Assessment of perception about oral habits in ….

Sri Lanka Journal of Child Health, 2022; 51(2): 196-203

Assessment of perception about oral habits in children among healthcare

professionals: A cross sectional study
*Neha Kohli1, Shivayogi M Hugar1, Sanjana P Soneta1, Nivedita Saxena1, Chandrashekhar M Badakar1,
Krishna S Kadam1

Sri Lanka Journal of Child Health, 2022; 51(2): 196-203

DOI: http://dx.doi.org/10.4038/sljch.v51i2.10117

Abstract (Key words: Attitude, Healthcare professionals,

Background: Digit sucking, lip biting, nail biting, Knowledge, Oral habits in children, Practices)
mouth breathing and bruxism are commonly
occurring oral habits in children which can result in Introduction
malocclusion in developing teeth. Healthcare Oral habits can be an aspect of a child’s normal
professionals are most likely to encounter children development or can be a symptom with a deep-
with oral habits and it is necessary that they should rooted psychological cause1. Digit sucking, lip
be aware of the causes, effects and treatment biting, nail biting, mouth breathing and bruxism are
modalities for such habits. commonly occurring oral habits in children, the
prevalence of which is reported to be around 25% in
Objective: To assess the perception about oral habits school children2,3,4. Some habits can be viewed as
in children among healthcare professionals, other normal for a specific age group but if continued for
than the dentist, by evaluating their knowledge, a long duration, may cause dento-alveolar problems
attitudes and practices. as well as skeletal deformations such as greater
mandibular canine arch width, narrower maxillary
Method: A cross-sectional survey was conducted arch width, increased overjet, and increased
among healthcare professionals, excluding dentists, prevalence of open bite and posterior crossbite5. The
from Medical, Homeopathy, Nursing, Ayurveda and relationship of oral habits with these problems also
Physiotherapy specialities. A sample size of 400 was depends upon the amount of force with which they
calculated using standard sample size formula by are performed and the treatment for such problems
referring previously published articles. A 15-item is less effective if the habit persists. Therefore, it is
validated questionnaire, containing four domains of advisable to break the habit between the second and
professional demographic data, knowledge, attitude third year of life6.
and practices were distributed among participants.
There also exists a relationship between the
Results: Our study showed that most of the occurrence of parafunctional habits and anxiety, the
respondents were unaware about the causes of severity of anxiety contributing to prevalence of
deleterious oral habits and had unsatisfactory these habits. Previous studies correlating the
knowledge regarding their effects on children. A psychological status with oral habits have concluded
lack of awareness regarding the prevention and that subjects with parafunctional habits have higher
treatment of oral habits was also observed. The anxiety and depression rates7. Furthermore, children
correlation between knowledge, attitude and subjected to stressful life events are more likely to
practices was highly significant (p<0.001). perform oral habits8. Some studies highlight the
significant predisposition of oral habits among girls,
Conclusions: Majority of participating healthcare single children, children in poor physical health and
professionals were not adequately aware about the children with chronic health problems9. Therefore, it
causes, effects and prevention of oral habits. is important to intervene early on these aetiological
_________________________________________ factors to prevent development or worsening of
1
KLE VK Institute of Dental Sciences, India malocclusion and, if already developed, correct it by
*Correspondence: [email protected] early orthodontic treatment.

https://orcid.org/0000-0002-8130-5222 Due to lack of awareness, oral habits are often

(Received on 10 September 2021: Accepted after overlooked. Healthcare professionals are most likely
revision on 22 October 2021) to encounter children with oral habits and it is
The authors declare that there are no conflicts of essential that they should be aware of the causes,
interest effects and treatment modalities for such habits. A
Personal funding was used for the project. literature search showed that very few studies have
Open Access Article published under the Creative been conducted regarding knowledge, attitude and
practices about oral habits in children among
Commons Attribution CC-BY License healthcare professionals.

