Hindawi

International Journal of Dentistry

Volume 2020, Article ID 3472753, 11 pages
https://doi.org/10.1155/2020/3472753

Research Article
Nutrition Awareness and Oral Health among Dental Patients in
Palestine: A Cross-Sectional Study

Manal M. H. Badrasawi ,1 Nour H. Hijjeh,2 Rana S. Amer,2 Reema M. Allan,2

and Mohammad Altamimi1
1
Department of Nutrition and Food Technology, Faculty of Agriculture and Veterinary Medicine, An-Najah National University,
Nablus 30500, State of Palestine
2
Healthy and Therapeutic Nutrition Program, Faculty of Applied Sciences, Palestine Polytechnic University, Hebron 30500, State
of Palestine

Correspondence should be addressed to Manal M. H. Badrasawi; [email protected]

Received 14 August 2019; Revised 20 January 2020; Accepted 24 January 2020; Published 26 February 2020

Academic Editor: Alessandro Leite Cavalcanti

Copyright © 2020 Manal M. H. Badrasawi et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Nutrition plays a key role in oral and dental health. Similarly, oral health affects nutrition status and diet intake. Consumption of
much cariogenic nutrients such as sugar affects dental and gum health. The awareness of dietary practices that affect the oral health
is an essential component in the dental care system. The knowledge of the dietary factors that affect the oral health is a major
component in the treatment plan. In this vein, this study was conducted to determine the level of awareness of nutrition in-
formation affecting oral health among dental patients who visit the private and university dental clinics in West Bank, Palestine. A
total of 169 patients were invited to join the study and signed the consent form. A pretested questionnaire was used to collect the
required data which included patients’ sociodemographics, medical history, oral care practices, dietary practices, and oral health-
related nutritional awareness. Face and content validity were verified, followed by a pilot study to determine the questionnaire
reliability alpha, and the data were collected from October to November 2018. The Construct Validation was done using the Rasch
measurement model, and the descriptive statistical analysis was done to determine the level of awareness and the difference among
the groups using SPSS version 21. The total mean score of the nutrition awareness was (9.3 ± 2.8), with higher level of nutrition
awareness among females, and the highest score was 16 out of 17. The good oral health condition was reported among 44%, fair
32%, poor 16%, and bad 10% while excellent oral health was reported among only 5% of the participants. There was no significant
relationship between level of nutritional awareness with economic status, level of education, or area of living. For oral health,
females showed significantly better oral and gum health levels (p < 0.05). The overall level of nutrition knowledge among the
participants is insufficient. These results point to the need for oral health and nutrition educational courses and programs to
improve oral and nutritional awareness and knowledge among Palestinian people and dental patients in particular. Improving the
dietary habits and oral practices with lifestyle changes should also be encouraged.

1. Introduction immunodeficiency virus/acquired immunodeficiency syn-

drome (HIV/AIDS) related oral disease and orodental
Oral diseases are the most common noncommunicable trauma [1]. Oral health is an essential part in general health.
diseases (NCDs) spread in developed and developing It affects and is affected by nutritional status and overall
countries. They are among the major public health problems health status. Moreover, it has an impact on the quality of life
worldwide that have affected half of the world’s population and health outcomes of the patient [2]. Poor oral health is
(i.e., about 3.58 billion people) [1]. Such diseases include associated with many chronic diseases such as diabetes
dental caries, periodontal disease, tooth loss, oral mucosal mellitus, cardiovascular diseases, respiratory infections, and
lesions, and oropharyngeal cancers. In addition to, human gastrointestinal pathologies. Moreover, poor oral health has
2 International Journal of Dentistry

