Nigerian Journal of Medicine

: 2022  |  Volume : 31  |  Issue : 4  |  Page : 383--389

Oral Health Knowledge and Behavior among Public Primary Schoolchildren in Lagos, Nigeria

Chioma Love Nzomiwu1, Oladipupo Solomon Ayedun2, Omolola Olubunmi Orenuga2,  
1 Department of Child Dental Health, Faculty of Dentistry, College of Medical Sciences, University of Calabar, Calabar, Nigeria
2 Department of Child Dental Health, Faculty of Dental Sciences, College of Medicine University of Lagos, Lagos, Nigeria

Correspondence Address:
Dr. Oladipupo Solomon Ayedun
Department of Child Dental Health, Faculty of Dental Sciences, College of Medicine University of Lagos, Lagos


Aim: To evaluate the oral health knowledge and behavior among primary school pupils. Patients, Materials and Methods: This was a cross-sectional, descriptive study, in which a systematic sampling method was used to enroll 450 subjects into the study. The data collection tool was a self-administered, structured, pretested questionnaire. Results: Of the 450 enrollees, 434 pupils who duly completed their questionnaires participated in the study. Their mean age was 11.7 ± 1.64 years and more than half (229, 52.8) of the pupils were of male gender. About half (52.3%) of the pupils had adequate level of oral health knowledge. Majority had never visited a dentist (75%) before and had never used dental floss (66.6%). A higher proportion (72.3%) of the pupils with adequate level of oral health knowledge received parental supervision during brushing, had visited the dentist, and had frequent dental visit. Conclusion: The study revealed that about half of the study population had adequate level of knowledge. It also revealed inadequate oral health behaviour among the pupils. Pupils who had adequate knowledge had better behaviour.

How to cite this article:
Nzomiwu CL, Ayedun OS, Orenuga OO. Oral Health Knowledge and Behavior among Public Primary Schoolchildren in Lagos, Nigeria.Niger J Med 2022;31:383-389

How to cite this URL:
Nzomiwu CL, Ayedun OS, Orenuga OO. Oral Health Knowledge and Behavior among Public Primary Schoolchildren in Lagos, Nigeria. Niger J Med [serial online] 2022 [cited 2022 Oct 5 ];31:383-389
Available from:

Full Text


Oral health is very essential to the overall health and well-being of children and adolescents.[1] Good oral health enables individuals to communicate effectively and to eat and enjoy a variety of foods and is important in overall quality of life, self-esteem, and social confidence.[2] In addition, oral diseases pose a major health burden in many countries and affect people throughout their lifetime, causing pain, discomfort, disfigurement, and even death.[3]

Oral health knowledge is considered an essential requirement for health-related practices,[4] and studies[5],[6] have demonstrated the association between increased knowledge and better oral health. Individuals who have imbibed good knowledge and feel a sense of personal control over their oral health are more likely to adopt self-care practices.[7]

Health behavior refers to a person's actions regarding their health and well-being which is often a reflection of their belief.[8] Oral health behavior consists of individual and professional care and entails tooth brushing, dental flossing, visiting a dentist, and following a proper diet plan.[9] However, some factors such as frequency, duration, techniques of tooth brushing, and dental flossing play important roles in the effectiveness of this behavior.[10] Oral health behaviours as well as beliefs and attitudes develop during childhood and adolescence.[11],[12] Childhood and adolescent periods are receptive periods for new information and establishment of lifelong healthy behaviours. The earlier, an individual imbibes and establishes healthy habits, the greater the impacts on the individual.[11] Levin and Shenkman[13] in their study among young Israelis observed that adolescents with less dental caries had better oral health attitude and behavior. Undoubtedly, one of the methods for the prevention of diseases is to improve the knowledge of the individual and the community regarding positive health behaviour.

In Tanzania, oral health education has been part of the primary school curriculum and implemented by teachers at primary school level.[14] However, it was observed to be deficient in content and methods.[15] In Nigeria, oral health education is not yet incorporated in the school curriculum. Second, school health policies that encourage healthy eating habit and discourage the sales of sugary foods and drinks in the school premises have not yet been implemented. Children are therefore left to obtain both correct and incorrect information from various sources. It is therefore necessary to initiate young minds early in life and impart correct and adequate oral health knowledge at an early stage. It is known that adequate information, motivation, and practice when given can bring about the needed change to healthy attitude and practice.[16]

To create this desired level of health education, the assessment of the knowledge, attitude, and practice is essential for baseline information and future planning.[17] This will also assist in the specification of oral health messages as well as the development of behaviour modification strategies relevant to Nigerian children.

