Oral Health Aspects in Primary School Children of Three Major Cities of Pakistan

Oral Health Aspects in Primary School Children of Three Major Cities of Pakistan
Mozaffer Rahim Hingorjo*, Farhan Jaleel**, Asghar Mehdi***

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J Pak Dent Assoc 2010;19(4): 211-215


This cross-sectional study was done to evaluate tooth brushing and oral addictive habits of primary school children (aged 5-10 years) .


This was a cross-sectional study, conducted in 2000, across Pakistan in three major cities. Data was collected using simplified WHO Oral Health Assessment Form (1997), with questions regarding oral hygiene practices such as brushing and use of areca nut. The participating dental surgeons were initially trained for data collection using WHO guidelines and then evaluated and calibrated. After satisfactory results from a pilot study, it was extended to three major cities of Pakistan. 7005 students studying in classes 1 to 3 (age 5-10 years) were included in the study. Data was collected from 22 schools of upper socio-economic class (SEC)


There were 56.77% boys and 43.23% girls in the study group, with an average age of 7.2 years. Almost all the children (99.22%) were brushing their teeth, most (92.96%) using toothpaste. Once, twice, and thrice daily brushing was 37.53%, 54.29%, and 7.45%, respectively, with more boys brushing once and more girls brushing twice daily. Regarding addictive oral habits, 13.38% children were addicted to areca nuts. Family history revealed that 23.38% and 19.41% parents were addicted to quid/pan and smoking, respectively


Correct tooth brushing technique and frequency, removes dental plaque and prevents dental caries effectively. Parents should start educating their children at a very young age to maintain proper oral hygiene, such as, tooth-brushing and keeping a check on oral addictives. The need of the hour is to promote oral health awareness through parents, teachers, and community based oral health surveys, with media playing an important role in it.


Tooth brushing, Oral health awareness, Areca nut.


Oral health is a reflection of the general well being of a person, and is defined by the World Health Organization as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity”. Habit building starts at a young age, during childhood and adolescence. Information regarding oral health given during this period to children will clear their concepts and help promote a healthy society. Schools provide a supportive environment for the student, promoting oral health by way of awareness programs, and in fact ensuring that the oral health policies learned are implemented. Education of parents is also important to avoid promotion of risk behaviors such as frequent intake of refined carbohydrates, oral addictive habits, and not brushing the teeth at the proper timeDental caries affects 60 90 % of school aged children and a vast majority of adults of industrialized countries.2 Until recently, in most developing countries the level of dental caries was low, however, due to the increased consumption of sugar and inadequate exposure to fluoride, the DMFT index has increased. On the other hand, the severity of dental caries has declined in developed countries over a period of 20 years or so. This is due to effective public health measures that include adequate use of fluoride and a change in lifestyle behavior with a stress on self care.3 According to a survey done by WHO in 1988 in Pakistan, the dental caries status of children aged 12 years was 50% with a DMFT index of 1.0. A similar study involving urban population conducted in 1999 across 15 cities of Pakistan showed a decline in caries status to 36.25% with a marginal change in DMFT index of 0.9.4

Dental plaque, consisting of microbial organisms, is a soft, pale yellow colored, easily removable layer, found on tooth surfaces. Calcification of the plaque leads to calculus or tartar and develops if the plaque is not effectively removed. Tooth brushing, if done with a proper technique, twice a day using fluoride toothpaste, removes dental plaque, thereby preventing its consequent development of caries and periodontitis.5,6,7 Awareness regarding timing and frequency of brushing is lacking in the general population. It is seen that brushing once daily is enough to remove the layer of dental plaque, whereas brushing forcefully may remove the layer of enamel that may have been softened by an acidic exposure such as carbonated drink or citrus juice. Because of the non-compliant nature of young children a midway approach would be to advise brushing twice daily. In order to create awareness regarding the correct brushing habits, including brushing methods, timing, and frequency, the dental professional have an important role to play.5Oral addictive habits play a major role in the pathogenesis of diseases related to dentition and oral soft tissue, besides having a role in systemic illness. Areca nut, known as ‘chalia’ and Betel quid which consists of betel leaf, catechu, slaked lime, areca nuts and sometimes tobacco, are addictives used by 600 million people in the Southeast Asia.8 This also includes children as young as 3 to 5 years.9,10 Areca nut causes preneoplastic disorders such as submucosal fibrosis, that progress to cancers due to the presence of carcinogenic nitrosamines in areca nuts.11

There is also sufficient evidence that betel quid as well as areca nut chewing causes esophageal and liver cancers.12,13 Studies regarding oral health status of children have been conducted throughout the world; however, the literature review shows that there is a lack in the data of oral health status and oral addictives habits in primary school children of Pakistan. We have selected brushing habits and the use of areca nut for our study which was a part of the Nation Wide Oral Health Promotion Campaign Survey on “Oral Health Awareness” in School Going Children of age

5 to 10 years. Another aim of the study was to promote awareness among the students regarding their oral health because this is an important period of life with regards to personality building; habits developed at this age are likely to be carried out though out one’s life..


This study was conducted in the year 2000, across Pakistan in three major cities and was a collaborative campaign of Fatima Jinnah Dental College Hospital and Glaxo Smith Kline Beecham. It was a cross-sectional study and convenient sampling was done. A total of 22 schools from upper socio-economic class (SEC) were selected, 9 from each Karachi and Lahore, and 4 from Faisalabad. 7005 students studying in classes 1 to 3 (age 5-10 years) were included in the study. This age group was targeted so as to make the study uniform.

