https://orcid.org/0000-0003-4386-6667
Figures
Abstract
Introduction
Inadequate toothbrushing practice is define as brushing teeth less than two times per day. Inadequate toothbrushing during adolescence can lead to oral health problems and disease burden in adults. Moreover, inadequate practice can lead to low quality of life and inadequate self-esteem.
Objective
This study aimed to determine the prevalence of inadequate toothbrushing practice among adolescents aged 13 to 17 years in Malaysia and its association with sociodemographic and other related risky lifestyles.
Method
This study was part of a national cross-sectional study, Global School Health Survey 2017. 27,497 students were agreed to participate in this study, with response of 89.2%. A validated self-administered bilingual, comprised of topics related to sociodemographic as well as adolescent health and risky lifestyles; substance use (alcohol, drug, smoking cigarettes), eating patterns, hygiene (inclusive of oral and hand hygiene), mental health status, lack of peer and parental/guardian support, truancy, physical activity, and body mass index (BMI). Analysis was performed using IBM SPSS for Windows version 26.0 involving complex sampling analysis and logistic regression.
Results
A total of 12.7% (95% CI: 11.8–13.6) of in-school adolescents had inadequate toothbrushing practices. Higher prevalence of inadequate toothbrushing were found among male, Indian, had ever drug use, had three or more lack of protective factors and had inadequate hand hygiene practices. Adolescents who had inadequate toothbrushing were significantly higher odd among males, Indian ethnic, ever drug use, inadequate hand hygiene practices and adolescents who had three or more lack of peer and parental/guardian support.
Conclusion
Approximately 1 out of 10 adolescents had inadequate toothbrushing practices with several factors associated, such as male gender, Indian ethnicity, inadequate hand hygiene, ever drug use and lack of protective factors are identified to be associated. By emphasizing the significance of frequent brushing, we can encourage positive changes and reduce the burden of preventable dental problems on adolescents.
Citation: Mohamad Anuar MF, Mohamed N, Awaluddin SM, Yacob H (2025) Inadequate toothbrushing practice and associated factors among in-school adolescents in Malaysia: Findings from Global School Health Survey (GSHS) 2017. PLoS ONE 20(1): e0317484. https://doi.org/10.1371/journal.pone.0317484
Editor: Francisco Wilker Mustafa Gomes Muniz, Universidade Federal de Pelotas, BRAZIL
Received: July 12, 2024; Accepted: December 30, 2024; Published: January 31, 2025
Copyright: © 2025 Mohamad Anuar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The datasets generated and/or analysed during the current study are not publicly available due to the sensitive nature of the information of the respondents provided but are available from the corresponding author or Head of Biostatistics and Data Repository, Dr. Mohd Azahadi Bin Omar (email: drazahadi@moh.gov.my) on reasonable request. This is to protect and maintain respondents’ anonymity and confidentiality. The data are kept saved in order not to expose the feelings of the respondents to the public. The National Institute of Health (NIH) also keep the data for this study in Data Repository System (NIH-DaRS) for long-term preservation and data accessibility.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors declare that they have no competing/conflicts of interest.
Background
Good oral health can be defined as a functional, structural, aesthetic, physiologic, and psychosocial state of well-being and is essential to an individual’s oral health and quality of life [1, 2]. Oral health care and good oral hygiene practices are important across all age groups. Since permanent teeth are already erupted during adolescence, oral health among adolescents is a strong predictor of adult oral health status.
Toothbrushing is one of the oral hygiene practices that has usually been highlighted and considered to be a good indicator in evaluating individual oral health care. Furthermore, toothbrushing can also be considered a fundamental self-care behaviour for the maintenance of oral health. Twice a day toothbrushing is considered a social norm in maintaining oral health through effective plaque control [3, 4]. As such, inadequate toothbrushing define as brushing teeth less than two times per day [5, 6]. Previous studies show the prevalence of inadequate toothbrushing among school adolescent (13–17 years old) in six Southeast Asian countries varies from 10.8% in Indonesia to 36.4% in Bangladesh [5].