been associated with low birth weight and preterm delivery [16] while a study conducted on school teachers in India
[2]. On the other hand, good nutrition enhances healthy found that a fair level of oral health awareness was reported.
teeth and gum development and reduces the risk of some Having searched scientific databases including PubMed,
oral diseases [3]. Both macronutrients and micronutrients Springer’s, Science Direct, and Scopus, it was noticed that
have an impact on oral health, teeth development, enamel literature was lacking studies reporting knowledge or
and dentin synthesis, dental mineralization, and tooth awareness of public or dental patients regarding the nu-
protection [3]. tritional factors that affect oral health. A study was con-
Dental caries is a disease that results from microbiome ducted in India to assess students’ knowledge in nutrition
dysbiosis with the involvement of multiple cariogenic spe- and oral health relationship [8] and has found a low level of
cies, including mutans streptococci (MS), lactobacilli, dental nutrition knowledge whose significance has differed
Scardovia wiggsiae, and several Actinomyces species that according to the student’s year of study. In Palestine, a study
have the cariogenic traits of acid production and acid tol- to address the relationship between oral health and nutri-
erance [4]. The relationship between nutrition and dental tional knowledge among dental patients was recommended.
caries is a well-defined relationship; the anaerobic meta- Therefore, this study was designed to fill in such a gap by
bolism of dietary sugar by certain bacteria in the cavity leads determining the levels of factors of oral health related nu-
to demineralization of enamel and dentin of the tooth by tritional knowledge.
organic acid metabolites [5]. Depending on this mechanism,
food items are categorized according to their effect on teeth 2. Materials and Methods
into cariogenic, cariostatic, and anticariogenic food [3]. The
carcinogenicity of food depends on bioavailability, digest- 2.1. Study Design. This study utilized the cross-sectional
ibility, and texture of the consumed food [6]. Meaning that survey design. The main aim was to assess the level of
liquid food is less cariogenic than solid, while chewy food is nutrition and oral health awareness and to determine the
less cariogenic than sticky ones [3, 5, 6]. Type of sugar also relationship between nutritional status, oral practices, and
plays a specific role; that is, lactose has less effect than other oral health among adult patients.
sugars; and xylitol (alcohol sugar) reduces the risk of caries The Al-Quds University Ethical committee approved the
through its inhibitory effect on bacterial growth. Con- study protocol (reference number (55/REC/2018)). The
sumption of food and drinks that affect the oral cavity acidity researchers briefed the participants about the objectives of
(soft drinks, sweetened coffee and tea, candies) leads to teeth the study and gave them the right to participate in or
demineralization and causes tooth decay [7]. withdraw from the study at any time. The researchers then
Previous findings have highlighted the preference of obtained signed consent forms. The data collection has taken
consuming fresh fruits to fruits juices because chewing two months from October to November 2018. The data
stimulates more saliva production and promotes washing included participants’ sociodemographics, medical history,
effect; and fruit juices may have extrinsic sugars and lower oral health related practices, nutritional status assessments,
pH that contributes to erosive tooth wear. Concerning the oral health related nutrition knowledge, and oral health
meal patterns, it was reported that less frequent meals are status.
recommended over more frequent meals due to their effect
on dental caries; similarly, eating dessert after meals is
preferred compared to eating them after a period of time [8]. 2.2. Sample Size and Sampling Procedures. Sample size was
Nutrition education on oral and dental health plays a calculated using G-power software for t-test with pre-
vital role in preventing oral diseases and related problems. determined margin of error of 5% and confidence level of
Hence, it should be included in management plans for any 95%. The required sample size was 120 participants. Thirty
dental or oral problems. It maintains good oral health, participants were added in case of the drop out given a total
enhances treatment outcomes, and prevents further dental of 150 participants were recruited using the convenient
problems. Higher nutritional knowledge is associated with sampling techniques. Eligible participants had to be adults
better eating behaviors and with better nutritional status [9]. aged 18–60 years and who had visited the dental clinic for
To the best of the researchers’ knowledge, studies con- treatment, scaling, or follow-up. The participants with
ducted to assess oral health nutrition related knowledge congenital oral problems or under chemotherapy of ra-
among dental patients or any age groups are very sparse. On diotherapy were excluded from the final analysis. The se-
the contrary, there are many studies conducted to assess the lected participants were invited to fill in the questionnaire
awareness, practices, and attitudes on oral health in general, without referring to any information resources while an-
without focusing on nutrition related knowledge among swering the questions. No incentive was provided to the
secondary school students [10, 11], primary schools students participants.
[12], housewives and mothers [13], and adults [14]. Some
studies go further to assess the pediatricians’ knowledge on 2.3. Research Instrument
dental caries prevention [15]. In Saudi Arabia, a knowledge,
attitude, and practices study was conducted to explore the 2.3.1. Nutritional Knowledge Questionnaire Development.
awareness level of oral health practices among adolescents The items of the questionnaire were developed based on the
age 10–18 years. It has found sufficient level of awareness literature that reported the relationship between diet and
without significant differences between males and females oral health and oral diseases, in addition to the studies
International Journal of Dentistry 3