The aim of this study therefore was to assess the level of oral health knowledge and behavior among primary school pupils in Lagos, Nigeria.

 Patients, Materials and Methods

Study location

The study was carried out in Alimosho Local Government Area (LGA) of Lagos State, Nigeria, and it is the largest LGA in Ikeja division, Lagos, with 1,288,714 inhabitants according to the Official 2006 Census. At the time of this study, there were 60 public primary schools and 31 public secondary schools in this LGA. Alimosho LGA. has about 50,583 primary school pupils, which is the highest number of primary school pupils in Lagos state (according to the records of the State Universal Basic Education Board).

Study design

A cross-sectional, descriptive study design was used for the study to assess oral health knowledge and behavior among primary school pupils.

Sampling methods

Participants were selected using the multistage sampling technique where six primary schools were selected from 60 primary schools in Alimosho LGA. This was done using the simple random sampling technique for the first school and subsequent ones were selected by systematic random sampling. From each of the selected schools, a range of 3–5 arms constitute a class (A, B, C, D, and E). Two arms in each Basic 5 and 6 classes of the schools were selected randomly using the lottery method by drawing from a hat. Using the class register, 20 pupils were selected from each of the selected arm of Basic 5 and 6 classes in each of the schools using a table of random numbers.

All the selected pupils who presented their parent-signed informed consent forms in the selected schools and who met the inclusion criteria were eligible. Pupils with medical conditions such as cerebral palsy, Down syndrome, and intellectual disability and those whose parents did not consent to participate in the study were excluded from the study.

Data collection instrument

A pretested questionnaire adopted from Petersen et al.[18] and Stenberg et al.[19] was used for data collection. The questionnaire included items designed to evaluate the knowledge and behavior of young schoolchildren regarding their oral health. The self-administered, pretested, structured questionnaires were used to obtain information from the respondents. The questionnaire consisted of three sections; A, B, and C.

Section A consisted of the sociodemographic characteristics of the respondents.

Section B had 12 questions assessing the knowledge of the respondents about oral health with one correct response. A correct response was scored 1 and a wrong response was scored 0. Thus, the level of knowledge had scores ranging from 0 to 12, with 0 being the lowest possible score of a respondent and 12 being the highest possible score of a respondent, indicating better knowledge. The level of knowledge was regrouped into two categories using a mean score: a score of 8 and above was graded as adequate level of knowledge, while a score of 7 and below was graded as inadequate level of knowledge. These criteria were based on a previous study.[20]

Section C assessed the oral health behaviors of the respondents.

Socioeconomic status was calculated for each child and was constructed from a combination of father's occupation and mother's educational status as proposed by Olusanya et al.[21]

Ethical clearance

Approval for the study was obtained from the Research and Ethics Committee of the Lagos University Teaching Hospital with an assigned number of ADM/DCST/HREC/APP/1031. Written approval was also obtained from the State Universal Basic Education Board. Permission was obtained from the head teachers in the schools; however, written informed consent and assent were obtained from the parents and pupils, respectively.

Data analysis

Collected data were analyzed using the IBM SPSS software package version 21 (IBM, Armonk, NY, USA). Categorical variables were reported as frequencies and percentages and presented as tables and figures. Continuous variables such as age were reported as mean ± standard deviation. Chi-square test of association was used to determine significant statistical associations for categorical variables such as the association between sociodemographic variables and the level of knowledge. The level of statistical significance was set at P < 0.05.


