Analysis of the Phobia of Brushing Teeth in High School Students in Palopo City, Indonesia During COVID-19

ABSTRACT

Objective:

To analyze the phobia and social anxiety of brushing their teeth among high school students in Palopo City, Indonesia, during COVID-19.

Material and Methods:

Social phobia was obtained with the MINI-Spin questionnaire and anxiety with the GAD-7 questionnaire. The questionnaire consists of 15 questions with a Likert scale. Primary data type with logistic regression analysis.

Results:

The results of the logistic regression analysis showed that men are more likely to brush their teeth twice a day than women (OR=2.01; 95CI 1.3-2.9). Subjects who reported not having social phobia were not significantly (OR = 0.9; 95CI 0.6-1.4) more likely to brush their teeth twice a day than those who tended to have social phobia. Subjects who reported no significant anxiety (OR = 0.7; 95CI 0.5-1.5) were more likely to brush their teeth twice a day than those who tended to have anxiety.

Conclusion:

The frequency of brushing teeth in students who do not have a relationship is more likely to brush their teeth twice a day than students who tend to have phobias and social anxiety. Regarding the relationship between brushing teeth frequency and gender criteria, there is a relationship between female students brushing their teeth twice a day more often than male students during COVID-19.

Keywords:
Behavior and Behavior Mechanisms; Dental Anxiety; Students; Coronavirus Infections

Introduction

COVID-19 and lockdown measures have had a serious impact on physical and mental status and daily behavior, including oral health care behavior; in addition, routine medical activities have been severely disrupted amid the pandemic. We are concerned about the oral health of the public in the midst of this outbreak. It is very important to explore the impact of COVID-19 on oral health, namely phobias and oral hygiene, dental problems encountered, how people deal with these problems, and whether these problems exacerbate their anxiety[¹,²,³,⁴].

Interestingly, one study showed that increased levels of anxiety, depression, and stress lead to increased levels of oral parafunctional habits during the COVID-19 pandemic, and the authors suggested that this may result in an increased prevalence of orofacial pain and temporomandibular disorders in the future[⁴,⁵]. Oral health is an important part of overall health, and oral disease is associated with chronic health conditions. General risk factors for oral health are very influential in integrating oral health into general health[⁶,⁷].

Many changes mark the transition period from childhood to adulthood. During this period, independence from parents increases, which results in behavioral changes, including those related to eating habits, smoking, and lifestyle behaviors. The development of this independent behavior can affect oral health and form lifelong behavioral patterns[⁸,⁹].

In addition, as the need for independent functioning increases in adolescence, anxiety and social phobia can affect a young person's ability to cope and can adversely affect a person's quality of life. Symptoms of anxiety and SP often appear in late childhood or adolescence. Anxiety disorders, including generalized anxiety disorder, panic disorder, agoraphobia, social phobia, and specific (simple) phobia, are more common in adults than other mental disorders. Mild to moderate anxiety is a normal emotional response to many stressful life situations[⁸,⁹,¹⁰,¹¹,¹²].

Gender differences in tooth brushing in adolescents have been reported, with girls brushing more often than boys. Several authors have described these gender behavioral differences according to the social and psychological impact of oral health, finding that women perceive oral health as having a greater impact than men on their general quality of life[¹³,¹⁴].

Brushing your teeth is the most effective method of cleaning your teeth and mouth. The universally recommended frequency is brushing your teeth twice a day. Studies have shown links between stress and dental health among adults, including an association between depression and anxiety with lower tooth brushing frequency and an association between stress and depressive symptoms and poor oral health. A European study has reported that adolescents with stress brush their teeth twice a day less often than adolescents with good mental health. The relationship between periodontitis and stress dimensions has been documented in adolescents and poor maternal factors (e.g., low education and psychological stress) can have a cumulative impact on adolescents' future caries experience[⁶,¹³,¹⁴].

