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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 1-6

Oral health knowledge, attitudes, and behavior of primary school teachers of Tehran, Iran

Department of Periodontology, Faculty of Dentistry, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran

Date of Submission20-Oct-2020
Date of Decision18-Nov-2020
Date of Acceptance25-Nov-2020
Date of Web Publication20-May-2021

Correspondence Address:
Dr. Mahmood Ghasemi
No. 9, 9th Neyestan St., Pasdaran Ave., P. O. Box: 19585175, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njecp.njecp_44_20

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Introduction: Schools are the valuable place for promotion of oral health, and primary school teachers have a unique position to influence oral hygiene practices in children. The aim of this study was to evaluate the knowledge, attitudes, and practices of primary school teachers of Tehran, Iran. Materials and Methods: A cross-sectional questionnaire-based survey was conducted among 195 primary school teachers of Tehran, Iran. The multiple-choice questionnaire regarding dental disease prevention is comprised of ten questions on knowledge, seven on practice, and five on attitude. Distribution of individuals in terms of variables was expressed as numbers and percentages, and a logistic regression test was used to investigate the relationship between variables. Results: 61.6% of the primary school teachers in Tehran had good knowledge on oral health, but their attitude, especially about their role in teaching oral health, is very unfavorable. Teachers with higher education and participation in continuing educational courses had a positive effect on their performance. Conclusion: All teachers should be trained at regular intervals, given the importance of oral health and raising awareness about improving oral health for their students.

Keywords: Attitude, knowledge, oral health, primary school, teachers

How to cite this article:
Shojaei RK, Ghasemi M. Oral health knowledge, attitudes, and behavior of primary school teachers of Tehran, Iran. Niger J Exp Clin Biosci 2021;9:1-6

How to cite this URL:
Shojaei RK, Ghasemi M. Oral health knowledge, attitudes, and behavior of primary school teachers of Tehran, Iran. Niger J Exp Clin Biosci [serial online] 2021 [cited 2022 Dec 10];9:1-6. Available from: https://www.njecbonline.org/text.asp?2021/9/1/1/316531

  Introduction Top

Oral hygiene (OH) is a necessity and part of general health today, and failure to comply with it can lead to dental and general health problems, low self-confidence, chronic infections, and a decline in quality of life, especially in children. Primary schools have an incredible potential for affecting the well-being behavior of a child. During this period, the child experiences dynamic formative stages[1],[2] and also develops skills, beliefs, and attitude which they practice throughout their lives. The role of educators during these formative phases of the child is significant. Consequently, teachers can assume a significant role in oral well-being instruction programs at school levels. Therefore, in attempts to achieve the best oral health outcomes for children, teachers should be considered as key person in ensuring the well-being of children.[3] Oral well-being instruction can be educated as a particular subject or as a component of different subjects, tending to the underlying physical, mental, and social determinants of oral and general well-being. Therefore, since school teachers spend a significant amount of time on students, are effective in creating informed knowledge and ideal practice in the minds of students, and are in charge of implementing medical and oral health in school, they should be taken into consideration.[4]

Geographically, Iran with about 82 million populations, being the 18th largest country in the world, is located in Southwest Asia. The integration of oral health in the primary healthcare system was implemented about 20 years ago. The initial target population in this reform is 7 million primary school students at the national level.[5] According the data provided by Iran Ministry of Education, there are about 800000 teachers for near 14 million students in all three levels of Primary. Junior and Senior high school levels. In primary schools the ratio is about 26.8 students per teacher. Training of dental specialists, dentists, as well as other allied dental health technicians, has now been done locally for over six decades. In 2017, the total number of dentists was reported to be about 30,000 and the number of local graduates was about 1500 annually and expected to increase by 8%–10% annually[5] and about 90% are working in the private sector.[6] Similar to many communities, OH procedures used by Iranian's include daily tooth brushing and dental flossing. Asgari et al.[7] reported that the percentage with minimum recommended daily OH practices was 3.7% among men and 7.7% among women. Urban citizens were more likely to have their teeth cleaned compared to rural people. In addition, OH status improved significantly by increase in both level of education and economic status.[7]