A total of 434 pupils participated in the study, of which more than half were of the male gender (229, 52.8%). Their ages ranged from 8 to 15 years with a mean age of 11.6 ± 1.50 years. Participants aged 10–11 years were in the majority. Majority (273, 62.9%) of the participants were from low socioeconomic class [Table 1].{Table 1}

Almost all the respondents (415, 95.6%) selected tooth brush and tooth paste as the best item for cleaning the teeth. Majority of the respondents had correct response on most questions on oral health knowledge. However, about three-quarters (318, 73.3%) did not know what dental floss was, more than half (240, 55.3%) did not know that it is necessary to visit the dentist for routine checkup, while 248 (57.1%) did not know that general body health has a relationship with oral and dental diseases [Table 2].{Table 2}

About one-third (142, 32%) of the participants knew that fluoride makes teeth stronger while about two-thirds (288, 68%) felt fluoride made teeth whiter, weaker, reduces mouth odor, or did not know what it does [Figure 1].{Figure 1}

Although a higher proportion of the participants had adequate level of oral health knowledge, nearly half (47.7%) of the participants had inadequate oral health knowledge [Figure 2].{Figure 2}

There was a statistically significant relationship between gender and level of oral health knowledge with more female participants (130, 59.9%), showing adequate knowledge compared to the males (97, 44.7%) (P = 0.001) [Table 3].{Table 3}

With regard to oral health behavior, almost all the respondents used tooth brush and tooth paste for cleaning their teeth (400, 92.2%). About one-third of the participants (141, 32.4%) used soft tooth brushes, 138 (31.8%) did not receive assistance from their parents during brushing, and about half of the participants (220, 50.7%) cleaned their teeth twice a day. Three-quarters (326, 75.1%) had never visited a dentist before, and about two-thirds (289, 66.6%) had never used dental floss. Among those who had not visited the dentist before, nearly half of them (159, 48.8%) did not visit because they felt they had no problems with their teeth [Table 4].{Table 4}

Majority of the respondents with adequate level of knowledge received parental assistance during brushing (164, 72.3%), had used dental floss (85, 37.4%), had visited the dentist (65, 28.9%), and had visited the dentist within the recommended period of six months (61, 91%), and these associations were statistically significant [Table 5].{Table 5}


Results from this study revealed a high proportion of pupils with adequate level of knowledge on oral health. Most of the pupils had adequate knowledge on the various preventive measures of oral diseases, such as knowing the best item for cleaning the teeth, knowing that it is ideal to brush their teeth after breakfast in the morning and last thing at night, that foods and drinks contain sugar destroy teeth, that it is necessary to go for dental check-up at least once in a year, that dental decay means dental caries, and that it is possible to prevent oral diseases by brushing, flossing, and avoiding sugary diet. These findings are similar to those reported in Malaysia[17] and Nepal[23] but contrary to other reports in Nigeria,[24],[25] Sweden,[26] Kuwait,[22] Iran,[27] and China,[28] which reported inadequate knowledge. These differences in knowledge among different studies could be as a result of using different oral health questions, sample sizes, location of the study, and the method of analysis used for the study and the characteristics of the population. The high knowledge observed in this study could be because the study was conducted in Lagos, an urban city, where children have more access to media compared to those who dwell in rural areas. The children also acquire knowledge during marketing promotions of oral health products by companies in schools. In addition, several dental care product manufacturing companies have sprung up, thus encouraging competition in the sales of these products. These companies promote and advertise their products in schools, hoping the children would have an influence over their choices of oral health products by their parents.

Despite all these exhibitions of adequate knowledge about oral health, majority of them did not know what dental floss is and did not know that it is needful to visit a dentist for routine checkup. This confirms the reason why many studies[29],[30],[31] reported poor utilization of dental services, with majority of the people visiting the dentist only when they have pain.[27],[29]

In this study also, most of the participants did not know the action of fluoride on teeth; majority of them felt that fluoride either makes teeth whiter, weaker, or causes the teeth not to smell. Yet, fluoride is one of the most important components of Nigerian-used tooth pastes and is highly recommended that tooth paste should contain a certain amount of fluoride to help make teeth stronger.

Again, majority of the participants were not aware that general body health has a relationship with oral and dental diseases regardless of the Surgeon General's report that oral health is an integral part of general health.[1] This is a category of knowledge that an individual will possess through teachings in schools and by oral health professionals. Unfortunately, oral health is not part of the primary school curriculum in Nigeria unlike in Tanzania,[14] where oral health is part and parcel of the primary school curriculum and continues through secondary school with the involvement of professionals in the field. Osazuwa-Peters[32] reported that in Nigeria, school curriculum, from primary to secondary, still lacks a primary oral health education program. He noted that if oral health education and counseling have been incorporated into the curriculum of these schools (e.g., appropriate oral hygiene, topical fluoridation, and regular dental visits), there would have been a lot of improvement regarding oral health attitudes and behaviors of Nigerian children.[32]

The knowledge that oral health is an integral part of general health will enable individuals pay more attention to their oral health as diseases of the oral cavity can affect an individual's physical, emotional, and social well-being.