assessing the basic nutritional knowledge of an ordinary excellent; for calcification, the assessment depends on the
individual. The researcher with the help of three research presence or absence of calcification [21].
assistants and an expert in the nutrition field prepared the
first draft of the questionnaire which was composed of 20
items written in the participants’ native language (i.e., the 2.4. Statistical Analysis. The Statistical Package for the Social
Arabic language). Nine experts in assessment, nutrition, and ™
Sciences SPSS , version 21, was used to analyze the collected
data [22]. The normality test was done for the nutritional
dentistry have verified the content and face validity of the
questionnaire. A pilot study including 22 subjects from the knowledge scores using the Kolmogorov–Smirnov test.
private dental clinics in Hebron city was conducted to assess Descriptive analysis including the means and the standard
the internal reliability test of the questionnaire using SPSS™ deviations was used to analyze the data pertained to con-
version 21. Cronbach’s alpha coefficient was 0.85, indi- tinuous dependent and independent variables. The cate-
cating the items have acceptable internal consistency. The gorical data were described by percentages. The independent
final version of the questionnaire included 17 items. The samples t-test and ANOVA test were conducted to examine
items were presented as statements; and the subjects have the differences in the total score of the nutritional knowledge
to select if each statement is “correct,” “false,” or “I do not due to selected independent variables at alpha <0.05. The
know.” In the analysis phase, the answers were coded as the Winsteps software program, version 4.1.0, was used to
following: (1 mark for the correct answer and 0 marks for conduct the Rasch analysis to further examine the psy-
the false or “I do not know” answers). The sum of the chometric properties of the developed questionnaire on
answers was calculated to get the total score out of sev- nutritional knowledge [23].
enteen for each subject. It is important to add that the
psychometric properties of the 17-item questionnaire de- 3. Results
veloped to assess the participants’ nutritional knowledge
were further examined using the Rasch Measurement 3.1. Subjects’ Characteristics. The total number of the par-
model. According to Bond and Fox [17], Rasch measure- ticipants invited and agreed to join the study was 169.
ment model is used for research instruments validation Among them, 19 participants were excluded due to missing
because it ensures that the research instruments have met data. Only 150 participants were included in the final
the fundamental measurement requirements of research analysis. Table 1 shows the demographic characteristics of
instrument, for both the whole instrument and the indi- the sample presented in frequencies and percentages.
vidual item as well as person [17]. The collected data were The results revealed that smoking prevalence among
analyzed using the Winsteps software program, version males is higher compared to females (p < 0.05). Among the
4.1.0 [18]. Overall, the Rasch analyses revealed that the total sample, 13 patients reported presence of chronic dis-
questionnaire met the measurement requirements as re- eases: 2 asthma, 5 diabetes, 4 hypertension, 1 thyroidism,
ported in the results section below. and 1 heart disease. The cigarettes smokers’ percentage is
52.1% of the total participants.

2.3.2. Nutritional and Oral Health Status Assessment.

Nutritional status was evaluated using anthropometric 3.2. Participants’ Oral Health Practices. Table 2 presents the
measurements, diet intake, and dietary practices. The an- oral care practices among the study sample. There was
thropometric measurement included body weight and significant relationship between oral health practices and
height, which were done following the standard protocol gender for the following items: “cleaning the teeth regularly,”
documented in Lee and Nieman [19]. The body mass index “using teeth floss,” and “visiting the dentist for checking
was calculated for each participant and the WHO cutoff every 6 months.” The female participants recorded higher
points were used to categorize the nutritional status (obese, percentages in the aforementioned practices than the males.
overweight, normal weight, and underweight) [19]. Food Females were found to use complementary or alternative
frequency questionnaire (FFQ) was used to assess the dietary methods such as using of salt, lemon, cloves, and cardamom
intake. The questionnaire was validated in the Palestinian in cleaning their teeth more as compared to males.
context (i.e., current study setting) by Hamdan et al. [20].
The questionnaire also included questions about nutritional
practices to get detailed information about the eating pat- 3.3. Dietary Habits. Dietary habits of the participants are
terns and food choices of the participants. The evaluation of presented in Table 3. There was significant relationship
overall oral health, oral hygiene, gum health, and presence of between dietary habits and gender only for “daily con-
calcification was done by the dentists from the selected sumption of milk and its dairy products,” p < 0.05, where
clinic. The rating score for oral hygiene, gum health, and females tended to consume more milk daily and dairy
overall oral health was done following the standard pro- products compared to males.
cedures from Carranza’s Clinical Periodontology for oral Table 4 presents the results of the participants’ oral
health assessment using Periodontal examination chart health status. Oral hygiene was significantly associated with
which include Plaque index, Gingival index, mobility of the gender, p < 0.05. The item “good” oral hygiene was higher in
teeth, presence of calcification, and teeth furcation. The end females than males. General oral health was also lower in
score divided the oral health status into poor, fair, good, and males than females.
4 International Journal of Dentistry

Table 1: Participants sociodemographic characteristics presented in numbers and percentages.

Demographic characteristics Number (N) Percentage (%)
Male 44 32.8
Gender
Female 90 67.2
Single 60 44.8
Married 70 52.2
Marital status
Divorced 3 2.2
Widowed 1 0.7
City 81 60.4
Area of living Village 49 36.6
Camp 4 3
Secondary 51 38.1
Educational level University 73 54.5
Postgraduate studies 4 3
Less than 1500 NIS 26 19.4
1500–3000 NIS 47 35.1
Monthly income
3000–4500 NIS 29 21.6
More than 5000 NIS 28 20.9
NIS: New Israeli Shekel.