Based on the Indonesian Basic Health Research (Riskesdas) in 2018, dental and oral health problems in the city of Palopo were around 8.9%, with details of carious teeth at 58.42%, easy bleeding gums at 23.29%, and recurrent canker sores at 6.97%. The percentage of daily tooth brushing behavior in Palopo City residents aged 3 years and over is 95.32%. However, the percentage of those who brushed at the right time was only around 9.68%. The prevalence of Palopo City residents aged 15 years and over who experience depression is around 10.40%. This depression mainly occurs in the 15-24 years age group[¹⁵,¹⁶,¹⁷].

Journals that discuss the effect of stress on dental and oral health behavior among adolescents are still rare. Therefore, the authors wanted to conduct this study to know the relationship between toothbrushing frequency, stress, and related factors (gender, parental education, family structure, smoking habit, and perceived general health perception) among high school youth in Palopo. The authors hypothesized that those with more psychological stress would brush their teeth twice a day less frequently than those with less psychological stress[⁶,¹³,¹⁴].

The purpose of this study was to determine the relationship between toothbrushing frequency, stress, and related factors (gender, parental education, family structure, smoking habits, and perceived general health perception) among youth at public high schools in Palopo City, South Sulawesi Province, Indonesia.

Material and Methods

Study Design and Ethical Clearance

This type of research is analytic observational with a cross-sectional design. This research was conducted in November-December 2021 online. Recommendations for ethical approval issued by the Health Research Ethics Committee Number: 0161/PL.09/KEPK FKG-RSGM UNHAS/2021.

Participants and Data Collection

This research was conducted in six public high schools in Palopo City, South Sulawesi Province, Indonesia, which returned a questionnaire in the form of a Google form totaling 661 students using the snowball sampling method. The research instrument consisted of an adapted questionnaire[⁶]. The questionnaire also included the reliable and validated GAD-7 questionnaire[¹⁸,¹⁹].

The questionnaire consists of 15 questions in three parts. The first part is related to the subject's social demography (toothbrushing habits, parental education, family structure, smoking habits, general health perception). The second part (Mini Spin Questionnaire) is questions to detect the subject's social phobia, and the third part (GAD-7 questionnaire) is questions to detect subject anxiety.

The assessment criteria for the questionnaire consist of 15 questions, with a Likert scale in the second part: 0 (Not at all), 1 (Slightly), 2 (Enough), 3 (Many), and 4 (Very Much). The third part is 0 (Not the same—once every 2 weeks), 1 (Multiple days in 2 weeks), 2 (More than half the time in 2 weeks), and 3 (Almost every day in 2 weeks).

The level of influence of social phobia and anxiety on the frequency of brushing the subject's teeth was measured by the total score of the answer choices on the questionnaire, which was divided into two groups in the second and third parts. The second part is 0–5 points (no SP), 6–12 points (possibly SP). The third part is 0–9 points (no, mild or mild anxiety), 10–21 points.

Data Analysis

Descriptive statistics, including frequencies and percentages, were used to analyze the data. Logistic regression analysis was performed for confirmatory analysis and estimation of confidence intervals (CIs). SPSS version 25 for Windows (IBM Corp., Armonk, NY, USA) was used to analyze the data at a 5significance level.

Results

A total of 661 individuals were included, of which 31.3were female. Based on age, subjects aged 14 years were 17 subjects (2.6%), 15 years were 178 subjects (26.9%), 16 years were 264 subjects (36.9%), 17 years were 180 subjects (27, 2%), and 18 years were 22 subjects (3.3%). Based on school origin, subjects from Public Senior High School (PHS) 1 as many as 285 subjects (43.1%), from PHS 2 as many as 25 subjects (3.8%), from PHS 3 as many as 209 subjects (31.6%), from PHS 4 as many as 30 subjects (4.5%), from PHS 5 as many as 43 subjects (6.5%), and those from PHS 6 as many as 69 subjects (10.4%).