WHO Oral Health Assessment Form (1997),14 was simplified and used for the collection of data. Questions regarding oral hygiene status included frequency and timing of brushing teeth, usage of toothpaste and oral addictive habits such as eating betel nuts (gutka, areca nuts, and pan) and family history of smoking and eating pan was recorded. A team of dental surgeons who were participating in the study were initially given hands on training regarding data collection using WHO guidelines. Proper evaluation of the participating members was done and they were calibrated. A pilot study was carried out in a primary school of Karachi and the results were assessed on satisfactory yield. The sphere of study was then extended to cover three major cities of Pakistan. The materials were provided by Fatima Jinnah Dental College Hospital. Written informed consent was taken beforehand from the parents of each child. Thereafter, referral cards were filled out to inform the parents about the oral hygiene status of their children. The study was approved by Fatima Jinnah Dental College Research and Ethical Committee.


Of the 7005 school children examined, 56.77% were boys and 43.23% girls. The average age of students was 7.2 years (range 6.4 8.1 years). Students belonging to Karachi, Lahore, and Faisalabad were 48.29%, 34.85%, and 16.86% respectively (Table 1). The brushing habits of children examined are detailed in Table 2. Tooth brushing was seen in 6954 students, with highest number of students brushing twice daily (54.29%). Once daily

Brushing was found out to be 37.53% with almost all brushing in the morning, and higher number of boys as compared to girls. The use of toothpaste was slightly more common in girls as compared to boys

The children were questioned about their addictive oral habits. A significant number were addicted to areca nuts (13.38%). The family history revealed that 23.38% and 19.41% parents were also addicted to quid/pan and smoking, respectively (Table 3).


Oral health is now being considered as an important aspect of the general health of a person. Oral health awareness should be started at a very young age to inculcate the habits leading to good oral hygiene. The present study was conducted to evaluate oral health in young school going children, as well as to promote an awareness regarding oral health. We included 7005 school going children, both boys and girls, from 3 different major cities of Pakistan. The socioeconomic status of the subjects was mainly upper class.

Oral habits of the children revealed that tooth brushing was common among them, most brushing twice daily (54.29%) using toothpaste. However, a significant proportion of the children (37.5%) brushed once daily, mainly in the morning, as opposed to the recommended practice of brushing once again before going to bed to maintain oral hygiene. Although rigorous tooth brushing once daily is sufficient to remove dental plaque, many are unable to achieve this level; therefore the recommendations are for twice daily brushing.15 The efficacy improves if brushing is done after meals, as it reduces the contact of tooth with sucrose. Despite the brushing frequency seen in our study group, the level of dental plaque was 20%. This may be due to multiple factors, such as improper brushing technique, brushing in the morning only, as well as, a diet consisting of significant amounts of sugared fluids, thereby allowing cariogenic organisms to form a plaque matrix that outpaces the subject’s ability to keep their teeth plaque free. A proper brushing technique require that brushing be done for 2 to 3 minutes, gently, using the Bass technique or its modification, however, many adults are unaware of this method.16 Being parents, this knowledge is not transferred to their children. Das and Singhal,17 found children as young as 3 11 years having manual dexterity for tooth brushing, stressing the need to teach them the proper method. The dental services that are currently being provided to children are not enough,18 calling for an effective school based and community based oral health education program providing knowledge regarding the use of tooth paste and correct tooth brushing technique so as to prevent formation of dental plaque and dental caries.19

The habit of betel quid use and areca nut chewing is common in Southeast Asia. Due to its easy availability and parental influence, the younger generation is becoming more addicted to it. This is evident in our study where 13.38% children and 23.38% parents from the upper SEC were using these addictives in various forms. This addiction is much more common in low SEC as shown by SM Shah et al, 2002.9,12 The International Agency for Research on Cancer has identified areca nut to be one of the agents that cause cancer.20 Parental smoking has a detrimental effect on the health of children, who are subjected to passive smoking and are inclined and encouraged at a tender age to develop the habit themselves. Smoking leads to stained teeth, bad breath, heart diseases, and oral cancers.

Children exposed to the smoking effect by their parents have a higher level of oxidative stress markers in their blood such as cotinine, a byproduct of nicotine, as the exposure to smoke is equivalent to smoking 60 to 150 cigarettes per year.21 Our study included family history of smoking, which was found to be 19.41%.


It is the responsibility of the dental doctors to give proper oral health education to the parents and children attending their clinics.

 Stress should also be given to include oral health education in the course curriculum of school going children to promote their oral health. The school teachers are more effective in this regard in conveying the message across to the children. Parents should start educating their children at a very young age to maintain proper oral hygiene, such as, tooth-brushing and keeping a check on oral addictives.

 The best thing parents can do to reduce the chances of children acquiring addicted habits, is to quit those habits themselves. Children will be less likely to smoke when they grow up with parents who don’t smoke.
 The need of the hour is to promote oral health awareness through oral health surveys, school and community based oral health education programs and at mass scale via electronic and print media, so as to cover both urban and rural population.


The authors would like to thank the Dept. of Community Dentistry of Fatima Jinnah Dental College Hospital for their time given to collect data and examine children of different cities of Pakistan.

These include Dr.Inayat Padihar, Dr.Sania Usman, Dr.Shahid Mittha, Dr.Arsalan Sami, Dr.Shahrukh Navaee, Dr.Amber Jameel, Dr.Riffat Abbas, Dr.Shazia Nadeem, Dr.Azmina Hussain. We would also like to thank the representatives of Glaxo-Smith-Kline, Mr.Aijaz and Mr.Haroon for their support


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