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Objectives and the importance of referral of such children to a

To assess the perception about oral habits in children paediatric dentist was also highlighted in the health
among healthcare professionals other than the talk.
dentist by evaluating their knowledge, attitude and
practices. Ethical issues: Approval for the study was obtained
from the Research and Ethics Committee, KLE VK
Method Institute of Dental Sciences, KLE University,
A cross-sectional study was carried out in the Karnataka India (Sl. No. 1388). Written informed
Department of Paediatrics and Preventive Dentistry, consent was obtained from all the participants.
KLE VK Institute of Dental Sciences, India. Sample
size of 386 was calculated using the standard sample Data analysis: The collected forms were analysed in
size calculating formula and was rounded to 40010. MS Excel sheet (Microsoft Corp.). The data were
A questionnaire consisting of 15 questions covering entered using IBM SPSS software (version 20.0
various aspects essential for this study was prepared Chicago IL, USA) and percentages were calculated.
by taking references from articles published in the The test–retest reliability of the survey questions
recent past. Questionnaire comprised 4 components. was determined by administering the questionnaire
The first component asked participants to provide to 15 participants selected randomly, and after 2
their demographic data, the second dealt with weeks, a repeat test was done. The data were then
knowledge of oral habits, the third dealt with attitude subjected to statistical analysis, and based on the
and the fourth dealt with the practices for prevention test, the reliability, Cronbach’s α co-efficient of 0.82
of oral habits. Responses to the questions were was calculated, which indicates acceptable internal
measured on a five-point Likert scale: ‘Strongly consistency. Descriptive statistics were generated
disagree’, ‘disagree’, ‘neutral’, ‘strongly agree’, for all questions, and for each answer, frequency
‘agree’. distributions and percentages were examined.

The validity of the content was approved by a group Results

of professionals. The inclusion criteria for the study There were no dropouts in the study as all 400
were Faculty, Practising Professionals, Post- participants returned a completely filled
graduates and Interns of Medical, Homeopathy, questionnaire. Of the respondents 69.5% were
Nursing, Ayurveda and Physiotherapy specialities. females and 31.5% were males. Mean age of this
The exclusion criteria for our study were the population was 27.71±10.24 years. According to
Undergraduate students and the ones who did not designations, 58% were graduates, 12.5% were
give their consent to participate. postgraduates, 16% were practising professionals
and 13.5% were faculty members. Participants came
The participants were instructed regarding filling of from different backgrounds like Ayurveda and
the questionnaire, and a pilot study was conducted Homeopathy, Medical, Nursing, Pharmacy and
among 20 participants to ensure ease and lucidity of Physiotherapy.
answering the questionnaire. These participants
were then excluded in the final study, and the The participants were posed with a wide array of
questionnaire did not require any modifications. questions that tried to evaluate their awareness level.
Instructions regarding the questionnaire were given For the elucidation of the results, (agree + strongly
and the questionnaire was then distributed among agree) and (disagree + strongly disagree) were
the 400 participants. Abundant time was given to the combined. Among all respondents, 50% were
participants to complete their questionnaire; unaware about the influence of peer groups and
thereafter, the questionnaires were collected from siblings on oral habits. Only 41.3% of respondents
them. The identity of the surveyor was kept had the knowledge about the effect of intensity,
anonymous. frequency and duration of performing such habits on
the severity of malocclusion. Only 26.5% of
After the completion of questionnaire, the respondents were aware about the correct age for
participants were made to sit in a room and were intervention and the psychological impact of early
educated through a health talk regarding oral habits intervention in a young child. Moreover, 59.8 % of
and their adverse effect on overall general health. respondents believed that putting social pressure can
They were made aware about different treatment help a child break out of the habit (Table 1).
modalities that could be rendered to such children

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Table 1: Question-wise responses of respondents