Another study revealed that dental care utilization is more concentrated among socioeconomically advantaged households in Iran and its provinces. The proportion of any dental care utilization among households was 1.73% and 7.69% among the poorest and the wealthiest socioeconomic status groups, respectively.[8]

Previous studies carried out in different population concerning primary school teachers' knowledge and attitudes toward dental health showed conflicting results. Some of them[2],[4],[9],[10] have concluded that most school teachers had a positive attitude toward educating school children about oral health as well as toward school-based oral health promotions and the school teachers had a fair amount of idea about poor oral health conditions of children and willing to get involved in the oral health education programs and keen to receive training. However, others[11],[12],[13] have shown that teachers' knowledge about oral health was inadequate and was inaccurate in some instances. Locally, in Iran, we have limited almost old data available on school teacher's knowledge, attitude, and self-practices. The reports are published in local dental journals, and so, the present study was done to assess the knowledge, attitudes, and practices (KAP) of government base school teachers of Tehran, Iran.

  Materials and Methods Top

This descriptive, cross-sectional study conducted between September 2019 and January 2020 involved 195 teachers employed in the government base primary schools in Tehran, Iran. This study was approved by the ethical committees of Research Council of Dental faculty, Tehran Medical Sciences, Islamic Azad University (IR.iau.Dental.Rec. 129). The schools were selected using a stratified cluster sampling method according to the number of health officials in each region, from all 19 educational districts of Tehran. According to a pilot study of 35 teachers using the confidence intervals for one proportion-new option, taking α = 0.05, P = 0.2, and d = 0.1, the total sample size required was 195. Permission to carry out the study was obtained from all the selected school principals, administrators, and management. Informed consent was obtained from the school teachers. All the participants were assured of the confidentiality of their responses. Only teachers involved in oral and general health education in each school were requested to participate in the study. To calculate the validity of the questionnaire, six dental specialists of the Islamic Azad University expressed their views on the questionnaire, and all of them agreed that the accuracy of the questions was satisfactory. Further, with the information obtained from the questionnaires completed by 35 volunteers, the reliability was double checked and the reproducibility coefficient of Kappa was 0.74, and according to 35 samples, content validity index: 0.85 and content validity ratio: 0.82 were evaluated. All candidates were then asked to complete a two-part questionnaire. The first part includes the demographic and educational data, and the second part was designed to consist of three sections (KAP). Knowledge level was assessed by 10 questions, attitude of 7 questions, and practice of 5 multiple-choice questions; regarding the knowledge, each question had a correct answer and score 1 was given to the correct and score zero to the wrong answer. Moreover, teachers obtaining 7 and above got a good, 5–7 average, and <5 poor knowledge scores. Further, for all questions, the percent distribution of each answer was calculated and recorded. At the end of the interview, pamphlet containing OH instructions was given to raise participant awareness. Data were statistically analyzed using SPSS software version 24 (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). The statistical methods used included descriptive statistics in which the distribution of individuals in terms of variables was expressed as numbers and percentages and a logistic regression test was used to investigate the relationship between variables.

  Results Top

Description of demographic variables

The data provided were related to teachers working in public schools of different education areas in Tehran, Iran. The results were tabulated and percentage (100%) was calculated and the conclusions were drawn. [Table 1] shows the general information of the individuals. Their mean age was 45.52 years, with the youngest subject being 29 years and eldest being 61 years. It was observed that about 96% of the health officials were women and only 8 of the volunteers were men. It was also found that half of the candidates (50%) had more than 5 years of work experience as health officials in schools.
Table 1: Demographic characteristics of primary school heath teachers

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Oral health knowledge attitude and practice of primary school teachers

[Table 2] shows the frequency distribution of correct and incorrect answers to people's knowledge questionnaire. More than three-quarters were aware of the number of permanent and deciduous teeth, and this was less pronounced for deciduous teeth. 34.87% were unaware of the first permanent tooth and 41.54% were unaware that the deciduous teeth could undergo endodontic treatment. A high percentage of awareness about the nature of gum disease (92.31%), the reason for the presence of fluoride in toothpaste (93.85%), and the age of onset of pediatric dentistry (85.13%) were expressed by these people. Nearly one-third was unaware of the microbial plaque.
Table 2: Knowledge of the primary school heath teachers