3.4. Nutrition Knowledge Score. The Rasch measurement gave the correct answer for question 10, “brushing or
model was used to examine the psychometric properties riddling the teeth after every meal reduces the decay.” On
for the questionnaire developed to measure the partici- the other hand, the participants were not able to give the
pants’ nutritional knowledge. Overall, the Rasch analyses correct answers to other specific questions; for example,
showed that the research instrument has met the mea- 84.4% wrongly answered question 17, “eating nuts with
surement requirements. The item and person reliability cariogenic foods protects the teeth,” and 76.3 % wrongly
indices and unidimensionality through three indicators answered question 6; “increasing the number of the meals
(item polarity, item fit, and PCA residuals) were examined increases dental caries.”
as shown in Table 5. Table 5 shows that the reliability of The differences in the level of nutrition awareness and
item difficulty measures was very high (0.98) which in- sociodemographic (age, gender, and marital status) were
dicates that replicability of the item difficulty ordering and not significant. However, the monthly income shows sig-
the item separation index was 6.66, greater than > 2 [18]. nificant relationship with awareness (p < 0.05). Patients
Table 5 also shows that all the item polarities (i.e., point- with monthly income of more than 5000 have higher
measure correlation coefficients) are positive and ranged awareness scores. Awareness scores of females were also
from 0.28 to 0.60, indicating that all the items are moving higher than those of males; however, no significance was
in the same direction to measure the intended construct noticed.
[18]. The infit and outfit mean square statistics are also In terms of the relationship between nutrition awareness
within the recommended range (0.5–1.5) [17], implying and oral health, there was no significant relationship be-
that the items are contributing meaningfully to measure tween awareness level and oral health or oral hygiene.
the intended construct as expected by the model. However, Table 8 shows the relationship between the dietary intake
the outfit square for item one is 1.52 due to misfitting with the oral and gum health. Participants with poor gum
persons. The Zstd values for both the infit and outfit health have shown significant higher sugar intake while the
statistics are within the range − 2 to +2, except for infit relationship between oral health and sugar intake was found
statistics for item 1 (− 3.2), which is still closer to the in patients with poor oral health; however, the relationship
recommended range. did not reach the significant level.
The principal component analysis of residuals is used to
ensure if the data fit the model and items are measuring a 4. Discussion
single unidimensional construct. Table 6 shows that uni-
dimensionality is not violated. The variance explained by the This study aimed at assessing the level of nutritional
measure is 45.3%, and the largest factor extracted from the awareness (related to oral health) and its relationship with
residuals is equivalent to 2.0227 units which have the oral and dental health among adult patients visiting dental
strength of about 2 items [18]. clinics in Palestine. Overall, the results of the study revealed
Overall, the participants showed inadequate knowl- that the study sample lacked the essential nutritional
edge about the specific dietary practices and oral health. knowledge indicated by their low scores on the given items
Table 7 demonstrates that the majority of participates regardless of their demographic characteristics. However,
answered the basic nutritional questions correctly; for the level of income showed significant difference in the mean
example, 94.1% knew the answer for question 1, “food scores of nutritional knowledge, supported by the significant
plays an important role in the teeth health,” and 93.3% mean differences among the groups.
International Journal of Dentistry 5

Table 2: Oral health practices according to gender presented in n (%).

Total Male Female
p value
n % n % n %
Yes 86 64.7 19 14.3 67 50.2 0.00
Cleaning teeth regularly
No 47 35.3 25 18.8 22 16.5
Morning 31 24.8 10 8 21 16.8 0.456
Evening 17 13.6 8 6.4 9 7.2
Cleaning time
Morning and evening 60 48.0 16 12.8 44 35.2
More than once a day 17 13.6 5 4.0 12 9.6
Circular 41 34.2 11 9.2 30 25.0 0.689
Horizontal 34 28.3 9 7.5 25 20.8
Cleaning method
Linear 28 23.3 9 7.5 19 15.8
Vibration 17 14.2 7 5.8 10 8.3
Less than 2 min 61 49.2 22 17.7 39 31.5 0.159
Cleaning duration 2-3 min 57 46.0 16 12.9 41 33.1
More than 5 min 6 4.8 0 0.0 6 4.8
Yes 40 30.8 7 5.4 33 25.4 0.025
Visiting the dentist for checking every months
No 90 69.2 34 26.2 56 43.1
Yes 27 20.9 4 3.1 23 17.8 0.060
Visiting the dentist for cleaning every 6 months
No 102 79.1 36 27.9 66 51.2
Always 26 19.4 8 6.0 18 13.4 0.052
Often 22 16.4 3 2.2 19 14.2
Cleaning teeth after eating food and sweets Sometimes 43 32.1 13 9.7 30 22.4
Rarely 28 20.9 11 8.2 17 12.7
Never 15 11.2 9 6.7 6 4.5
Always 11 8.3 1 0.8 10 7.6 0.056
Often 8 6.1 0 0.0 8 6.1
Using teeth floss Sometimes 20 15.2 6 4.5 14 10.6
Rarely 29 22 13 9.8 16 12.1
Never 64 48.5 24 18.2 40 30.3
Always 28 21.4 10 7.6 18 13.7 0.158
Often 19 14.5 3 2.3 16 12.2
Using mouth wash regularly Sometimes 32 24.4 11 8.4 21 16.0
Rarely 24 18.3 5 3.8 19 14.5
Never 28 21.4 13 9.9 15 11.5
Always 7 5.6 1 0.8 6 4.8 0.367
Often 8 6.3 3 2.4 5 4.0
Rubbing teeth with salt Sometimes 23 18.3 7 5.6 16 12.7
Rarely 16 12.7 3 2.4 13 10.3
Never 72 57.1 29 23.0 43 34.1
Always 6 4.9 2 1.6 4 3.3 0.551
Often 5 4.1 2 1.6 3 2.5
Rubbing teeth with salt and lemon Sometimes 13 10.7 6 4.9 7 5.7
Rarely 13 10.7 2 1.6 11 9.0
Never 85 69.7 31 25.4 54 44.3
Always 4 3.4 1 0.8 3 2.5 0.834
Often 0 0 0 0 0 0
Using coal Sometimes 4 3.4 2 1.7 2 1.7
Rarely 9 7.6 4 3.4 5 4.2
Never 102 85.7 35 29.4 67 56.3
Always 10 8.1 2 1.6 8 6.5 0.129
Often 6 4.8 1 0.8 5 4.0
Using cloves Sometimes 16 12.9 3 2.4 13 10.5
Rarely 19 15.3 4 3.2 15 12.1
Never 73 58.9 31 25.0 42 33.9
Always 2 1.7 0 0.0 2 1.7 0.154
Often 3 2.5 1 0.8 2 1.7
Using cardamom Sometimes 5 4.2 4 3.4 1 0.8
Rarely 14 11.9 3 2.5 11 9.3
Never 94 79.7 33 28.0 61 51.7
6 International Journal of Dentistry

