The oral health and periodontal diseases awareness and knowledge in the Iraqi population: Online‐based survey

Abstract Objectives This study aimed to evaluate oral health (OH) and periodontal diseases (PD) awareness in the Iraqi population. Material and methods This study was a questionnaire‐based online survey of two weeks duration. The questionnaire was built using a Google platform and was distributed randomly via social media (Facebook and Telegram). The questionnaire consisted of a demographic data section and two other main sections for the evaluation of OH and PD awareness. Each response was marked with “1” for a positive answer and “0” for the other answers. For each respondent, answers were summed to give an overall score. The frequency of positive responses was used to determine the association of awareness with demographic data and the level of awareness into low, moderate, and high levels. Results A total of 1,465 were included in the final analysis after application of exclusion criteria. The respondents showed significantly higher levels of awareness about PD (mean ± SD = 3.66 ± 1.42) than OH awareness (mean ± SD = 2.19 ± 1.29). Analysis of data showed that OH awareness was mainly associated with high degree holders (OR 1.851) and age > 45 years (OR 1.730). However, PD awareness did not show any evident association with demographic variables investigated. In general, the respondents exhibited low levels of OH knowledge and low to moderate level of PD knowledge. Conclusions Despite limitations, this study revealed inappropriate levels of OH and PD awareness and knowledge in the Iraqi population and provided the baseline data necessary for the development of Governmental educational programs and health awareness campaigns which are highly suggested particularly focusing on the primary and high schools, in an attempt to improve the levels of awareness.


| INTRODUCTION
The use of appropriate oral hygiene measures is a key to maintaining a healthy dentition and periodontal tissues. In addition, adopting good oral hygiene regimes has a positive impact on the individual's general wellbeing and quality of life (Sheiham, 2005).
The World Health Organization (WHO) campaign "oral health for a healthier life" highlights the importance of oral cavity as a gateway to the body, reflecting systemic health (Bopp, 2001). Further support for this premise can be found in the literature with several papers indicating the benefits of improving oral hygiene in terms of systemic health one example of this is type 2 diabetes where a bidirectional relationship is proposed (Bascones-Martinez, Munoz-Corcuera, & Bascones-Ilundain, 2015).
As periodontitis progresses to advanced disease it has a major impact on the patient including issues with masticatory function resulting in dietary changes, esthetic concerns, speech difficulties, and self-esteem issues which may result in social exclusion (Ferreira, Dias-Pereira, Branco-de-Almeida, Martins, & Paiva, 2017;Tonetti, Jepsen, Jin, & Otomo-Corgel, 2017). However, such consequences could easily be prevented by early intervention to improve oral hygiene (Han & Park, 2017;Lertpimonchai, Rattanasiri, Arj-Ong Vallibhakara, Attia, & Thakkinstian, 2017); the uptake of appropriate oral hygiene practices is related to the degree of awareness and knowledge the subject has about the oral health (OH) care and periodontal diseases (PD). The adoption of high levels of oral hygiene in industrialized countries has been associated with a reduced prevalence of periodontitis (Kandelman, Arpin, Baez, Baehni, & Petersen, 2012). This was the result of the introduction of intensive educational and preventive oral-care programs. This is not the case in developing countries, which are lacking in these types of program (Kandelman et al., 2012). Level of awareness of appropriate OH practices and levels of knowledge about PD seem to be affected by a range of factors including gender, age, profession, educational level, systemic conditions, and smoking (Ehizele, Chiwuzie, & Ofili, 2011;Nyorobi, Carneiro, & Kabulwa, 2018;Oberoi, Mohanty, Mahajan, & Oberoi, 2014;Peltzer & Pengpid, 2014;Umeizudike, Onajole, & Ayanbadej, 2015).
Based on the deficiency in the educational programs, the authors hypothesized that awareness and knowledge about OH and PD in Iraqi community are low, and that this would affect the long-term OH of the population. Thus, this online-based study aimed to evaluate OH and PD awareness, in the Iraqi population, taking into account a number of demographic variables.

| Study design
This study utilized a questionnaire-based online survey for surveying OH and PD awareness among Iraqi individuals. The survey was open for completion for two weeks. The questionnaire was built using a Google platform and the subsequent link was distributed via social media (Facebook and Telegram) with participants completing the form anonymously. The distribution was performed through sponsored ads and mailing to members of certain Iraqi Facebook groups which were assigned using simple randomization-lottery method to minimize bias in selection. The issue with participants making more than one entry was excluded by using an IP-protection protocol. This study was approved by a local ethics committee in the Department of Periodontics, College of Dentistry, University of Baghdad in accordance with Helsinki declaration for human researches. A consent statement was included at the beginning of the questionnaire and agreement was made prior to participation.
This study followed the guidelines recommended by STROBE statement for observational studies.

