Knowledge and Practices Regarding Oral Hygiene, Cariogenic Diet Intake, and Dental Check-Ups Among Registered Nurses in Nigeria: A Pilot Study

Abstract Objectives  To investigate the knowledge and practices of registered nurses in Nigeria concerning oral hygiene, cariogenic diets, and dental check-ups through a pilot study. Methods  This study was an online survey of 129 registered nurses in Nigeria. Data were collected via the WhatsApp social media using an electronic questionnaire (Google form). Data analysis was done using the SPSS version 26 software (IBM Corp, New York, USA). Results  The response and completeness rates of this pilot study were 41.7% (129/311) and 96.9% 9125/129), respectively. The majority (62.2%) of the respondents were females. The majority (89.1%) had average/above average score on basic oral health knowledge; however, there was no significant relationship between their level of basic oral health knowledge and their sociodemographic characteristics ( p  > 0.05). The majority (66.7%) of the respondents brushed twice daily, 86.8% used a fluoridated toothpaste, and 60.5% changed their toothbrush every 3 months. Furthermore, more than half (55.8%) consumed sugary snack/drink on daily basis, while 55.0% rinsed their mouth with water immediately after taking sugary snack, and only 55.8% did floss their teeth. Among those who flossed their teeth, only 37.5% did it once daily. It is also striking that 26.4% of the respondents had never visited a dentist for a dental check-up. Conclusion  Study findings showed a high level of basic oral health knowledge and a lower level of appropriate oral self-care practices among nurses in Nigeria. However, there is a need for a nationally representative study of nurses in Nigeria to further establish these findings.


Introduction
5][16][17] Healthy diets nourish the body and protects the body from chronic nutrition-related diseases, which have devastating oral disease manifestations. 18Foods rich in appropriate quantities of micronutrients, vitamins, and proteins build the body immunity against oral infections and enhance the growth, development, functioning, and repair of oral tissues. 18][12] Also, the frequent consumption of cariogenic diets such as chocolates, candies, and sugar drinks cause dental caries. 137][28] For example, in a hospital-based survey in Jos City (North-central Nigeria), by Idowu et al, 26 the prevalence of dental caries among nurses was 43.8%. 26lso, only a minority of them had good oral hygiene status (22.7%), flossed their teeth (10.4%), used medium-textured toothbrush (33.1%), and brushed twice per day (31.9%). 26In another hospital-based survey of nurses in Benin City (South-southern Nigeria), by Azodo et al, 27 only 28.1% of the surveyed nurses had good knowledge of common oral diseases.Pertinently, to the best of the authors' knowledge, none of these studies investigated the KAPS of nurses in Nigeria concerning issues pertaining to cariogenic diets and dental check-ups. 26Also, all the known literature were reports of single center studies.
Nurses are frontline healthcare workers in Nigeria, and they are being consulted by people, particularly at the community level, for oral health care.This shows that the importance of a nurse's KAPS concerning oral health care cannot be overemphasized-as they are expected to stay healthy and be at the frontline delivery healthcare services to the populations. 29,30It is therefore imperative to know the KAPS of nurses concerning oral healthcare, particularly on cariogenic diets and dental check-ups, as this knowledge will provide insights concerning these issues among nurses in Nigeria.
To date, there is no known multi-center study on the KAPS concerning oral health among nurses in Nigeria.There is a need to investigate this phenomenon among nurses at a large scale, involving multiple centers.To achieve this, it is intuitive to first conduct a pilot multi-center study.Pilot studies helps to determine/test the feasibility of participant recruitment process and data collection and analysis approaches to be used for a bigger research project. 31It also helps to identify beforehand a broad range of issues and challenges associated with a research design. 31Therefore, this current research-an online multi-center pilot study-aims to investigate the knowledge and practices of registered nurses in Nigeria concerning oral hygiene, cariogenic diets, and dental check-ups.Importantly, the findings obtained from this pilot study will provide deep insights and inform the planning and implementation of larger surveys on the KAPS concerning oral health among nurses in Nigeria.