Few studies have stated that inadequate toothbrushing is associated with the development of dental caries and periodontal disease [5, 7]. Burden of oral diseases varies among school children (11 to 12 years old), with caries prevalence of 26.3% in India [8], 33.3% in Malaysia [9] to 39.9% in China and caries severity with mean Decayed, Missing, and Filled Teeth (DMFT) of 0.17 among Malaysian school children to 3.29 among Brazilian school children [10]. Studies have shown that many factors are associated with inadequate toothbrushing practices among adolescents, such as male gender [5, 11, 12], health risk behaviours such as smoking [6, 11, 12], alcohol and drug use (such as cannabis) [13], inadequate exercise [6, 12], inadequate fruit/ vegetable intake [5, 13], psychological distress [5, 13], lack of peer and parental/guardian support [5, 13] and obesity [12]. These findings may indicate risky lifestyle behaviour that need to be highlighted when associating inadequate toothbrushing among adolescents.
In Malaysia, an adolescent health survey was conducted as a nationwide survey with the aim of assessing the prevalence of health risk behaviours and protective factors among adolescent students (13 to 17 years old) attending school, in conjunction with the Global School Health Survey (GSHS). Therefore, it is crucial for in-depth analysis to be conducted especially in exploring toothbrushing behaviour among adolescents, with relevant association with health risk behaviour and protective factors. In-depth analysis can further investigate the issue in detail and uncover the hidden patterns relationships between the inadequate toothbrushing with relevant factors. Thus, this paper will explore the prevalence of inadequate toothbrushing among 13- to 17-year-old in school adolescents in Malaysia as well as the association with relevant factors such as sociodemographic factors, health risk behaviours as well as factors associated.
Methods
Adolescent survey
This study was part of the GSHS 2017, which was a national cross-sectional survey designed to study adolescent health and risky lifestyle behaviour among in-school teenagers, aged between 13 to 17 years in Malaysia. The survey utilized a two-stage stratified sampling design to ensure the representativeness of school adolescents. The first stage of sampling was the selection of schools to represent each state and federal territory (16 states/federal territories) in Malaysia and the second stage was the selection of the class in the schools that were selected. Schools were randomly selected using probability sampling, proportionate by school enrolment size while the classes in school were selected using systematic random sampling. A total of 212 schools were selected with a range of 4 to 10 classes to meet the requirement sample for each state and federal territory. Upon selection, all students in the class were eligible to participate in the survey. No exclusion criteria were applied as the survey include all the students selected in the class. A total of 30,832 eligible students were recruited based on school registration and 27,497 students agreed to participate the survey with the consent from the parents, for a response rate of 89.2%. However, this study only includes data from 25,284 students due to incomplete data on the studied variables due to the students did not answer the modules. More information about this section can be obtained from the GSHS 2017 report [14].
Survey instrument
Validated self-administered bilingual (Malay and English) questionnaires adopted from the Malaysia GSHS 2012 were used to capture adolescent health and risky lifestyle behaviour. The instruments used computer-scan-able answer sheets, which were also known as optical mark reader (OMR) sheets, to capture all the answers given by the respondents. The questionnaires comprised 77 questions that addressed topics related with adolescent health and risky lifestyles [14]. For this study, several topics were chosen to be included: substance use (alcohol, drug, smoking cigarettes), eating patterns, hygiene (inclusive of oral and hand hygiene), mental health status, peer and parental/guardian support, truancy, physical activity, and body mass index (BMI). In ensuring the quality of the data collection, a pilot study was conducted on 6th February 2017 at a few selected schools in state of Selangor. Data collection was conducted from 26th March until 3rd May 2017. Prior to data collection, a training course was held on 19th March 2017 for data collectors in Peninsular and East Malaysia.
Hygiene
The module comprised two hygiene components in adolescent health; oral hygiene and hand hygiene. For the oral hygiene component, respondents were asked “During the past 30 days, how many times per day did you usually clean or brush your teeth?” with the response given as frequency numbers of brushing teeth per day. Brushing teeth less than 2 times and not cleaning or brushing for the past 30 days were categorized as inadequate toothbrushing practices, while others were categorized as adequate toothbrushing practices [6, 14].