Table 1 shows the results of the MINI-SPIN questionnaire items and the responses received in the form of a percent. The question for this questionnaire is “How much has the following problem bothered you over the past week?” with three responses. For the response “Afraid of being embarrassed causes me to avoid doing something or talking to people”, the subject answered not at all 20.4%, answered slightly 49.0%, answered moderately 19.7%, answered a lot 7.9%, and answered very much 3.0%. Responses “I avoid activities where I am the center of attention” subjects, answered not at all 21.5%, answered slightly 36.9%, answered moderately 21.6%, answered a lot 14.4%, and answered very much 5.6 %. Responses “Being embarrassed or looking stupid is one of my worst fears” subjects answered no at all 21.5%, answered slightly 28.3%, answered moderately 18.2%, answered a lot 18.5%, and answered very much 13.6%.

Table 1
Items MINI-SPIN Questionnaire and subject responses.

Question: How much has the following problem bothered you over the past week?'	Not at all %	A Little %	Currently %	Many %	A huge amount
Fear of embarrassment causes me to avoid doing things or talking to people.	20.4	49.0	19.7	7.9	3.0
I avoid activities where I am the center of attention.	21.5	36.9	21.6	14.4	5.6
Being shy or looking stupid is one of my worst fears.	21.5	28.3	18.2	18.5	13.6

Table 2 shows the results of the GAD-7 questionnaire items and the responses received in percent. The question for this questionnaire is, "Over the past two weeks, how often have the following problems bothered you?" with 6 responses. For responses "Feeling nervous, anxious or restless," subjects answered not at all in 2 weeks (31.3%), several days (48.0%), More than half the time (13.6%), and almost every day (7.1%).

Table 2
GAD-7 Questionnaire items and responses of subjects.

Question: 'Over the past two weeks, how often have the following problems bothered you?	Response
	Not at all in 2 weeks %	Few days in 2 weeks %	More than half the time in 2 weeks %	Most days in 2 weeks %
Feeling nervous, anxious, or restless	31.3	48.0	13.6	7.1
Inability to stop or control worry.	45.3	39.0	10.1	5.6
Worrying too much about different things.	33.9	42.2	14.2	9.7
It's hard to relax.	43.7	35.2	11.3	9.7
Becomes so restless that it's hard to sit still.	61.6	26.8	5.4	6.2
Feeling scared, as if something bad was going to happen.	39.9	39.2	13.0	7.9

Regarding “Inability to stop or control worry”, 45.2of the participants answered not at all in 2 weeks and 39.0reported few days in 2 weeks. Concerning “Too worried about different things”, 33.9of the participants answered not at all in 2 weeks and 42.2reported few days in 2 weeks.

Regarding “Difficult to relax”, 43.7of participants reported not at all in 2 weeks and 35.2reported few days in 2 weeks. Regarding the answer “Become so restless that it is difficult to sit still”, 61.6answered not at all in 2 weeks and 26.8reported few days in 2 weeks. Finally, regarding the question “Feeling afraid, as if something bad will happen”, 39.9answered not at all in 2 weeks and 39.2reported few days in 2 weeks.

Table 3 shows that female subjects who brush their teeth twice a day represent 78.0%, while for men, this percentage corresponds to 65.7%. For the characteristics of parental education, subjects with basic parental education or less who brush their teeth twice a day represented 67.0%, subjects with secondary parental education who brush their teeth twice a day represented 76.0%, and subjects with high parental education brushing their teeth twice a day represented 75.0%.

Table 3
Frequency of brushing teeth.

Variables	Brushing Teeth
	≤ 1 Time a Day N (%)	≥ 2 Times a Day N (%)	Total N (%)
Gender
Male	71 (34.3)	136 (65.7)	207 (100.0)
Female	100 (22.0)	354 (78.0)	454 (100.0)
Parental Education
Basic Education	39 (33.0)	79 (67.0)	118 (100.0)
Middle Education	81 (24.0)	257 (76.0)	338 (100.0)
Higher Education	51 (25.0)	154 (75.0)	205 (100.0)
Family Structure
With Both Parents	102 (24.0)	332 (76.0)	434 (100.0)
Other	69 (30.0)	158 (70.0)	227 (100.0)
Smoking Habit
Smoker	08 (40.0)	12 (60.0)	20 (100.0)
Do not smoke	163 (25.0)	478 (75.0)	641 (100.0)
General Perceived Health
Very Good	39 (21.0)	148 (79.0)	187 (100.0)
Pretty Good	106 (26.0)	303 (74.0)	409 (100.0)
Bad	26 (40.0)	39 (60.0)	65 (100.0)