Table 3: Dietary habits and practices according to gender presented in n (%).

Total Male Female
p value
n % n % n %
Always 15 11.2 5 3.7 10 7.5 0.727
Often 51 38.1 17 12.7 34 25.4
Are the meals consistent throughout the days Sometimes 34 25.4 10 7.5 24 17.9
Rarely 27 20.1 11 8.2 16 11.9
Never 7 5.2 1 0.7 6 4.5
Always 40 30.1 14 10.5 26 19.5 0.978
Often 37 27.8 12 9.0 25 18.8
Do you eat fresh fruits daily (as whole or juiced) Sometimes 41 30.8 14 10.5 27 20.3
Rarely 12 9.0 3 2.3 9 6.8
Never 3 2.3 1 0.8 2 1.5
Always 47 35.6 16 12.1 31 23.5 0.983
Often 32 24.2 11 8.3 21 15.9
Do you eat vegetables daily (as raw or cooked) Sometimes 34 25.8 10 7.6 24 18.2
Rarely 14 10.6 5 3.8 9 6.8
Never 5 3.8 2 1.5 3 2.3
Always 16 12.0 4 3.0 12 9.0 0.258
Often 16 12.0 3 2.3 13 9.8
Do you eat brown bread Sometimes 25 18.8 12 9.0 13 9.8
Rarely 33 24.8 9 6.8 24 18.0
Never 43 32.3 16 12.0 27 20.3
Always 6 4.5 4 3.0 2 1.5 0.216
Often 10 7.5 2 1.5 8 6.0
Do you eat processed meat Sometimes 34 25.4 14 10.4 20 14.9
Rarely 38 28.4 10 7.5 28 20.9
Never 46 34.3 14 10.4 32 23.9
Always 17 12.8 6 4.5 11 8.3 0.712
Often 23 17.3 8 6.0 15 11.3
Do you eat fast food Sometimes 42 31.6 15 11.3 27 20.3
Rarely 32 24.1 7 5.3 25 18.8
Never 19 14.3 7 5.3 12 9.0
Always 33 24.6 6 4.5 27 20.1 0.022
Often 32 23.9 15 11.2 17 12.7
Do you drink milk and its constitutes daily Sometimes 29 21.6 6 4.5 23 17.2
Rarely 19 14.2 10 7.5 9 6.7
Never 21 15.7 7 5.2 14 10.4
Always 38 28.8 12 9.1 26 19.7
Often 35 26.5 13 9.8 22 16.7
Do you drink enough water (10 cups and more) Sometimes 41 31.1 14 10.6 27 20.5 0.776
Rarely 12 9.1 2 1.5 10 7.6
Never 6 4.5 2 1.5 4 3.0
Always 9 6.8 2 1.5 7 5.3 0.386
Often 14 10.6 3 2.3 11 8.3
Do you watch your calorie intake within a meal Sometimes 21 15.9 6 4.5 15 11.4
Rarely 26 19.7 7 5.3 19 14.4
Never 62 47.0 26 19.7 36 27.3
Always 30 22.4 16 11.9 14 10.4 0.072
Often 29 21.6 10 7.5 19 14.2
Do you eat nuts at least twice a week Sometimes 36 26.9 9 6.7 27 20.1
Rarely 28 20.9 7 5.2 21 15.7
Never 11 8.2 2 1.5 9 6.7
Always 15 11.2 8 6.0 7 5.2 0.233
Often 15 11.2 7 5.2 8 6.0
Do you eat fish regularly twice a week Sometimes 30 22.4 9 6.7 12 15.7
Rarely 45 33.6 13 9.7 32 23.9
Never 29 21.6 7 5.2 22 15.4
International Journal of Dentistry 7