The females in this study had better knowledge than the males and the respondents with adequate knowledge also used dental floss more than those with inadequate knowledge. This is similar to some studies in Iran[27] and Qatar[33] with reports that females were more knowledgeable than males when it comes to oral health. However, Darout et al.[34] reported gender equality in knowledge and practice among their participants, while Gao et al.[28] reported no significant difference between gender and oral health knowledge among their participants in Western China.

This study also showed that individuals who were more knowledgeable visited the dentist more regularly and received assistance from their parents during tooth brushing. Blaggana et al.[35] in their study reported better oral hygiene knowledge and practices among students who visited dentists regularly. Drummond et al.[36] and Habibian et al.[37] have shown that it is beneficial for an adult to assist in tooth brushing until a child has the dexterity to remove plaque effectively by themselves and this is when the child is about 8–10 years old.

Tooth brush and tooth paste were the most commonly used oral hygiene aids, similar to what has been reported in Nigeria,[38] Kuwait,[26] China,[39] and Saudi Arabia.[40]

Despite the fact that majority of the participants used tooth brush and tooth paste to take care of their teeth, some still made use of chewing sticks alone regardless of the fact that the study was conducted in an urban city. This depicts the fact that as children, they would make use of that which is made available by their parents. It could also be due to learned cultural practices and beliefs of their parents which were adopted by the children. In addition, as reported by Rotimi and Mosadomi,[41] chewing sticks are readily available, cheap, and efficacious and thus easier to afford as majority of the respondents in this study are in the low socioeconomic class.

In this study, however, the oral health behavior of the pupils was not a reflection of their high knowledge about oral health. For example, most of them still used hard bristled tooth brushes instead of the recommended soft textured tooth brushes for their ages. Tooth brushes as cleaning aids should be well selected and taken care of for effective cleaning. It is possible that the choices of their tooth brushes were made by their parents who also may not have adequate knowledge about oral health and its practices and therefore do not take into consideration the qualities and specifications of tooth brushes made available for their children.

It is also of interest to note that more than three quarter of the participants had not visited the dentist before in their lifetime. This can be described as having poor knowledge and poor health-seeking behavior. The reason given by majority of them was that they did not have any problem with their teeth. This is similar to the report of Denloye[30] and Eigbobo,[31] where 82.2% and 64.3% of the participants in Ibadan and Port-Harcourt, respectively, gave a report of no perceived need to see a dentist. It is recommended that dental visits be at least twice a year for prophylaxis and parents should be involved in oral health education programs involving children so as to draw their attention toward practicing regular dental visit and thus prevent future dental diseases.[27]

From the findings of this study, dental floss, one of the important interdental cleaning aids used in maintaining oral hygiene, was still poorly utilized. More than half of the participants had never used dental floss before, and this exhibits poor oral health behavior. In previous reports, only 5.8% and 3% of university students in Nigeria[42] and Turkey,[43] respectively, had used dental floss. In contrast, it is the finding in San Francisco where 75% of the 12–14-year-old students used dental floss at least once per day.[44] Poor utilization of dental floss, in this study, may be due to several reasons such as the dental floss not being readily available in Nigeria like other basic daily oral hygiene products. It is also more expensive than tooth paste and only available in big malls and super marts. In addition, oral health education in Nigeria places more emphasis on tooth brushing (frequency, methods, and materials) and rarely discusses adjunct dental cleaning, interdental cleaning, and/or flossing.

This study was able to assess only pupils from one locality in Lagos, Nigeria. The authors therefore recommend further studies from other regions or geopolitical zones so as to compare similar parameters among pupils of the same grades.


Adequate level of knowledge of oral health was seen in about half of the study population. Majority of pupils who had adequate level knowledge of oral health had better oral health behavior. However, most of the respondents' oral behavioral practices were inappropriate and needed improvement, especially in relation to dental visits, use of dental floss, and parental assistance/supervision during tooth brushing.