In addition, there were two questions related to the oral hygiene component. The respondents were asked “Do you use dental floss to clean your teeth?” with the response either “yes” or “no”. Another question was “When was the last time you saw a dentist or dental nurse for a check-up, teeth cleaning, or other dental treatment?” with the response given as follows: a = during the past 12 months, b = between 12 and 24 months ago, c = more than 24 months ago, d = never, and e = I do not know. Respondents who chose during the past 12 months were considered routine attenders, while others were nonroutine attenders [14, 15].
The hand hygiene component comprised three questions related to daily hand washing practices. Respondents were asked for the past 30 days how often they practice the following behaviour: use of soap when washing their hands, wash hands before eating and wash hands after using the toilet. The responses given for each question were as follows: a = never, b = rarely, c = sometimes, d = most of the time, and e = always. Respondents who chose “most of the time” and “always” were considered had good practice, while others were considered poor practice. In this study, poor hand hygiene practice was considered if the respondents had at least one poor practice in any of the three questions given [14].
Substance use
For smoking cigarettes, respondents were asked “During the past 30 days, on how many days did you smoke cigarettes?”. In addition, the respondents were asked if they smoked e-cigarettes or vape for the past 30 days, with the same question structure as smoking cigarettes. For alcohol drinker status, the respondents were asked “During the past 30 days, on how many days did you have at least one drink containing alcohol?”. Both smoking and alcohol drinker status had the same answer selection: a = 0 days, b = 1 or 2 days, c = 3 to 5 days, d = 6 to 9 days, e = 10 to 19 days, f = 20 to 29 days, and g = all 30 days. Respondents were considered current users (for each substance) if they smoked or drank at least 1 out of 30 days. For drug use, the respondents were asked “During your life, how many times have you used drugs?” with the response as follows: a = 0 times, b = 1 or 2 times, c = 3 or 9 times, d = 10 to 19 times, and e = 20 or more times. Respondents were considered to have ever used drug if they had a history (at least 1 time) in their life, regardless of drug type [14].
Eating pattern
Respondents were asked four eating patterns which were direct questions regarding their food/drink intake or serving. Respondents were asked “During the past 7 days, how many days did you eat food from fast food restaurants, such as McDonalds, KFC and Pizza Hut?” with the response option in days. Respondents were considered had frequent fast-food intake if they took 3 days or more. In addition, with the fast-food intake, the respondents were also asked “During the past 30 days, how many times per day did you usually drink carbonated soft drinks such as Coca Cola, Sprite and Pepsi?” with the response also in days. Respondents were considered carbonated drinkers if they consumed at least 1 time per day during the past 30 days. For fruit or vegetable serving intake, the respondents were asked how many times per day they had eaten fruits or vegetables for the past 30 days. Both questions had the same response in days. Respondents who reported that they consumed fruits (or vegetables) 1 times per day or none were considered had inadequate consumption patterns [14].
Mental health status
A standardized, validated and translated bilingual Depression Anxiety and Stress Scale (DASS) 21 was used to determine the mental health status of the respondents [16]. The questionnaire comprises 21 questions with four answer selections as follows: a = did not apply to me at all, b = applied to me to some degree or some of the time, c = applied to me to a considerable degree or a good part of time, and d = applied to me very much, or most of the time. The scoring and grouping of the mental health status (depression, anxiety, stress) followed the standard procedure of using the DASS 21 [14, 16].
Peer and parental/guardian support
Peer and parental/guardian support were assessed with five items on peer support at school, parental or guardian supervision, connectedness, bonding, and respect for privacy of the respondents. Peer support at school was assessed with the question “During the past 30 days, how often were most of the students in your school kind and helpful?”, parental or guardian supervision “During the past 30 days, how often did your parents or guardians check to see if your homework was done?”, parental or guardian connectedness “During the past 30 days, how often did your parents or guardians try to understand your problems and worries?”, parental or guardian bonding “During the past 30 days, how often did your parents or guardians truly know what you were doing with your free time?” and parental or guardian respect privacy “During the past 30 days, how often did you parents or guardians go through your things without your approval?”. All the items had the same response option as follows: a = never, b = rarely, c = sometimes, d = most of the time, and e = always. For peer support at school, parental or guardian supervision, connectedness and bonding items, respondents were considered had peer and support factors if they chose always and most of the time in the response selection. However, for the respect for privacy item, respondents were only considered had peer and support factors if they selected never or rarely in the response selection [14].