Methods
This pilot study was an online survey of registered nurses in Nigeria; this study also forms a part of a wider collaborative research projects of the Cephas Health Research Initiative Inc., Nigeria. 29,30Approval to conduct the project was obtained from the Research Committee, Department of Community Health, Aminu Musa Habib College of Health Science and Technology, Yauri, Nigeria.
The study instrument was an anonymous electronicbased questionnaire (a Google form) which was adapted from an existing questionnaire. 32The questionnaire was then assessed by the research team and other public health experts for face validity, and then tested on five dental surgeons before its use in this pilot study.The questionnaire had three sections.The first section obtained information about their sociodemographic characteristics.The second section assessed their knowledge on oral health (focusing on oral hygiene, cariogenic diets, and dental check-up) through a set of 14 structured questions (►Table 1). 2,32-44Lastly, the third section obtained information concerning their oral health practices.
Being a pilot study, a convenient sample size of 120 registered nurses was considered appropriate for the study.
A total of 311 registered nurses were invited electronically, via a link posted on their WhatsApp chat groups, to participate in this study.They were all informed about the aims and objectives of the study; they were also informed that their participation was completely anonymous and voluntary.Only 129 registered nurses responded to the questionnaire, they all gave their informed consent, electronically, before participation.Their participation was completely voluntary and anonymous.
The data collected were analyzed using the Statistical Package for Social Sciences (SPSS) version 26 software (IBM Corp, New York, USA).Descriptive statistics was used to summarize all sociodemographic and outcome variables.Particularly, the assessment of the respondents concerning their knowledge of oral health was determined using knowledge scores.A score of one was given to each of the correct responses provided by the respondents to those questions assessing their oral health knowledge (►Table 1).The cumulative scores of each respondent were determined.The highest obtainable score was 14 while 0 was the lowest obtainable score.A cumulative score below 7 was considered to be below average score, while a cumulative score of 7 or above was considered to be an average or above average score.Bivariate analysis of variables was done using Chisquare and Fisher's exact tests.The findings obtained from the statistical analysis were presented in texts, tables, and a chart.

Results
This study had a response rate of 41.7% (129/311) and a completeness rate of 96.9% (125/129).The majority (77.5%) of the respondents were Christians, 64.3% were single, 62.2% were females, 43.4% were in the age range of 25 to 29 years, 51.9% were practicing in a public setting, and 89.9% were within their first to ninth years of nursing practice (►Table 2).
Ninety-one percent (91%) of the respondents had received oral health training (►Fig. 1).The majority (89.1%) of the respondents had average/above average score in their oral health knowledge assessment (►Table 3).There was no statistically significant relationship between oral health knowledge and the respondents' sociodemographic characteristics and status on oral health training history (►Table 3).
The majority (66.7%) of the respondents brushed twice daily, 46.5% brushed in the morning before meal, 86.8% used a fluoridated toothpaste, and 60.5% changed their toothbrush every 3 months.Furthermore, a little above half (55.8%) of the respondents consumed sugary snack/drink on daily basis, 55.0% rinsed their mouth with water immediately after taking sugary snack, and only 55.8% flossed their teeth.Among those who flossed their teeth, only 37.5% did it once daily.Also, 26.4% of the respondents had never visited a dentist for a dental check-up.From the bivariate analysis, there was no statistically significant relationship between the participants' gender and their oral hygiene and dietary practices (►Table 4).