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[Figure 1] shows the level of awareness of people according to the score obtained. The awareness scores of the health officials surveyed regarding oral health varied from 3 to 11, and it was determined that 61.6% of the health officials studied had good awareness, 30.26% had moderate, and 8.2% had poor.
Figure 1: Level of awareness of primary school health teachers

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The findings regarding the attitude of health officials of public primary schools are given in [Table 3]. Almost everyone believed in the impact of oral health on general health (95.4%) and the need to floss the teeth (93.33%). In contrast, only 28.20% showed a positive attitude toward the similar effect of dental floss on the prevention of caries and periodontal disease. 14.36% and 56.92% believed that health education or periodic oral examinations were not their duty and should be performed by a dentist, respectively.
Table 3: Attitude of the primary school heath teachers

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The findings regarding the performance of the candidates are given in [Table 4]. More than half of them brush twice a day (53.33%), but less than half of them (48.71) use floss twice a day. 11.79% of health officials had more than a year since their last dental visit, and 31.79% of these people referred to the dentist when necessary and in pain. 57.44% of these people also changed their toothbrushes every 3 months.
Table 4: Practice of the primary school heath teachers

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Investigate the relationship between variables


The linear regression test showed that among the general variables of individuals, participation in continuing education courses and work experience of individuals have affected the level of awareness. It was also found that the higher the level of work experience and the higher the level of education, the higher the probability of the correct answer to this question. In the case of microbial plaque awareness (Question 8), only the work experience factor was effective, and the higher the work experience, the higher the probability of the correct answer to Question 8.


The test showed that the three factors of participation in the continuing education courses, having health issues at the time of study and the place of obtaining a degree (teacher training/non-teacher training), have affected the attitude. Those who participated in the continuing education courses, and those who had health issues during their studies had a better attitude, as well as health officials who studied in nonteacher training centers.


It has been observed that the number of brushes decreases with age. Also, the teachers educated in non-teacher training centers brushes their teeth more than the teachers educated in teacher training centers, and those who had oral health topics while studying are brushing more often. Only participation in the continuing education courses has been associated with the use of flossing. It takes longer for health education officials at teacher training centers to change their toothbrushes. The more work experience they have, the faster they change their toothbrush, and if they have had oral health issues while studying, they have changed their toothbrush in less time.

  Discussion Top

The present study was conducted to evaluate the KAP of teachers working in government base schools because it is thought that such institutions are suitable for the development of health education programs.[14] OH is an integral part of preschool health.[15] Good OH, including healthy teeth and gums, is an important part of a person's overall health. Dental care can sometimes be a forgotten part of our healthy lifestyle, while its importance is often underestimated.[16]

Undoubtedly, teachers are the most important personnel involved in any oral health activity in schools. It is also important for teachers to have sufficient knowledge of oral health and supportive attitude toward extracurricular activities.

Score knowledge of oral health officials of Tehran primary schools showed that more than half (61.54%) of school teachers had very good oral health knowledge and <10% had poor awareness. Tikare and AlQahtani[17] also observed the same level of general awareness (65.4% and 5%) in teachers in Saudi primary schools.

More than two-thirds of the participants were aware of the number of deciduous (75.9%) and permanent (89.2%) teeth, which are higher than the reports given by Onwudi et al.[18] (75.9% and 13.1%) and Ahmad et al.[19] Mota et al.[20] reported that only 45.5% of preschool and primary school teachers in India were aware of the number of deciduous teeth, and interestingly, about 40% stated that, only permanent teeth erupt in the mouths and were unaware of deciduous teeth.