Table 4: Characteristics of oral health according to gender pre- 4.1. Oral Health Status and Nutrition-Related Factors. The
sented in n (%). current study found that the relationship between nutrition
Total Male Female knowledge and oral health was not significant. Participants
p
with higher nutrition knowledge scores did not have better
n % n % n % value
oral or gum health. However, “good oral health status” was
Bad 19 14.7 11 8.5 8 6.2 0.009
significantly higher in females compared to males. In ad-
Health of the Fair 36 27.9 14 10.9 22 17.1
gum Good 69 35.5 16 12.4 53 41.1
dition, “bad gum health” in males was significantly higher
Excellent 5 3.9 0 0 5 3.9 compared to females. Females reported better oral health
compared to men, which may be due to the presence of other
Existed 69 53.5 29 22.5 40 31.0 0.008
Calcification Not factors as smoking. Numerous studies have shown that
60 46.5 12 9.3 48 37.2 tobacco use would lead to and increase incidences and se-
existed
Poor 25 19.4 15 11.6 10 7.8 0.001 verity of periodontal diseases and higher rates of tooth loss.
Fair 37 28.7 14 10.9 23 17.8 The adverse effects of cigarette smoking and other forms of
Oral hygiene tobacco are numerous, and tobacco use has been associated
Good 62 48.1 12 9.3 50 38.8
Excellent 5 3.9 0 0 5 3.9 with gingival, oral mucosa, and dental alterations [32].
Bad 10 7.8 7 5.4 3 2.3 0.004 Females gained higher scores on nutrition knowledge and
Poor 16 12.4 5 3.9 11 8.5 got better practices related to oral health compared to males,
Oral health Fair 41 31.8 18 14 23 17.8 which illustrate that females may be more interested in
Good 57 44.2 10 7.8 47 36.4 nutrition and oral health than men [33].
Excellent 5 3.9 1 0.8 4 3.1 There were no significant differences between body mass
index (BMI) and oral health, gum health, and oral hygiene.
The overall mean score of the nutritional knowledge However, another study reported the association between
related to oral health was insufficient. The current study is body mass index (BMI) and oral health among adults;
unique because it has assessed nutritional knowledge in obesity and abdominal obesity were associated with in-
oral health, whereas many other studies have focused on creased prevalence of periodontal disease, while being un-
knowledge, attitude, and practices related to oral health in derweight was associated with decreased prevalence of
general, mainly hygienic practices. A study conducted periodontal diseases. It concluded that obesity could be a
among nutrition and dietetic students in India highlighted potential risk factor for periodontal disease [34]. Chafee and
low dental nutrition knowledge among nutrition/dietetics Weston suggested a bidirectional relationship between
students [8]. This finding raised the issue that lacking obesity and periodontal diseases, as obesity, insulin resis-
nutrition knowledge related to oral health is a problem tance, and periodontal diseases all are accompanied with
even among health professionals. By comparing the hyperinflammatory status, oxidative stress, and increased
findings of this study with other studies focusing on oral level of adipocytokines [35].
health, almost similar trends were reported. For example, The frequencies and percentages of correct answers were
Szatco and his colleagues reported that Polish mothers variable among the items. General questions reported higher
lacked nutrition knowledge which affected adversely their percentages of correct answers compared to oral nutrition
kids’ oral health [24]. Another study showed that Jor- specific items. Questions 1 and 10 asked about the role of
danian adults’ poor level of knowledge related to peri- food in oral health and brushing teeth preventing caries,
odontal diseases and the study recommended more respectively. Both items asked about basic general knowl-
educational programs to improve oral health awareness edge, which is well known to most of age groups. Similar
[25]. findings were reported in different studies targeting different
The study sample was comparably distributed according populations. Among school teachers in Saudi Arabia, sat-
to gender: the study found no significant differences between isfactory level of knowledge was found in general oral health
males and females in the level of knowledge and awareness questions such as oral hygiene practices [36]. Majority of
even though females usually recorded higher level of school children was found to be familiar with the effects of
awareness and knowledge. Available literature reported a oral hygiene on oral health [37].
higher nutritional knowledge among females compared to However, high percentages of participants gave wrong
males [26–29], and females showed more interest in nu- answers to questions 2, 3, 4, 7, 12, and 13 asking about sugar
trition and health, while no significant differences in nu- and dental caries. Specifically, they were asked about the
trition knowledge and awareness levels between males and effect of sugars on dental caries, effect of other types of
females were reported in Sarawak, Malaysia [10]. In terms of sweetener, frequency and the length of exposure between
oral health, similar trend to the current study was reported; sugar and teeth, eating more frequent meals, and increasing
men showed less oral health knowledge compared to women the risk of caries by consuming sticky dessert which stays at
[30]. In a study conducted in Palestine, significant gender the oral cavity for longer time. Such findings were sur-
differences were reported in knowledge attitude and prac- prisingly reported in Bapat et al., who found lack of
tices of dental and oral health between males and females knowledge of similar questions among nutritionist and
[31]. In Kuwait, poor oral health knowledge and practices dietetic students. [8].
among male students compared to female students were also Questions 11, 16, and 7 focused on protective dietary
reported [30]. factors against dental caries (i.e., nutrients that play
8 International Journal of Dentistry