For the characteristics of family structure, 76.0who live with both parents brush their teeth twice a day and 70.0who do not live with their parents. For the characteristics of smoking habits, participants who have a smoking habit brush their teeth twice a day represented 60.0%, and subjects who do not have a smoking habit brush their teeth twice a day represented 75.0%. For the characteristics of general health perception, 79.0of the participants with very good general health brushing their teeth twice a day, while subjects with good general health brushing their teeth twice a day represented 74.0%, and subjects with good general health brushing their teeth twice a day represented 74.0%. Thirty-nine participants with poor general health brush their teeth twice a day (60.0%).

The total scores of the Mini-SPIN and GAD-7 questionnaires among State High School students in Palopo City are presented, with the number of Mini-SPIN 6 or more indicating the possibility of social phobia in as many as 232 people (35.1%). The total score of GAD-7, which has a total score of 10 or more, indicates the possibility of anxiety in as many as 138 people (20.5%).

Table 4 shows the frequency of brushing teeth with social phobia and anxiety in Palopo State High School students. Social phobia was detected using the MINI-Spin questionnaire, while anxiety was identified using the GAD-7 questionnaire. Ninety-seven male subjects (67.0%) who did not have social phobia (MINI-Spin score 6) brushed their teeth twice a day. For women whose social phobia was not detected, 79brushed their teeth twice a day, while for those with social phobia, this percentage was 76%. Ninety-four male subjects (72.0%) who did not have anxiety (GAD7 score 10) brushed their teeth twice a day. Women who were not detected as having social phobia accounted for 79.0and those who were detected as having anxiety accounted for 77.0%.

Table 4
Tooth brushing among males and females according to the Mini-SPIN and GAD-7 classifications.

Variables	Tooth Brushing		Total N (%)
	≤ Once Daily	≥ Twice Daily N (%)
Male
Mini-SPIN Classification
0–5 points (No SP)	48 (33.0)	97 (67.0)	145 (100.0)
6–12 points (Possible SP)	23 (37.0)	39 (63.0)	62 (100.0)
Category GAD-7.2
0–9 points (None, Little, or Mild Anxiety)	36 (28.0)	94 (72.0)	130 (100.0)
10–21 points (Moderate to Severe Anxiety)	35 (45.0)	42 (55.0)	77 (100.0)
Female
Mini-SPIN Classification
0–5 points (No SP)	59 (21.0)	225 (79.0)	284 (100.0)
6–12 points (Possible SP)	41 (24.0)	129 (76.0)	170 (100.0)
Category GAD-7.2
0–9 points (None, Little, or Mild Anxiety)	45 (21.0)	165 (79.0)	210 (100.0)
10–21 points (Moderate to Severe Anxiety)	55 (23.0)	189 (77.0)	244 (100.0)

• p<0.001 for all associations; chi-square test.

Logistic regression analysis (Table 5) showed that male subjects were more likely than female students (OR=2.01; 95CI 1.3–2.9) not to brush their teeth twice a day. Student subjects whose parents only had primary education were not significantly (OR=1.02; 95CI 0.6–1.5) more likely not to brush their teeth twice a day than students whose parents had secondary education or above. Participants who lived with both parents were not significantly more likely to brush their teeth twice a day compared to students who did not live with both parents (OR=0.7; 95CI 0.5-1.1). Students who had a smoking habit were not significantly more likely to not brush their teeth twice a day than students who did not smoke (OR=1.8; 95CI 0.6–4.9). Students with a good perception of health were not significantly more likely to brush their teeth twice a day compared to those with a poor health perception (OR=0.5; 95CI 0.2–0.8). Students who reported not having social phobia were not significantly more likely to brush their teeth twice a day than students who were likely to have social phobia (OR=0.9; 95CI 0.6–1.4). Students who reported not having anxiety were not significantly more likely to brush their teeth twice a day than students who were likely to have anxiety (OR=0.7; 95CI 0.5–1.5) (Table 5).