Truancy
Respondents were asked “During the past 30 days, on how many days did you miss classes or school without permission?” with response options in days. Respondents were considered had truancy if they missed class or school at least 1 day in the past 30 days [14].
Physical activity
Respondent’s physical activity was assessed based on the self-reported answer on the OMR sheet. Respondents were asked “During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day?” with the response option in days. Respondents were considered active for at least 60 minutes per day (sum of all the time spent in any kind physical activities), with a minimum of 5 days per week [17]. Sedentary behaviour was also assessed by asking the respondents “How much time do you spend during a typical or usual day sitting and watching television, playing computer games, talking with friends, or doing other sitting activities?” with response in hours per day. Respondents were considered had sedentary behaviour if they spent at least 3 hours in sitting activities [14, 17].
Body mass index (BMI)
Height and body weight were assessed by using a portable measuring scale, in the presence of data collectors. The international age-gender specific child BMI cut off points were used in this study to define the underweight, normal, and overweight/obesity status of the respondents [17, 18]. The interpretation of cut-offs as follow: Overweight: >+1SD (equivalent to BMI 25 kg/m2 at 19 years), Obesity: >+2SD (equivalent to BMI 30 kg/m2 at 19 years), Thinness: <-2SD, Severe thinness: <-3SD, normal: 0. The interpretation was based on z-scores chart and well-trained nurses evaluated the age-gender specific child BMI cut off points for each student [14, 17, 18].
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia and registered with the National Medical Research Register (NMRR-16-698-30042). The survey follows the guidelines and regulations provided by the Ministry of Health Malaysia to abide by the ethics in this study. All the participants were given a written consent form prior to data collection. All the participants and legal guardians / parents were briefly informed by the written consent form on the study conducted before given their consent to participated their children. Informed consent was then obtained from all the participants and legal guardians/parents for the study before the data collection start.
Data analysis
Data analysis was performed using IBM SPSS for Windows, Version 26.0. The prevalence of inadequate toothbrushing was determined using complex sampling analysis with a 95% confidence interval applied, and a weighting factor was used to adjust for non-response students and for varying probabilities of selection. Factors associated with inadequate toothbrushing practice were determined at both univariate and multivariable levels using simple logistic regression and multiple logistic regression respectively. Independent variables such as sociodemographic and factors associated that had been included in this study were used in the model. The outcome was a binary variable coded as “0” for adequate toothbrushing practice and “1” for inadequate toothbrushing practice among in-school adolescents. For crude odd ratio, the p-value less than 0.25 were determine as acceptable criteria to be included in adjusted odd ratio analysis. The goodness of fit of the model was determined using the Hosmer-Lemeshow goodness-of-fit test with a non-significant p value (>0.05). Interactions between variables and multicollinearity must show no significant interaction result, and the classification table value with receiver operating characteristics (ROC) curve value were also determined, with the value at least 0.70. The final model was presented with an adjusted odds ratio (aOR) and 95% confidence interval (95% CI), with the level of significance set at p-value of less than 0.05 to ensure the quality of the model.
Results
Prevalence of inadequate toothbrushing
Overall, approximately 12.7% (95% CI: 11.8–13.6) of in-school adolescents had inadequate toothbrushing practices during the past 30 days in Malaysia. In sociodemographic, higher prevalence was seen in male adolescents (17.9%, 95% CI: 16.7–19.3), Chinese (21.7%, 95% CI: 19.7–23.9), Indian (21.4%, 95% CI: 17.2–26.3) and adolescents who had their parents divorced/widow(er)/separated (15.3%, 95% CI: 13.6–17.2), respectively (Table 1).