| Study sample
The sample was stratified according to the age, the study attempted to include Iraqi subjects over 14 years of age. Iraqi population data, according to the official record, indicated that within this age group there were 24,986,590 subjects (IndexMundi, 2020).
In order to ensure the proposed study had sufficient participants a sample size calculation was performed: Sample Size = (Distribution of 50%)/([Margin of Error%/Confidence Level Score] 2 ).
The calculated sample was equal to 385 subjects, which was rounded up to 400, which was then multiplied by 4 to allow 25% response rate (Teoh, Marino, Stewart, & McCullough, 2019); thereby, the final targeted number of respondents was 1,600.

| Design of the questionnaire and score calculation
The questionnaire has been validated in a previously published research (Dayakar, Kumar, Pai, Shivananda, & Rekha, 2016). It was adapted and then translated into Arabic language for use in the current study. The questionnaire included a demographic data section, which included age, gender, smoking, employment status, educational level, and nationality. Evaluation of awareness was conducted using two main sections; the first one (from question #1 to #7) was dedicated for evaluating OH awareness whereas the second part (from question #8 to #14) was designed to evaluate PD awareness ( Figure 1). The questionnaire form was submitted online and distributed via social media for 2 weeks. Each response was marked with "1" for a positive answer and "0" for the other answers. Once each individual response was marked, answers were summed to give an overall score for each of the two sections of the questionnaire; the means were then calculated in order to determine OH and PD awareness. The inclusion criteria were Iraqi individuals, aged 14 years and above, having at least primary education and capable of reading and responding to the questionnaire. Any response from non-Iraqi nationality or Iraqis living in other countries, from a dentist, incomplete, lacking agreement to consent statement was excluded from the final F I G U R E 1 Oral health and periodontal disease awareness questionnaire analysis. The exclusion was based on the age, nationality, country of residence, and occupation as reported by the individual.

| STATISTICAL ANALYSIS
Both descriptive and inferential statistics were used for analyzing the data. Comparisons of OH and PD awareness for all participants were determined using Mann-Whitney U test. For answers in each awareness section, χ 2 was used to compare percent of correct response in relation to different demographic variables and levels of knowledge. Association of these variables with correct answers was determined by calculating odds ratio (OR) at 95% confidence interval (CI). All analyzes were performed by using SPSS software (Version 21, IBM, USA). Differences were considered significant when p < .05.

| RESULTS
A total of 3,514 viewed the questionnaire online and 2073 had anonymously responded to it, 59% response rate of those who viewed the questionnaire online, of whom 1,465 met the criteria for inclusion and were considered in the final analysis ( Figure 2). This number of the respondents was equal to 91.6% of the calculated sample size; thus, it was considered satisfactorily representative for the targeted population. The demographic data of the respondents was summarized in Table 1.
The majority of respondents correctly answered the question about the potential adverse effect of PD on the general health. While, the lowest correct response percentage was about the most common reason for gingival recession (Figure 3a). In general, respondents showed significantly higher levels of awareness about PD (median = 4, mean ± SD = 3.66 ± 1.42) than OH awareness (median = 2, mean ± SD = 2.19 ± 1.29) (Figure 3b).
Analysis of answers for OH awareness questions according to the demographic variables is shown in Table 2. In general, non-smoker, ≥45 years, female, and respondents who holding high educational degrees brushed their teeth twice a day on regular basis more than their counterparts. No significant difference in the reported time taken for tooth brushing with exception for age groups in which respondents ≥45 years were the highest. The only significant difference for the use of interdental aids was observed according to educational level as the high degree holders were the highest and age groups as the oldest subjects being the highest. The responses for using mouthwashes, results showed significant difference between female versus male, and employed versus non-employed. Results according to educational level, and age groups showed a similar pattern to the responses for the previous question. Answers about the potential staining effect of tea and coffee on teeth showed only  Table 3).
Some of the respondents in this study exhibited low levels of OH knowledge; significant differences were observed between gender, educational level, and age groups (p < .05). Interestingly, they also had low to moderate level of PD knowledge (Table 4).