Table 5: Items measures, fit statistics, and point-measure correlation coefficient.

Infit Outfit PT-measure
No. Item Measure S.E ZSTD ZSTD
MNSQ MNSQ CORR
1 Food plays an important role in the oral health − 3.36 0.46 1.20 0.6 1.52 0.9 0.29
2 Sugar is one of the food elements that causes dental caries − 2.25 0.31 1.08 0.4 0.90 − 0.1 0.38
3 Chewing free-sugar gum reduces dental caries 0.88 0.20 0.99 − 0.1 1.03 0.2 0.44
Using artificial sweeteners in candies and juices reduces the
4 1.84 0.23 1.01 0.1 0.85 − 0.5 0.40
dental caries
Drinking fruit juice cause dental caries more than eating the
5 1.38 0.21 1.06 0.6 1.01 0.1 0.38
whole fruit
6 Increasing the number of the meals increases dental caries 1.9 0.23 1.08 0.7 0.99 0.1 0.35
The frequency of eating sugar is more cariogenic compared
7 0.22 0.20 1.00 0.1 1 0.1 0.44
to the amount of the sugar
8 Food leftovers in the mouth are associated with dental caries − 2.45 0.33 1.02 0.2 0.9 − 0.1 0.40
Eating sweets with meals is better than eating sweets between
9 1.55 0.21 0.96 − 0.4 0.95 − 0.1 0.43
meals on dental caries
Brushing or flossing the teeth after every meal reduces the
10 − 3.16 0.43 0.83 − 0.4 0.64 − 0.4 0.47
caries
Drinking milk and dairy products protect the teeth from
11 − 1.82 0.27 1.15 0.9 1.48 1.3 0.30
caries
Eating sweets that melt in the mouth and swallowed faster
12 are less harmful than the sweets that stay for a longer time in 0.07 0.20 0.77 − 3.2 − 0.71 2.0 0.60
the mouth.
Sticky sweets increase the probability of teeth decay
13 − 0.08 0.20 0.92 − 1.1 − 0.81 1.2 0.51
compared to melty sweets
Foods that increase the saliva secretion increase the
14 1.79 0.22 0.90 − 0.8| 0.79 − 0.8 0.46
possibility for tooth decay
Reduction of food eaten before bed helps protecting from
15 − 0.45 0.20 0.91 − 1.0 0.84 − 0.9 0.50
dental caries
The presence of proteins and fats with sugar-containing
16 1.38 0.21 1.18 1.8| 1.23 1.0 0.30
meals decrease the decay
Eating nuts with tooth decay-causing foods protects the teeth
17 2.55 0.27 1.03 0.3 1.35 1.1 0.28
from decay
Means 0.00 0.26 1.01 − 0.1 1.00 0.− 1
Reliability and separation
Item reliability 0.98
Item separation 6.66
Person reliability 0.71
Person separation 1.57

Table 6: Standardized residual variance in eigenvalue units (� item information units).

Eigenvalue Observed (%) Expected (%)
Total raw variance in observations � 31.1017 100.0 100.0
Raw variance explained by measures � 14.1017 45.3 44.9
Raw variance explained by persons � 5.3887 17.3 17.2
Raw variance explained by items � 8.7129 28.0 27.7
54.7
Raw unexplained variance (total) � 17.0000 55.1
100.0
Unexplained variance in 1st contrast � 2.0227 6.5 11.9

protective roles against dental caries if consumed with polypeptides found on milk and dairy products that have the
cariogenic food, including dairy products, nuts, and pres- carioprotective effect [38].
ence of protein or fat with sugars) [3]. The protective effect of The questions on the role of salivary flow effect and the
dairy products got 84% of correct answers, while the other acidity of food received lower percentage of correct answers
items reported much lower percentages of correct answers 26.7% and 40.7% though the questions are dealing with well-
(31% and 14.8%). This variation may be due to the rec- known documented effects. This may be due to lack of
ommendations of drinking milk and dairy products for nutrition consultation in the dental clinic, or maybe dentists
healthy teeth as a calcium source and not due to their did not focus on dietary behavior that affects oral health and
awareness of effect of bioactive compounds and types of rather they only focused on oral hygienic practices.
International Journal of Dentistry 9

Table 7: Frequencies and percentages of correct answers.