For risky and unhealthy behaviour, higher prevalence was seen in adolescents who had inadequate fruit servings (16.6%, 95% CI: 15.5–17.8), inadequate vegetable servings (14.5%, 95% CI: 13.4–15.6), current smokers (21.9%, 95% CI: 18.8–25.2), current e-smokers (20.9%, 95% CI: 17.7–24.5), current alcohol drinkers (25.6%, 95% CI: 22.4–29.0) and ever drug users (38.3%, 95% CI: 32.4–44.5), respectively (Table 1). In terms of social, higher prevalence was seen in adolescents who reported had three or more lack of peer and parental/guardian support (14.1%, 95% CI: 13.1–15.1), truancy (15.5%, 95% CI: 14.1–17.1) had two or more mental issues (anxiety, stress, depression) (17.7%, 95% CI: 15.2–20.5), respectively (Table 1).
For the hygiene component, adolescents who reported poor hand hygiene practices also had a higher prevalence of inadequate toothbrushing practices (18.3%, 95% CI: 16.9–19.8) than good hand hygiene practices. In addition, adolescents who reported as non-routine attenders (14.6%, 95% CI: 13.5–15.7) showed a higher prevalence than those routine attenders, respectively (Table 1).
By fitting all the sociodemographic and relevant factors, multiple logistic regressions showed that few sociodemographic and health behaviours were associated with inadequate toothbrushing practices. In sociodemographic, higher odds of inadequate toothbrushing were found significantly associated in male adolescents (aOR 2.46, 95% CI: 2.26–2.69) and among Indian adolescents (aOR 2.14, 95% CI: 1.82–2.52). For substance use, adolescents who had ever used drug also showed higher probability of inadequate toothbrushing practices, with a significantly associated of aOR of 2.53 (95% CI: 2.13, 3.00). In addition, adolescents who had three or more lack of peer and parental/guardian support (aOR 2.17, 95% CI: 1.49–3.17) and poor hand hygiene practices (aOR 2.01, 95% CI: 1.84–2.19) had significantly higher probability associated of inadequate toothbrushing practices. Other variables such as Chinese adolescents, parents’ marital status (divorced/widow(er)/separated), inadequate fruit intake, inadequate vegetable intake, overweight/obese BMI, inactive physical activity, sedentary status, current smoker, had psychological statuses and non-routine attenders also showed higher odds of inadequate toothbrushing practice. However, the value was considered low compared to other variables highlighted. Other variables were found not significant in this study (Table 2).
Discussion
Toothbrushing practice is one of the essential habits in achieving good oral health status. Effective removal of dental biofilm through toothbrushing and the use of fluoridated toothpaste is important in preventing the formation of dental caries [3, 19]. In this study, the prevalence of inadequate toothbrushing practice among adolescents was 12.7%, which is higher in Indonesia but much lower than in the Philippines, Thailand, Timor-Leste [5], Finland [11], Korean adolescents [6] and African countries [13]. Inadequate toothbrushing is considered factor associated for periodontitis [7, 20] and dental caries [3, 4]. Carious lesion occurred as time progress with inadequate toothbrushing during younger age. The lesion can lead severe damage to the teeth with tooth loss appeared in the final stage. Thus, it would suggest frequent toothbrushing can prevent the tooth disease, as per findings from previous studies [3, 4]. Even though the prevalence among adolescent is low, precautions are needed to prevent the poor practice to become nuisance in adult stage where other oral disease tend to occur. A previous oral health survey among adults in Malaysia in 2010 showed high oral disease burden with a dental caries prevalence of 88.9% (95% CI: 88.1, 89.6), and 94.0% (95% CI: 93.2, 94.8) presented with periodontal conditions [21]. Without proper intervention, dental caries will be a continuous process, which will lead to a high disease burden. Thus, it is crucial for preventive measures, such as frequent toothbrushing to reduce the oral health burden in adults as age continues.