| DISCUSSION
The current study used online-based platform to distribute the questionnaire via social media websites including Facebook and Telegram. The use of social media is found widely in the population and allows effective and rapid sharing of information (Boyd & Ellison, 2007 were significantly associated with gender and educational level. These results are consistent with a previous study conducted on non-medical professionals in Nigeria whom PD knowledge was relatively high but not oral hygiene practice (Umeizudike et al., 2015).
OH knowledge is an integral attitude to preserve a healthy oral cavity. Studies have indicated that subjects acquire this knowledge F I G U R E 3 Analysis of responses to oral health awareness questions showed that the highest response rate was associated with toothbrushing practice in which 65% positively answered about brushing, while the lowest response (10%) was associated with the use of interdental aids. For periodontal diseases awareness, about 83% of the respondents showed that they were aware about the effect of periodontal health on the general health; however, only 7% were able to determine the common cause for gingival recession (a). Comparing the mean of answers for both sections of the questionnaire showed that the population had significantly higher periodontal diseases awareness than oral health awareness (b) from different sources such as media (e.g., newspapers, radio, and television), self-experience, school, parents, and even from friends or relatives (d 'Almeida, Kagami, Maki, & Takaesu, 1997;Gholami, Pakdaman, Montazeri, Jafari, & Virtanen, 2014;Martensson, Soderfeldt, Halling, & Renvert, 2004;Miller, Lee, DeWalt, & Vann Jr, 2010). Unfortunately, most of these sources provide unreliable information and only few individuals follow the printed or verbal instructions given by dentists (Masood Mirza, Khan, Ali, & Chaudhry, 2007). Results from meta-analysis and systematic reviews recommended tooth brushing twice a day, in the morning and at bedtime, together with the use of appropriate interdental aids and regular dental attendance as suitable approaches to prevent PD (Lertpimonchai et al., 2017). Almost half of the sample positively responded to the frequency of tooth brushing but not visiting the dentist for regular examinations, which showed less than 10% response rate. A previous survey conducted in Kuwait showed that about two-thirds of the participants brush twice a day; yet, majority of them had not visited their dentist for regular examinations in the last 6 months (Al-Shammari, Al-Ansari, Al-Khabbaz, Dashti, & Honkala, 2007). Commitment to regular twice a day tooth brushing showed significant positive association with increasing age, which is inconsistent with a previous study that showed the opposite association with geriatric patients (Kulshreshta, 2017). This could be related to differences in sample size or the method of collecting the information in which the online survey used in this study, may attract individuals with higher educational level as compared to the use of a paper-  (Azodo & Omili, 2014;Nyorobi et al., 2018;Zavras, Vrahopoulos, Souliotis, Silvestros, & Vrotsos, 2002). Our findings suggested the presence of association between educational level and level of oral hygiene and PD knowledge, which is reflected by a significantly higher awareness, the same pattern, was reported by previous surveys (Macek et al., 2010;Márquez-Arrico et al., 2019;Nyorobi et al., 2018). Individuals with unfavorable habits such as smoking, that is known to cause deterioration of OH and systemic health, will potentially show lower concern about their levels of oral hygiene, this can be seen in the findings of the current study and has been clearly shown in a number of other studies(Abu-Gharbieh et al., 2019).
Generally, majority of the responses indicated low levels of oral hygiene knowledge in relation to all demographic variables included in this survey, which is similar to the previous published results (Macek et al., 2010). Interestingly, the knowledge about PD was found to be higher than OH knowledge, with responses almost equally distributed between "Low" and "Moderate" levels. There is no clear explanation for such variation in the knowledge of the two sections of the survey; nevertheless, advanced PD is more tangible by the subjects that may motivate them to seek information about the signs and treatments for these conditions. Another finding can be comprehended from the analysis that oral hygiene behavior was also deficient among the respondents. This was reflected by answers to questions about oral hygiene practices in the questionnaire such as details of tooth brushing, use of interdental aids and mouthwashes.
Limitation to access the internet or lack of the required knowledge to use it suggest using other methods of surveys such as paperbased or interviews to reach other members of Iraqi community who were not able to be engaged in the current online-surveys.

| CONCLUSIONS
Despite limitations, this study revealed inappropriate levels of OH and PD awareness and knowledge in the Iraqi population and provided the baseline data necessary for the development of Governmental educational programs and health awareness campaigns, which are highly suggested particularly focusing on the primary and high schools, in an attempt to improve the levels of awareness.