Table 5
Results of the logistic regression analysis of brushing teeth.

Variables	OR	95CI
Gender
Male	2.01*	1.3–2.9
Female	1.0
Parental Education
Basic Education	1.02	0.6–1.5
Secondary & Higher Education	1.0
Family Structure
With both Parents	0.7	0.5–1.1
Other	1.0
Smoke
Smoker	1.8	0.6–4.9
Do not Smoke	1.0
General Health Perception
Good	0.5	0.2–0.8
Bad	1.0
Mini-SPIN		0.6–1.4
0–5 points (No Social Phobia)	0.9
6–12 points (Probable Social Phobia)	1.0
GAD-7
0-9 points (No Anxiety)	0.7	0.5–1.5
10-17 points (Probability of Anxiety)	1.0

• Once a day or less often=1; *p<0.001.

Discussion

Stress is related to brushing your teeth. Those who probably had social phobia or moderate to severe anxiety were less likely to brush their teeth twice a day than those who had no possible problems with social phobia or reported low or no anxiety. The results support previous studies on adolescents in Asia, Africa, the Caribbean, and South America. Problems that cause stress can dominate so much of a teenager's attention that they cannot follow recommended oral health behaviors[¹⁵,¹⁹,²⁰]. According to a survey by Keles and Sancakli[²¹], 25.6of these people visited the dentist, while 74.4did not.

Problems in adolescents that cause psychological stress can dominate, so that they cannot follow the oral health behavior that is conveyed. The main motivating factor for brushing teeth is social benefits. The positive impact on clean teeth looks attractive, creates a fresh feeling and strengthens self-confidence[¹⁴]. The study's results by Girão Júnior et al.[²²] showed no difference between the fluoride concentrations analyzed one hour after brushing with different toothpastes.

The main motivating factor for brushing teeth is the social benefits: clean teeth look attractive, create a fresh feeling, and strengthen one's self-confidence. Fewer social problems can make teenagers more aware of the social benefits of brushing their teeth, increasing their motivation to brush their teeth regularly. Possible social phobia problems indicate a higher risk for oral health problems among adolescents[¹⁵,¹⁷].

In this study, male students brushed their teeth twice a day less often than female students. These findings are in line with Maes et al.[¹⁵] that reported aged 15 years brushing teeth according to the recommendation twice a day or more by 45in 2001-2002, the appropriate figure in this study is 53%. They are also in agreement with Yang et al.[²³], whose findings showed that 46.9of students experienced bleeding while brushing their teeth, while only 11.8reported professional teeth cleaning.

In this study, there was no relationship between the frequency of brushing teeth and parents' level of education. This is not in line with previous research, which found that higher levels of education and socioeconomic status of parents were associated with more frequent brushing of teeth in adolescents, in this case, State High School students. Higher parental education levels are positively associated with children's psychological health and reduced health complaints, which can also stem from a favorable socioeconomic situation. In addition, higher educational expectations from families are associated with better health behaviors, including brushing teeth[²⁴,²⁵,²⁶,²⁷].

The results of this study did not show a relationship between the frequency of brushing teeth and the students' family structure. Previous studies on the relationship between family structure and children's brushing habits have shown varying results in different countries. Parents greatly influence the brushing habits of their children, regular family routines and practices that promote good oral health from an early age are important to promote children's oral health. A regular family routine can be more easily achieved in a family with two parents than in a family where the father and mother are separated[²⁵,²⁸].

The results of this study did not show a relationship between the frequency of brushing teeth and the smoking habits of adolescent high school students. This result is not based on previous studies that showed a relationship between smoking and poor tooth brushing. In general, smokers tend to have poorer oral health than nonsmokers. Smoking affects a person's sense of smell and taste, smokers may not feel the clean and fresh feeling that brushing their teeth provides in the same positive way as nonsmokers do; they may also perceive oral health as less important than nonsmokers[²⁶,²⁹].