Question Strongly Disagree Neutral Agree Strongly
disagree agree
A high prevalence of oral habits is observed among 01 (0.25) 19 (4.75) 52 (13.0) 242 (60.5) 86 (21.5)
children. Do you agree? - n (%)
Children weaned later from breastfeeding have a 01 (0.25) 49 (12.25) 159 (39.75) 149 (37.25) 42 (10.5)
lower incidence of oral habits - n (%)
Habits are not influenced by peer groups or siblings 52 (13.0) 148 (37.0) 87 (21.75) 92 (23.0) 21 (5.25)
- n (%)
Children of working individuals who get to spend 07 (1.75) 69 (17.25) 78 (19.5) 182 (45.5) 64 (16.0)
less time with their parents tend to indulge more in
oral habits to seek attention from them - n (%)
Children experiencing issues adjusting to their 0 (0) 39 (9.75) 98 (24.5) 206 (51.5) 57 (14.25)
surroundings are more likely to indulge in oral
habits - n (%)
Oral habits directly impact a child’s facial profile 01 (0.25) 08 (2.0) 51 (12.75) 223 (55.75) 117 (29.25)
which in turn affects their self-esteem - n (%)
Intensity, frequency & duration of oral habits have 35 (8.75) 130 (32.5) 135 (33.75) 76 (19.0) 24 (6.0)
no relation to severity of malocclusion – n (%)
The deleterious effects of oral habits generally 02 (0.50) 26 (6.50) 133 (33.25) 205 (51.25) 34 (8.50)
subside if cessation occurs before the eruption of
permanent teeth – n (%)
Early intervention by discouraging certain habits 17 (4.25) 89 (22.25) 104 (26.0) 150 (37.5) 40 (10.0)
would have no effect on the basic physiology and
psychology of a young child (<3 years) – n (%)
Parental pressure or social pressure can help a child 17 (4.25) 62 (15.5) 82 (20.5) 187 (46.75) 52 (13.0)
break the habit – n (%)
Professionals should evaluate the child for 0 (0) 04 (1.0) 69 (17.25) 231 (57.75) 96 (24.0)
psychological overtones before embarking on habit
elimination – n (%)
Parental counselling with education about oral 01 (0.25) 05 (1.25) 28 (7.0) 227 (56.75) 139 (34.75)
health can serve as a preventive measure to reduce
the occurrence of oral habits – n (%)
Reminder therapy in conjugation with reward 01 (0.25) 07 (1.75) 86 (21.5) 207 (51.75) 99 (24.75)
systems can prove useful for early interception of
oral habits. – n (%)
Referral of such patients to paediatric dentists 01 (0.25) 12 (3.0) 56 (14.0) 214 (53.5) 117 (29.25)
should be advocated – n (%)
Presently, people tend to neglect these habits in 02 (0.50) 05 (1.25) 38 (9.50) 203 (50.75) 152 (38.0)
children, awareness for which can be spread through
web-based education – n (%)

With respect to the age groups evaluated using One better compared to other age groups with a ‘F’ value
Way ANOVA (Table 2), it was found out that of 4.4967 and a highly significant ‘p’ value <0.01.
healthcare professionals aged above 51 years had However, with regard to practices related to oral
better knowledge compared to other age groups with habits, healthcare professionals aged 31-40 years
a ‘F’ value of 7.0330 and ‘p’ value <0.001 which were better compared to other age groups with a ‘F’
was highly significant. With regard to attitude, again value of 11.0994 and a highly significant ‘p’ value
healthcare professionals aged above 51 years were <0.001.

Table 2: Comparison of age groups with mean knowledge, attitude and practice scores by one way ANOVA
Age groups Knowledge Attitude Practice Total
Mean SD Mean SD Mean SD Mean SD
<21yrs 17.08 2.23 15.63 1.96 19.55 2.27 52.26 4.05
21-30yrs 18.15 2.49 16.05 2.34 20.73 2.51 54.93 5.47
31-40yrs 18.84 3.23 17.02 2.54 21.64 2.28 57.50 6.06
41-50yrs 17.10 3.11 16.06 3.01 20.39 2.25 53.55 6.21
>51yrs 19.44 2.66 17.32 2.06 21.52 2.89 58.28 5.95
Total 18.00 2.68 16.16 2.37 20.61 2.52 54.78 5.63
F-value 7.0330 4.4967 7.3954 11.0994
p-value 0.0001 0.0015 0.0001 0.0001

With respect to the healthcare specialty evaluated from a medical background, closely followed by
using One Way ANOVA (Table 3), respondents Pharmacy were most aware of these oral habits.