It was also observed that almost all candidates were aware of the reason for using fluoride in toothpaste, which was reported to be 25.1% in the study of Onwudi et al.[18] and 54.6% in the study of Tangade et al.[21] Using fluoride toothpaste helps keep teeth to resist damaged by pathogenic bacteria. The mechanism of action involves the replacement of hydroxyl in the enamel structure with fluoride in the apatite crystal, which is more resistant to acid attack.[22],[23]

Similar to Tangade et al.'s[21] study, high percentage of teachers were aware of the bleeding gums and the cause of the bleeding gums. Majority of the school educators had a basic knowledge regarding the nature of dental caries and gum disease, and also aware of its association with bacteria. These data are in the range reported by Dawani et al.[24] and Mohiuddin1 et al.[25] These findings are encouraging compared to Kosovo school teachers,[26] and in a study conducted in Nigeria, only 9.6% of teachers were aware of the microbial plaque.[18] The probable rationality of such confirmatory knowledge in the present study may be that teachers have either received such information from dental professionals or obtained it through audio or video oral health programs or print media such as newspapers/magazines. In addition, the linear regression test showed that among the general variables of individuals, participation in continuing education courses and work experience of individuals have a positive effect on their level of knowledge.

Dental floss and other interdental cleaners are known to be an important part of dental hygiene and are needed daily to remove plaque and other particles from the teeth and maintain gum health.[27],[28] In the present study, only 28.2% of people believed that dental floss is effective in preventing caries and has no effect on the prevention of gum disease, and therefore, the necessary intervention to increase the knowledge and subsequent use of flossing is essential.

Majority of teachers believed that oral health education is not their duty and is the responsibility of dentists and also believed that periodic oral examinations in schools should be performed by a dentist. This attitude was also reported by Al-Jobair et al.[29] Haloi et al. stated that their respondents were most likely to accept responsibility for roles that did not involve loss of class time by students, out of school efforts.[30] The difference may be related to environmental, educational, and cultural factors that can affect people's attitudes toward health issues.

Conventionally, school teachers have been considered as the main factors of socialization and have been shown to affect the awareness, attitude, and future behavior of schoolchildren.[2],[31] In some studies, teachers have shown a willingness to participate in oral health education,[9],[10],[32] while in others, this role is not easily accepted.[15]

The benefits of using school staff as promoters of OH in children are many. Teachers have the ability to reach out to all children and instruct them on continuity. In addition, they can integrate oral health promotion with other activities, and ultimately, it is economically viable.[2],[31] However, one weakness may be that teachers may not have a sufficient background, knowledge, and attitude, which is partly the case in this and other study.[20] In the present study, it was found that participation in the continuing education courses, having topics related to oral health during their studying period and the place of obtaining a degree (teacher training/non-teacher training) have had a positive effect on their attitude.

Assessment of KAP includes important aspects of oral health such as brushing and the reason for visiting the dentist. The participants in the present study showed moderate practice. Maganur et al.[33] reported that approximately 34% of teachers brush their teeth once a day and 66% brush twice a day, which is similar to the study conducted by Tikare and AlQahtani.[17]

In the present study, participation in continuing educational courses had a positive effect on their flossing habit. People with higher education and those who have attended continuing educational courses have seen a dentist in less time, and the reason for their referral has been periodic check-up. Therefore, it can be said that the higher the level of knowledge of people, the more their performance will be affected by this. It should be noted that the present study has some limitations. In this study, only eight men in charge participated in the interviews, which did not examine the impact of gender on awareness, attitude, and performance. The fact that the study focuses on men or women has also been studied in another study,[24] but its limitations cannot be ignored. Other limitations include the lack of access to private school information, which was not allowed due to the lack of such information in education.

  Conclusion Top

The results of the study showed that the health officials of primary schools in Tehran have a relatively good awareness and performance, but their attitude, especially about their duty in teaching oral health, is very unfavorable and needs special attention. Iran is a developing country that wants cooperation. Interdisciplinary is in promoting oral health. Based on the above findings, it is recommended that teachers participate in educational and training programs to improve the strategy of oral health education in schools to benefit from the results of the future society of the country. All teachers should be trained at regular intervals, given the importance of oral health and raising awareness about improving oral health for their students with the help of staff or health organizations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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