T F
Knowledge items
n (%) n (%)
1-Food plays an important role in the oral health. 127 94.1 7 5.2
2-Sugar is one of the most food element that cause dental caries. 119 88.1 15 11.1
3-Chewing free-sugar gum reduces dental caries. 54 40 80 59.3
4-Using artificial sweeteners in candies and juices reduces the dental caries. 32 23.7 102 75.6
5-Drinking fruit juice causes dental caries more than eating the whole fruit. 55 40.7 79 58.5
6-Increasing the number of the meals increases dental caries. 31 23 103 76.3
7-The frequency of eating sugar is more cariogenic compared to the amount of the sugar. 71 52.6 63 46.7
8-Food leftovers in the mouth are associated with dental caries. 121 89.6 13 9.6
9-Eating sweets with meals is better than eating sweets between meals on dental caries. 38 28.1 96 71.1
10-Brushing or flossing the teeth after every meal reduces the caries. 126 93.3 8 5.9
11-Drinking milk and dairy products protect the teeth from caries. 114 84.4 20 14.8
12-Eating sweets that melt in the mouth and swallowed faster is less harmful than the sweets that stay for a longer
75 55.6 59 43.7
time in the mouth.
13-Sticky sweets increase the probability of teeth decay comparing to melty sweets. 79 58.5 55 40.7
14-Foods that increase the saliva secretion increase the possibility for tooth decay. 36 26.7 98 72.6
15-Reduction of food eaten before bed helps protecting from dental caries. 88 65.2 46 34.1
16-The presence of proteins and fats with sugar-containing meals decreases the decay. 42 31.1 92 68.1
17-Eating nuts with tooth decay-causing foods protects the teeth from decay. 20 14.8 114 84.4

Table 8: The relationship between oral health and oral hygiene and macronutrients, total calories, and sugar intake.
Poor Fair Good Excellent
Unit p value
Mean ± sd Mean ± sd Mean ± sd Mean ± sd
Oral health
Total calories Kcal/day 2750 ± 1722 1738 ± 1950 2650 ± 2149 1732 ± 1091 0.120
Fat Gram/day 118 ± 75 80 ± 46 115 ± 97 106 ± 20 0.252
Carbohydrates Gram/day 297 ± 204 167 ± 130 830 ± 3848 181 ± 98 0.742
Protein Gram/day 37 ± 46 63 ± 55 132 ± 236 86 ± 83 0.189
Sugar intake Gram/day 120 ± 87 58 ± 61 80 ± 76 87 ± 74 0.079
Oral hygiene
Total calories Kcal/day 2872 ± 1664 1576 ± 1004 2555 ± 2087 2253 ± 278 0.109
Fat Gram/day 127 ± 70 71 ± 45 113 ± 92 103 ± 13 0.115
Carbohydrates Gram/day 306 ± 202 156 ± 117 751 ± 3607 210 ± 61 0.821
Protein Gram/day 37 ± 44 62 ± 51 122 ± 224 105 ± 55 0.295
Sugar intake Gram/day 129 ± 84 83 ± 57 65 ± 76 60 ± 47 0.011

The rest of questions 6, 8, 9, and 15 have asked about the which may improve their oral health. The study suggests
relationship between food presence in oral cavity and tooth including oral health nutrition consultation regularly and
decay, including number of meals, food leftover inside the continuously at dental clinics, schools, and any other pos-
oral cavity, and dessert consumption immediately after meals sible places. Further research is needed utilizing different
[3]. The main concept for these 3 items was that the exposure study designs (follow-up and longitudinal and intervention
between meals, mainly carbohydrate and sugars in the oral designs) to determine the effect of poor and good nutrition
cavity, will increase the risk of decay. These results supported practices on oral health in short- and long-term practices.
the main finding which was the lack in the specific oral health Further research is needed to determine effective inter-
nutrition information among the study participants. vention programs that can be implemented in the Pales-
tinian dental clinics.
5. Conclusion
Data Availability
Overall, dental patients at dental clinics revealed insufficient
nutrition knowledge related to oral health. The participants The data are available upon request from the corresponding
were unaware of the various aspects of oral nutrition, with author.
the absence of the statistically significant differences between
male and female patients. The results of the study recom- Conflicts of Interest
mend educational programs targeting the individuals vis-
iting the dental clinics including all age groups to enhance The authors declare that there are no conflicts of interest
their nutrition-related knowledge and nutrition practices, regarding the publication of this paper.
10 International Journal of Dentistry

Acknowledgments in Bangalore: a cross-sectional study,” Journal of Indian So-

ciety of Pedodontics and Preventive Dentistry, vol. 28, no. 2,
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express their gratitude to the patients who agreed to par- among students of age 10–18 years old attending Jenadriyah
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