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Table 3: Comparison of healthcare speciality with mean knowledge, attitude & practice scores by one way ANOVA
Healthcare speciality Knowledge Attitude Practice Total
Mean SD Mean SD Mean SD Mean SD
Ayurveda and Homeopathy 16.75 2.11 16.25 1.98 20.13 2.55 53.13 4.47
Medical 19.23 2.90 17.32 2.58 21.62 2.16 58.16 5.98
Nursing 17.85 1.95 15.65 1.69 20.00 2.18 53.50 3.43
Pharmacy 18.17 2.13 14.87 1.87 21.04 2.58 54.09 3.76
Physiotherapy 16.93 2.20 15.48 1.90 19.66 2.48 52.07 4.25
Total 18.00 2.68 16.16 2.37 20.61 2.52 54.78 5.63
F-value 18.1670 19.1728 14.6386 31.6346
p-value 0.0001 0.0015 0.0001 0.0001

These observations can be banked on as both was observed that Faculty closely followed by Post
Kruskal Wallis ANOVA and one-way ANOVA test graduate students were really aware in terms of
indicated that these are highly statistically knowledge, attitude and practices about oral habits
significant results with ‘p’ value <0.001 and a ‘F’ and these results were highly significant with a ‘p’
value of 31.6346 (Table 3). value <0.001 (Figure 1). However, when
comparison was done based on gender, no
By analysing the test results based on designations statistically significant values were observed, either
using both Kruskal Wallis and One-way ANOVA, it with using Mann-Whitney U Test or with t-test.

The correlation between Knowledge, Attitude and Knowledge and Practice, a ‘r’ value of 0.4220 was
Practices was done using Karl Pearson’s correlation obtained with a highly significant ‘p’ value <0.001.
coefficient and it was observed that correlation Similar findings were observed on comparison of
between Knowledge and Attitude was highly Attitude and Practices and a ‘r’ value of 0.1961 was
significant with a ‘r’ value of 0.3575 and ‘p’ value obtained with a highly significant ‘p’ value <0.001
<0.001. When correlation was done between (Table 4 and Figures 2, 3 and 4).

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Table 4: Correlation between knowledge, attitude & practice scores using Karl Pearson correlation coefficient
Variable Summary Knowledge Attitude Practice
Knowledge r-value
p-value ---
Attitude r-value 0.3575
p-value 0.0001 ---
Practice r-value 0.4220 0.1961
p-value 0.0001 0.0001 ---

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Discussion were zero dropouts in our study indicating that

The saying “The mouth is the mirror image of all respondents were willing to take a step towards
diseases” holds true and the majority of healthcare spreading awareness to promote oral well-being.
professionals start their examination with the oral
cavity. However, even after a thorough examination, Studies by Aznar T, et al6, Grippaudo C, et al12 and
the oral cavity and its diseases are neglected and Viggiano D, et al13 concluded that oral habits are
looked down upon. It is only after the disease has among the major aetiologic factors leading to
reached a severe stage is referral to a dentist malformation in the dento-facial structures.
practised. Identification of a particular health issue However, this study showed that 58.8% of the
based on prevalence, severity or impact on quality respondents were unaware about the detrimental
of life is a preliminary step to achieve its prevention. effects of such habits on oral structure as they had
An amalgamation of community, professional and less knowledge about the impact of intensity,
individual strategies is essential for oral health frequency and duration of performing these habits5.
promotion and this is unachievable without creating These findings were in accordance with the study by
awareness. The aetiology, prevalence, adverse Kumar V, et al10. Literature suggests that active
effects and management of oral habits have been intervention of certain habits such as thumb sucking
focused on in the literature but little consideration before the age of three, is inadvisable and
has been given to spreading awareness which is of intervention at this age can be pernicious to the basic
the utmost importance for elimination of these physiology and psychology of a young child1,14.
habits. For this, we must first determine the current However, only 26.5% of respondents were aware of
level of knowledge. Furthermore, due to the this actuality. These findings highlight the amount
insignificant number of studies carried out in the of unawareness that exists regarding oral habits.
past regarding the healthcare professional’s However, on the brighter side, several respondents
awareness about oral habits, a need was felt for the were aware about the significance of the emotional
same. well-being of the child and how that can potentially
affect the occurrence of such habits. Majority
Our study was a cross-sectional questionnaire-based believed that initiatives such as parental counselling
one to explore the healthcare professional’s (91.5%) and web-based education (88.8%) can go a
awareness about oral habits. The study included a 5- long way in prevention of such habits. Furthermore,
point Likert scale due to its summative nature and in our study 82.8% of respondents agreed that
high reliability11. This study incorporated various referral of such patients to paediatric dentists should
specialities and assessed people with various be practised. This finding contrasted with studies by
designations to garner a more diverse data set. There Kumar V, et al10, Shah K, et al15 and Sharma R, et

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