The results of this study also did not show a relationship between perceptions of good or very good health and the frequency of brushing the teeth of State Senior High School adolescents. This is not by previous research. Brushing teeth is related to oral health, which is related to general health. Several studies have examined the relationship between tooth brushing and general health. One recent study found that a higher daily brushing frequency reduced the development of malignancies. In addition, because poor health behaviors tend to cluster, infrequent brushing of teeth, along with other poor health habits and other aspects of life, can contribute to perceptions of poor health[²⁷,³⁰].

The results in this study also did not show a relationship between the frequency of brushing teeth and the social phobia or anxiety of state high school students. This is not by previous research. Students who do not have social phobia or anxiety are more likely to brush their teeth twice a day than those who are likely to have social phobia or anxiety[¹⁶]. More frequent problems with social phobia among girls can lead to negative oral health effects due to psychological stress[¹⁸]. However, girls also reported brushing their teeth twice a day more often than boys, thus providing girls with greater protection from oral health problems[²⁰,²⁹,³¹].

This study has some limitations that should be addressed. First, because this is an online cross-sectional survey, there is a possibility of recall bias in the information, as well as the possibility that students have searched for answers to some of the questions before answering. Second, fewer subjects filled out online questionnaires than the total population. Lastly, as this is an internet-based online survey, responses from areas without internet access may not be captured, which could lead to demographic selection bias.

Conclusion

The frequency of brushing teeth in students who have no relationship are more likely to brush their teeth twice a day than students who tend to have phobias and social anxiety. The criteria for parental education, family structure, smoking habits, and general health perceptions also did not show a relationship. For the relationship between the frequency of brushing their teeth and gender criteria, there is a relationship that female students are more likely to brush their teeth twice a day than male students.