It can be concluded that oral health knowledge among this group of children did not absolutely translate to good behavioral practices.


Oral health knowledge of pupils should be further enhanced by organizing oral health programs involving dental professionals and not sales representatives of oral health products. Mothers and caregivers should be involved and included in oral health programs to enable them gain knowledge which will impact their children and other family members. In addition, oral health should be incorporated into the primary school.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
2Locker D. Measuring oral health: A conceptual framework. Community Dent Health 1988;5:3-18.
3WHO,Oral Health; 2014. Available from: [Last accessed on 2022 Mar 09].
4Ashley FP. Role of dental health education in preventive dentistry. In: Murray JJ, editor. Prevention of Dental Disease. Oxford, UK: Oxford University Press; 1996. p. 406-14.
5Haque SE, Rahman M, Itsuko K, Mutahara M, Kayako S, Tsutsumi A, et al. Effect of a school-based oral health education in preventing untreated dental caries and increasing knowledge, attitude, and practices among adolescents in Bangladesh. BMC Oral Health 2016;16:44.
6Hamilton ME, Coulby WM. Oral health knowledge and habits of senior elementary school students. J Public Health Dent 1991;51:212-9.
7Freeman R, Maizels J, Wyllie M, Sheiham A. The relationship between health related knowledge, attitudes and dental health behaviours in 14-16-year-old adolescents. Community Dent Health 1993;10:397-404.
8Health Behaviors and Promotion: Definition & Explanation; May 14, 2014. Available from: [Last accessed on 2022 Mar 10].
9Steptoe A, Wardle J, Vinck J, Tuomisto M, Holte A, Wichstrøm L. Personality and attitudinal correlates of healthy and unhealthy lifestyles in young adults. Psychol Health 1994;9:331-43.
10Davies RM, Davies GM, Ellwood RP. Prevention. Part 4: Toothbrushing: What advice should be given to patients? Br Dent J 2003;195:135-41.
11Bertness J, Holt K, editors. Promoting Oral Health in Schools: A Resource Guide – April 2009. Washington, DC: National Maternal and Child Health Oral Health Resource Center; 2009. Available from: [Last accessed on 2016 Apr 20].
12Oral Health: Oral Health through Health Promoting Schools. World Health Organization; 2013. Available from: [Last accessed on 2016 Apr 21].
13Levin L, Shenkman A. The relationship between dental caries status and oral health attitudes and behavior in young Israeli adults. J Dent Educ 2004;68:1185-91.
14Ministry of Health and Social Welfare, the National Plan for Oral Health 1988-2002, Dar es Salaam, Tanzania; 1988.
15Nyandindi U, Palin-Palokas T, Milén A, Robison V, Kombe N, Mwakasagule S. Participation, willingness and abilities of school-teachers in oral health education in Tanzania. Community Dent Health 1994;11:101-4.
16Smyth E, Caamano F, Fernández-Riveiro P. Oral health knowledge, attitudes and practice in 12-year-old schoolchildren. Med Oral Patol Oral Cir Bucal 2007;12:E614-20.
17Lian CW, Phing TS, Chat CS, Shin BC, Baharuddin LH, Jalil Che'Jalil ZB. Oral health knowledge, attitude and practice among secondary school students in Kuching, Sarawak. Arch Orofac Sci 2010;5:9-16.
18Petersen PE, Aleksejuniene J, Christensen LB, Eriksen HM, Kalo I. Oral health behavior and attitudes of adults in Lithuania. Acta Odontol Scand 2000;58:243-8.
19Stenberg P, Håkansson J, Akerman S. Attitudes to dental health and care among 20 to 25-year-old Swedes: Results from a questionnaire. Acta Odontol Scand 2000;58:102-6.
20Adeniyi A, Agbaje O, Braimoh M, Ogunbanjo O, Sorunke M, Onigbinde O. A survey of the oral health knowledge and practices of pregnant women in a Nigerian Teaching Hospital. AJRH 2011;15:14-9.