Discussion
The findings obtained in this study are interesting and of dental public health importance.To start with, the response and completeness rates recorded in this study were low.However, this is not too surprising because online surveys, unlike paper-based surveys, usually have lower response and higher completeness rates. 45Based on existing evidence, it can be suggested that the low response rate in this study may be because the nurses invited for the study were very busy, not interested in participating, or not highly digitally savvy. 46,47he majority of the respondents reported that they had received training on oral health.However, from the assessment of their basic oral health knowledge, it was observed that an history of oral health training did not have any significant impact on their basic knowledge of oral health.Furthermore, from the inter-group comparison of those who 2 How many times should the teeth be brushed in a day After meals [34][35][36] 3 How often should a toothbrush be changed Every 3 months 40 4 What kind of toothbrush is suitable for healthy people?Medium texture 42 5 At what age should dental flossing commence?As soon as there is contact between the teeth 32 6 When should flossing be done during the day?After meals 32 7 What should be done after eating refined carbohydrates?Brush teeth 36 8 How often is checkup for dental caries necessary?Once a year 41 9 Concerning the efficacy of brushing, which of these statements is correct?Tooth brushing alone is not enough, use dental floss 33 10 Do you know that poor oral hygiene is a risk factor of oral cancer?Yes 2 11 Do you know that poor oral hygiene is a risk factor of rheumatic heart disease?Yes 37 12 Do you know that poor oral hygiene is a risk factor of halitosis (bad breath)?Yes 38 13 Do you know that poor oral hygiene is a risk factor of periodontal diseases (e.g., gingivitis, pregnancy epulis, etc.)?
Yes 39 14 Do you know that poor oral hygiene is a risk factor of pre-eclampsia?Yes 43,44 had oral health training and those who had not, it was found that some of those who claimed to have such training scored below average in the assessment.Many factors might be responsible for this; it might be possible that those who scored below the average mark received such training long time ago and they had forgotten or the training they received was of poor quality. 27,48Therefore, it is recommended that more needs to be done in ensuring the frequency and quality of basic oral health training received by nurses is of consistent and good.The oral hygiene practices among nurses are still an issue of deep problematic concern, 26,[28][29][30] and the findings obtained in this present study corroborates this fact.Although many of the surveyed nurses surveyed reported good oral hygiene practices, the proportion with poor oral hygiene practices is still significant-although not statistically significant-when viewed from the lens of dental public health.For example, close to four-tenth of the participating nurses in this survey only brushed their teeth once a day; this prevalence is relatively lower than that reported (40.9%) among a sample of surveyed nurses in Israel. 49urthermore, only a minority (46.5%) of the respondents brushed in the morning, before meal, and in the night, before bed.4][35][36] Meanwhile, on the contrary, a whooping proportion of them used fluoridated toothpaste, which is very impressive.A fluoridated toothpaste is a known protective agent used for dental caries prevention. 33,50Unfortunately, the reported prevalence rate of dental caries (>60%) and poor toothbrushing practices (>40%) among Nigerian nurses is high. 26,28Based on the available evidence, it can be affirmed that nurses in Nigeria constitute a high-risk population group 26,28 ; therefore, it is  recommended that oral health education focusing on the benefits of a fluoridated toothpaste use should be targeted at the nursing population in Nigeria, as this may enhance the uptake of the use of such toothpastes among them.The consumption of sugary snacks and drinks are dental caries risk factors. 13However, this risk reduces if appropriate preventive measures such as mouth rinsing and toothbrushing are done immediately after their consumption. 51In this study, most of the respondents consumed sugared snacks and drinks on daily basis, while over one-third of them did nothing that is caries-preventive after consuming such substances.Unfortunately, these poor habits predispose them to dental caries 51 ; therefore, it is recommended that tailored interventions that discourage frequent consumption of sugared snacks and drinks should be implemented among nurses.
Dental flossing involves the use of a floss to remove debris from the interproximal surfaces of a teeth. 33,52Dental flossing helps to protect oral health through the removal of plaque, calculus, food debris, and other foreign bodies from the teeth surfaces. 33,52However, less than six-tenth of the respondents in this study reported to use dental floss, out of which roughly one-third of them rarely use it.
It is also noteworthy that the majority of the respondents had rarely/never visited a dentist for check-up.This finding is similar to that reported among a sample of nursing students in Nigeria. 30This suggests that the habit of regular dental visit is uncommon among nurses in Nigeria.
However, this study was a pilot study-which is a limitation to the findings. 53Being a pilot study, it will be difficult to make unguided generalizations based on the study data. 53herefore, there is a need for a bigger study, probably a paper-based type, to ensure that a nationally representative sample of nurses are represented.Also, the data reported in this study were based on self-reports of the participants; therefore, there is a possibility of recall bias. 54To reduce the bias possibility, a structured questionnaire was used for the study. 55otwithstanding this limitation, this study is believed to be the first internet-based study to investigate the knowledge and practices concerning oral hygiene, cariogenic diet intake, and dental check-ups among Nigerian nurses-a rarely investigated health profession population in Nigeria.Also, this study adds new information to the existing body of knowledge on the dental public health conditions of nurses in Nigeria.
In conclusion, this online pilot study recorded a low response rate with the obtained findings showing a high level of basic oral health knowledge and a lower level of appropriate oral self-care practices among nurses in Nigeria.There is a need for a nationally representative study of nurses in Nigeria, preferably a paper-based one, to further establish these findings.

Fig. 1
Fig. 1 History of oral health training among the respondents.

Table 1
Questions used to test the respondents' knowledge of oral health

Table 2
Sociodemographic characteristics of respondents

Table 3
Respondents' background characteristics and knowledge of oral health

Table 4
Tooth brushing and food intake practices, across gender, among respondents a Only those that responded "yes" to "Do you floss your teeth?" were analyzed.