• Financial Support
  None.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

References

• ¹
  Cullen W, Gulati G, Kelly BD. Mental health in the COVID-19 pandemic. Qjm 2020; 113(5):311-312. https://doi.org/10.1093/qjmed/hcaa110
  » https://doi.org/10.1093/qjmed/hcaa110
• ²
  Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatr 2020; 33(2):e100213. https://doi.org/10.1136/gpsych-2020-100213
  » https://doi.org/10.1136/gpsych-2020-100213
• ³
  Ahn E, Hwang J-M. Impact of the COVID-19 pandemic on tooth brushing and handwashing of adolescents: A secondary analayis of the Korea youth risk behavior web-based survey (2019∼2020). J Dent Hyg Sci 2022; 22(3):171-179. https://doi.org/10.17135/jdhs.2022.22.3.171
  » https://doi.org/10.17135/jdhs.2022.22.3.171
• ⁴
  Jung EH, Min JH. Effect of the Coronavirus Disease 2019 pandemic on oral health of Korean adolescents. Int J Dent Hyg 2023; 21(2):475-486. https://doi.org/10.1111/idh.12669
  » https://doi.org/10.1111/idh.12669
• ⁵
  Sun Q, Ren H, Bian Y, Xie Y, Shi H. Psychological factors and oral health during initial outbreak of COVID-19 in China: A cross-sectional study. J Int Med Res 2023; 51(2):3000605231152108. https://doi.org/10.1177/03000605231152108
  » https://doi.org/10.1177/03000605231152108
• ⁶
  Pohjola V, Nurkkala M, Virtanen JI. Psychological distress, oral health behaviour and related factors among adolescents: Finnish School Health Promotion Study. BMC Oral Health 2021; 21(1):6. https://doi.org/10.1186/s12903-020-01357-3
  » https://doi.org/10.1186/s12903-020-01357-3
• ⁷
  Hung M, Moffat R, Gill G, Lauren E, Ruiz-Negrón B, Rosales MN, et al. Oral health as a gateway to overall health and well-being: Surveillance of the geriatric population in the United States. Spec Care Dentist 2019; 39(4):354-361. https://doi.org/10.1111/scd.12385
  » https://doi.org/10.1111/scd.12385
• ⁸
  Goodwin GM. The overlap between anxiety, depression, and obsessive-compulsive disorder. Dialogues Clin Neurosci 2015; 17(3):249-260. https://doi.org/10.31887/DCNS.2015.17.3/ggoodwin
  » https://doi.org/10.31887/DCNS.2015.17.3/ggoodwin
• ⁹
  Honkala S, Honkala E, Newton T, Rimpelä A. Toothbrushing and smoking among adolescents--Aggregation of health damaging behaviours. J Clin Periodontol 2011; 38(5):442-448. https://doi.org/10.1111/j.1600-051X.2011.01709.x
  » https://doi.org/10.1111/j.1600-051X.2011.01709.x
• ¹⁰
  Bunnell BE, Joseph DL, Beidel DC. Measurement invariance of the social phobia and anxiety inventory. J Anxiety Disord 2013; 27(1):84-91. https://doi.org/10.1016/j.janxdis.2012.09.001
  » https://doi.org/10.1016/j.janxdis.2012.09.001
• ¹¹
  Eaton WW, Bienvenu OJ, Miloyan B. Specific phobias. Lancet Psychiatry 2018; 5(8):678-686. https://doi.org/10.1016/s2215-0366(18)30169-x
  » https://doi.org/10.1016/s2215-0366(18)30169-x
• ¹²
  Rudaz M, Ledermann T, Margraf J, Becker ES, Craske MG. The moderating role of avoidance behavior on anxiety over time: Is there a difference between social anxiety disorder and specific phobia? PLoS One 2017; 12(7):e0180298. https://doi.org/10.1371/journal.pone.0180298
  » https://doi.org/10.1371/journal.pone.0180298
• ¹³
  Ogundele MO. Behavioural and emotional disorders in childhood: A brief overview for paediatricians. World J Clin Pediatr 2018; 7(1):9-26. https://doi.org/10.5409/wjcp.v7.i1.9
  » https://doi.org/10.5409/wjcp.v7.i1.9
• ¹⁴
  Koivusilta L, Honkala S, Honkala E, Rimpelä A. Toothbrushing as part of the adolescent lifestyle predicts education level. J Dent Res 2003; 82(5):361-366. https://doi.org/10.1177/154405910308200507
  » https://doi.org/10.1177/154405910308200507
• ¹⁵
  Maes L, Vereecken C, Vanobbergen J, Honkala S. Tooth brushing and social characteristics of families in 32 countries. Int Dent J 2006; 56(3):159-167. https://doi.org/10.1111/j.1875-595x.2006.tb00089.x
  » https://doi.org/10.1111/j.1875-595x.2006.tb00089.x
• ¹⁶
  Decke S, Deckert K, Lang M, Laub O, Loidl V, Schwettmann L, et al. "We're in good hands there." - Acceptance, barriers and facilitators of a primary care-based health coaching programme for children and adolescents with mental health problems: A qualitative study (PrimA-QuO). BMC Fam Pract 2020; 21(1):273. https://doi.org/10.1186/s12875-020-01344-1
  » https://doi.org/10.1186/s12875-020-01344-1
• ¹⁷