21Olusanya O, Okpere E, Ezimokhai M. The importance of social class in voluntary fertility control in a developing country. West Afr J Med 1985;4:205-12.
22Al-Ansari JM, Honkala S. Gender differences in oral health knowledge and behavior of the health science college students in Kuwait. J Allied Health 2007;36:41-6.
23Prasai Dixit L, Shakya A, Shrestha M, Shrestha A. Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal. BMC Oral Health 2013;13:20.
24Ologun LM. Knowledge, Attitude and Practice of Dental Health Care among Primary School Pupils in Zaria. Dissertation for Masters of Health Education, Ahmadu Bello University, Zaria; 2010.
25Omale JJ. Oral Health Knowledge, Attitudes, and Practices among Secondary School Students in Nigeria. Walden Dissertations and Doctoral Studies; 2014.
26Hedman E, Ringberg C, Gabre P. Knowledge of and attitude to oral health and oral diseases among young adolescents in Sweden. Swed Dent J 2006;30:147-54.
27Kamran A, Bakhteyar K, Heydari H, Lotfi A, Heydari Z. Survey of oral hygiene behaviors, knowledge and attitude among school children: A cross-sectional study from Iran. Int J Health Sci 2014;2:83-95.
28Gao J, Ruan J, Zhao L, Zhou H, Huang R, Tian J. Oral health status and oral health knowledge, attitudes and behavior among rural children in Shaanxi, western China: A cross-sectional survey. BMC Oral Health 2014;14:144.
29Al-Omiri MK, Al-Wahadni AM, Saeed KN. Oral health attitudes, knowledge, and behavior among school children in North Jordan. J Dent Educ 2006;70:179-87.
30Denloye O, Ajayi D, Bankole O, Popoola B. Dental service utilization among junior secondary school students in Ibadan, Nigeria. Pediatr Dent J 2010;20:177-81.
31Eigbobo JO, Obiajunwa CC. Utilization of dental services among secondary school students in Port Harcourt, Nigeria. Eur J Gen Dent 2016;5:74-9.
32Osazuwa-Peters N. The Alma-Ata declaration: An appraisal of Nigeria's primary oral health care three decades later. Health Policy 2011;99:255-60.
33Al-Darwish MS. Oral health knowledge, behaviour and practices among school children in Qatar. Dent Res J (Isfahan) 2016;13:342-53.
34Darout IA, Astrøm AN, Skaug N. Knowledge and behaviour related to oral health among secondary school students in Khartoum Province, Sudan. Int Dent J 2005;55:224-30.
35Blaggana A, Grover V, Anjali, Kapoor A, Blaggana V, Tanwar R, et al. Oral health knowledge, attitudes and practice behaviour among secondary school children in Chandigarh. J Clin Diagn Res 2016;10:ZC01-6.
36Drummond B, Kilpatrick N, Bryant R. Dental caries and restorative paediatric dentistry. In: Handbook of Pediatric Dentistry. 2nd ed. London: Elsevier; 2003. p. 46.
37Habibian M, Roberts G, Lawson M, Stevenson R, Harris S. Dietary habits and dental health over the first 18 months of life. Community Dent Oral Epidemiol 2001;29:239-46.
38Umesi-Koleoso DC, Ayanbadejo PO. Oral hygiene practices among adolescents in Surulere, Lagos State, Nigeria. Nig Q J Hosp Med 2007;17:112-5.
39Lin HC, Wong MC, Wang ZJ, Lo EC. Oral health knowledge, attitudes, and practices of Chinese adults. J Dent Res 2001;80:1466-70.
40Al-Sadhan SA. Oral health practices and dietary habits of intermediate school children in Riyadh, Saudi Arabia. Saudi Dent J 2003;15:81-7.
41Rotimi VO, Mosadomi HA. The effect of crude extracts of nine African chewing sticks on oral anaerobes. J Med Microbiol 1987;23:55-60.
42Bashiru BO, Anthony IN. Oral self-care practices among university students in Port Harcourt, Rivers State. Niger Med J 2014;55:486-9.
43Kirtiloğlu T, Yavuz US. An assessment of oral self-care in the student population of a Turkish university. Public Health 2006;120:953-7.
44Walsh MM. Effects of school-based dental health education on knowledge, attitudes and behavior of adolescents in San Francisco. Community Dent Oral Epidemiol 1985;13:143-7.