In this study, male gender showed a higher prevalence and odds for inadequate toothbrushing practice. Gender differences in the adoption of preventive oral health care behaviours have been shown in other studies [22–27]. Female gender was reported to be more aware of the prevention of oral diseases [22], frequent toothbrushing [23–27], use of interdental floss and preventive dental check-ups [25] than their male counterparts. Female gender takes greater care of their oral hygiene regardless of age. Therefore, it is crucial to inculcate the importance of oral hygiene care, especially toothbrushing frequency. By ethnicity, Indians showed higher results in both prevalence and odds for inadequate toothbrushing compared to other ethnicities. Several factors may be associated with inadequate toothbrushing practices such as socio-cultural aspects and the perceived importance of good oral hygiene care. Other study also highlighted the negligence and lack of attitude toward oral hygiene among Indian ethnic has also a negative impact on the general hygiene [28]. With the negligence of the inadequate toothbrushing, periodontal diseases are among the most prevalent in the ethnic group [28]. Focus group discussions (FGD) or qualitative studies should be conducted among adolescents in Malaysia to better understand their inadequate behaviours.
Poor hand hygiene among adolescents is also associated with inadequate toothbrushing practices in this study. Similar findings were also observed among Iranian adolescents where there was an association between oral hygiene and general hygiene [23, 28, 29]. Poor hand hygiene and inadequate toothbrushing practices among adolescents can cause multiple disease burdens, and these poor habits may continue during adult life if no intervention is taken. Other study stated hand and oral hygiene practice are recommended as the most cost-effective way to reduce the spread of infectious diseases, as well as for reducing burden towards hygiene related diseases [29]. Study showed that not always or inadequate hand washing practice is associated with poor subjective oral health status, experience of oral disease symptoms, low frequency of brushing teeth, and non-use of oral supplements [29]. Therefore, well practice hand hygiene and oral hygiene practice in adolescence can have a lasting impact on health during growth and adulthood, reducing the burden of disease related with hygiene.
Another study suggested that attitudes, knowledge, beliefs, and self-efficacy are some of the measures that are thought to be on the causal pathway for behavioural changes [30]. Thus, adolescents are needed to also be exposed to the importance of maintaining good hand hygiene as well as oral hygiene. Good hand washing is important, especially for children and adolescents, as these groups are the most susceptible to infections gained from unwashed hands [30]. Other study also reported the lack of financial support, low parental knowledge, and unhealthy hygiene practice in adolescents’ families can contribute to inadequate oral hygiene practice among adolescents [29]. Therefore, education programs to spread awareness regarding the importance of preventive personal hygiene such as adequate hygiene practice should be recommended for parents as well as adolescents [29].
This study also found that a lack of peer and parental/guardian support and substance drug use were also associated with inadequate toothbrushing practices, which is consistent with other studies [5, 13, 27]. By practicing good oral hygiene, the prevalence of common oral disease can be prevented through frequent brushing practices. Inadequate oral hygiene and toothache had a significant association with inadequate school performance and school absenteeism [31]. Interventions to facilitate health-related behaviours should be made and geared to the most important risk factors related to unhealthy behaviours.
There were few limitations in this study. The survey was under GSHS, which only enrolled adolescents at the school. School-going adolescents may not be representative of all adolescents in a country, as the occurrence of frequent toothbrushing practice may differ between the two groups. The data obtained are more self-reported or perceived by the respondents which may lead to some biases. Furthermore, the data collection used the recall method. However, it should be reinforced that this study had great strength in using a nationally representative adolescent sample. The sampling units were based on the population and original school frame from the Ministry of Education Malaysia and the survey sample weights were adjusted to represent the adolescent population. In addition, the adolescents completed the questionnaires anonymously. This indicates that the results from this study are reliable and representative.
Conclusion
In summary, approximately 1 in 10 adolescents had inadequate toothbrushing practices. Adolescents who were male, Indian, had ever used drug, had three or more lack of peer and parental/guardian support, and poor hand hygiene practices had a higher prevalence of inadequate toothbrushing, with in-depth analysis showing an association of the factors mentioned with inadequate behaviour. Understanding the root of cause for inadequate toothbrushing is essential in developing targeted interventions and educational programs to encourage adolescents to adopt healthier oral care practices. Emphasizing the significance of frequent brushing, we can encourage positive changes and reduce the burden of preventable dental problems on adolescents.
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