  Day C, Briskman J, Crawford MJ, Foote L, Harris L, Boadu J, et al. An intervention for parents with severe personality difficulties whose children have mental health problems: A feasibility RCT. Health Technol Assess 2020; 24(14):1-188. https://doi.org/10.3310/hta24140
  » https://doi.org/10.3310/hta24140
• ¹⁸
  Remes O, Brayne C, van der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav 2016; 6(7):e00497. https://doi.org/10.1002/brb3.497
  » https://doi.org/10.1002/brb3.497
• ¹⁹
  Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006; 166(10):1092-1097. https://doi.org/10.1001/archinte.166.10.1092
  » https://doi.org/10.1001/archinte.166.10.1092
• ²⁰
  Peltzer K, Pengpid S. Oral health behaviour and social and health factors in university students from 26 low, middle and high income countries. Int J Environ Res Public Health 2014; 11(12):12247-12260. https://doi.org/10.3390/ijerph111212247
  » https://doi.org/10.3390/ijerph111212247
• ²¹
  Keles ZH, Sancakli HS. Evaluation of knowledge, attitude and behaviour on oral health through COVID-19 pandemic. Meandros Med Dent J 2020; 21:222-231. https://doi.org/10.4274/meandros.galenos.2020.60352
  » https://doi.org/10.4274/meandros.galenos.2020.60352
• ²²
  Girão Júnior FJ, Valadas LAR, Bottenberg P, Lotif MAL, Rodrigues Neto EM, Fonseca SGDC, et al. Salivary fluoride bioavailability after brushing with Brazilian red propolis dentifrice. Evid Based Complement Alternat Med. 2022; 2022:6148137. https://doi.org/10.1155/2022/6148137
  » https://doi.org/10.1155/2022/6148137
• ²³
  Yang R, Tang T, Wu S, Wu L, Lei L, Li H. Self-reported oral health habits, knowledge and conditions of schoolchildren and adolescents in mainland China. J Clin Pediatr Dent 2023; 47(3):96-102. https://doi.org/10.22514/jocpd.2023.017
  » https://doi.org/10.22514/jocpd.2023.017
• ²⁴
  Kristiana L, Paramita A, Andarwati P, Maryani H. Posisi Relatif Provinsi di Indonesia Berdasarkan Penggunaan Pengobatan Tradisional: Analisis Komponen Utama Biplot. Buletin Penelitian Sistem Kesehatan 2020; 23(3):178-187. https://doi.org/10.22435/hsr.v23i3.3244 [In Indonesian].
  » https://doi.org/10.22435/hsr.v23i3.3244
• ²⁵
  Ayuningtyas D, Rayhani M. Analisis situasi kesehatan mental pada masyarakat di Indonesia dan strategi penanggulangannya. Jurnal Ilmu Kesehatan Masyarakat 2018; 9(1):1-10. https://doi.org/10.26553/jikm.2018.9.1.1-10 [In Indonesian].
  » https://doi.org/10.26553/jikm.2018.9.1.1-10
• ²⁶
  Kobayashi D, Takahashi O, Shimbo T. Frequency of daily tooth brushing and development of any type of malignancy. Anticancer Res 2019; 39(8):4415-4421. https://doi.org/10.21873/anticanres.13613
  » https://doi.org/10.21873/anticanres.13613
• ²⁷
  Tanner T, Päkkilä J, Karjalainen K, Kämppi A, Järvelin MR, Patinen P, et al. Smoking, alcohol use, socioeconomic background and oral health among young Finnish adults. Community Dent Oral Epidemiol 2015; 43(5):406-414. https://doi.org/10.1111/cdoe.12163
  » https://doi.org/10.1111/cdoe.12163
• ²⁸
  Chhabra N, Chhabra A. Parental knowledge, attitudes and cultural beliefs regarding oral health and dental care of preschool children in an Indian population: A quantitative study. Eur Arch Paediatr Dent 2012; 13(2):76-82. https://doi.org/10.1007/bf03262848
  » https://doi.org/10.1007/bf03262848
• ²⁹
  Bright MA, Alford SM, Hinojosa MS, Knapp C, Fernandez-Baca DE. Adverse childhood experiences and dental health in children and adolescents. Community Dent Oral Epidemiol 2015; 43(3):193-199. https://doi.org/10.1111/cdoe.12137
  » https://doi.org/10.1111/cdoe.12137
• ³⁰
  Scrine C, Durey A, Slack-Smith L. Providing oral care for adults with mental health disorders: Dental professionals' perceptions and experiences in Perth, Western Australia. Community Dent Oral Epidemiol 2019; 47(1):78-84. https://doi.org/10.1111/cdoe.12427
  » https://doi.org/10.1111/cdoe.12427
• ³¹
  Underwood B, Birdsall J, Kay E. The use of a mobile app to motivate evidence-based oral hygiene behaviour. Br Dent J 2015; 219(4):E2. https://doi.org/10.1038/sj.bdj.2015.660
  » https://doi.org/10.1038/sj.bdj.2015.660

Edited by

Academic Editor: Wilton Wilney Nascimento Padilha

Publication Dates

• Publication in this collection
  12 Aug 2024
• Date of issue
  2024

History

• Received
  30 Sept 2022
• Reviewed
  23 Mar 2023
• Accepted
  12 Nov 2023