational status, occupation and geopolitical zoning on the tools used for mouth cleaning.

An interesting finding in our study was the fact that many participants using toothpaste were unaware of the fluoride content of their dentrifice. This is less than satisfactory and should be addressed urgently. It is important for people to be able to correctly determine the amount of fluoride they require based on the fluoride content of their water and dentrifices. Although a large number of the dentrifices available in the Nigerian market contain fluoride, there are areas with high levels of fluoride in Nigeria [29] and persons resident in such areas would require lower levels of fluoride in their dentrifices. The lack of knowledge displayed could on one hand result in worse cases of fluorosis in endemic areas or caries in areas where fluoride is inadequate.

A few participants reported using items such as cotton wool, water and salt for mouth cleaning. This is similar to other findings [19, 20, 22], which indicate that a variety of items are used for oral hygiene among Nigerians. There is no scientific evidence on the efficacy of such tools and promotion of their use should be done with caution. The use of other aids such as dental floss and mouthwash was not very common. This is probably because they are not readily available in many parts of the country especially in the rural communities. There is need to increase the availability of these tools as a step towards promoting their use countrywide.

It was surprising to note that more than a third of the participants reported twice-daily mouth cleaning. This is higher than has been observed in previous studies [19–22] but lower that what is reported in other countries [24, 25, 30]. Interestingly, all socio-demographic characteristics examined namely age; educational status and geopolitical zoning were significantly related to frequency of tooth-brushing. Accordingly, we suggest that efforts at promoting good oral hygiene should focus on older persons and persons with less education as they are more likely to have poor oral hygiene practices. A finding also reported in earlier studies [19, 20, 22]. A more sustainable and productive approach may be the promotion of good oral hygiene habits early in life. This is because habits are formed early in life and become difficult to change later in life [31]. This approach is likely to yield better results in the long term. The finding that oral hygiene practices were generally poorer in the northern zones may be unconnected with lower literacy levels in the region [17]. Therefore increased exposure to education may lead to increased oral health awareness in the region.

This study is not without limitations, the major limitation is its dependence on self-reported information; such information is often subject to response bias due to the different interpretations individuals can give to the questions [32]. Also, the responses may have been influenced by the social acceptability of their responses [33]. Another possible source of bias was the fact the survey was conducted in a predetermined location (often the local government headquarters), thus increasing the possibility of excluding persons who are unable to reach the specified location. This was especially noticeable in the south-south geopolitical zone, which comprises many riverine communities accessible only via the waterways. A better approach would have been the conduct of household surveys to reduce bias. The absence of clinical oral health data to compare the impact of perceived and normative oral health status limits the applicability of the results. Despite these limitations, the large sample size as well as the wide national coverage makes this data invaluable and the study provides veritable information on the oral health service utilization and common oral hygiene practices among adult Nigerians as well as socio-demographic factors possibly influencing the observed patterns.

Presently, most Nigerians assess their oral health status positively and majority report using toothbrushes for maintaining good oral hygiene but display poor dental visiting habits. The study findings suggest that although age, sex, educational status, occupation are important determinants of oral hygiene behavior among Nigerians, other factors may play an important role as well. Further studies to identify other factors influencing oral health behavior are suggested, as the high level of non-attendance demonstrated by the participants is undesirable.