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International Dental Journal (2003) 53, 289298

2003 FDI/World Dental Press

0020-6539/03/05289-10

Oral health knowledge, attitudes and

behaviour of children and

adolescents in China

Ling ZhuBeijing, China

Poul Erik PetersenGeneva, Switzerland

Hong-Ying Wang, Jin-You Bian and Bo-Xue ZhangBeijing, China

Objectives: A national representative study to describe oral healthbehaviour, illness behaviour, oral health knowledge and attitudes among12-year-old and 18-year-old Chinese, to analyse the oral health behaviourprofile of the two age groups in relation to province and urbanisation, and toassess the relative effect of socio-behavioural risk factors on dental cariesexperience. Methods:The total number of 4,400 of each age group wereselected and data were collected by clinical examinations (WHO criteria)

and self-administered structured questionnaires. Results: 44.4% of therespondents brushed their teeth at least twice a day but only 17% usedfluoridated toothpaste. Subjects who saw a dentist during the previous 12months or two years were 31.3% and 35.3% for 12-year-olds and 22.5%and 20.2% for 18-year-olds, respectively. Nearly one third (29%) of 12 year-olds and 40.5% of 18-year-olds would visit a dentist in case of signs ofcaries but only when in pain. Nearly half of the participants (47.2%) hadnever received any oral health care instruction. Significant variations in oralhealth practices were found according to province and regular dental carehabits were more frequent in urban than in rural areas. The risk of dentalcaries was high in the case of frequent consumption of sweets and dentalcaries risk was low for participants with use of fluoridated toothpaste.Conclusion: Systematic community-oriented oral health promotion

programmes are needed to target lifestyles and the needs of children,particularly for those living in rural areas. A prevention-oriented oral healthcare policy would seem more advantageous than the present curativeapproach.

Key words: Epidemiology, oral health knowledge, oral health behaviour, oral

health habits

Correspondence to: Dr. Poul Erik Petersen, World Health Organization, Non-Communica-ble Disease Prevention and Health Promotion, Oral Health Programme, 20 Avenue Appia,CH-1211 Geneva 27, Switzerland. Email: [email protected]

During the past two decades, manyindustrialised countries have expe-rienced a dramatic decline in dentalcaries prevalence of children andadolescents14. The reasons for theimproved oral health are complexbut may involve a more sensible

approach to sugar consumption,improved oral hygiene practices,fluorides in toothpaste, topical fluo-ride application, effective use oforal health services and establish-ment of school-based preventiveprogrammes510. In parallel with thechanging oral disease patterns therehave been significant improvementsin oral health awareness, dentalknowledge and attitudes of chil-dren and parents1113. Conversely,

increasing levels of dental carieshave been observed in severaldeveloping countries, especially forthose countries where preventiveprogrammes have not been imple-mented1416.

In China, surveys of oral healthstatus have been conducted indifferent provinces or localcommunities. Some variation in theoccurrence of oral disease is found,for example in recent studies the

mean dental caries experience of12-year-olds was reported at 0.41.9 DMFT1722. The analysis of oralhealth habits, knowledge and atti-


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tudes of children was initiated inthe late 1980s and these studies werecarried out in some provincesamong urban children19,22. How-ever, such oral health behaviourdata of children are scarce for rural

population groups. Since the intro-duction of the national Love TeethDay campaigns in 1988, a numberof health education projects havebeen implemented at province andcommunity-levels throughout thecountry.

National oral health behaviourdata are needed for national plan-ning and evaluation of healthpromotion programmes and system-atic analysis of oral health behaviourmay help the specification of oralhealth messages as well as devel-opment of behaviour modificationstrategies relevant to China. There-fore, the second national oral healthsurvey was designed in order toprovide nation-wide informationfor the analysis of both oral healthstatus and oral health knowledge,attitudes and behaviour of theChinese population of ages 12, 18,3544, and 6574 years. Theresults from the clinical investiga-tion of oral health conditions havebeen described separately17,23. Thepurpose of this report is todescribe the pattern of oral healthbehaviour, illness behaviour, oralhealth knowledge and attitudesamong 12-year-old and 18-year-old Chinese at the national level; toanalyse the oral health behaviourprofile of the two age groups in

relation to province and urbanisa-tion, and to assess the relativeeffect of socio-behavioural riskfactors on caries experience.

Study population andmethods

The present study is part of the2nd comprehensive national oralhealth survey, which was completedin China in 199617. The study popu-

lation and principles of samplinghave been detailed in previousreports17,24. The participants of thissurvey were chosen by multistage

stratified cluster random samplinginvolving 11 provinces and withineach province the total number of400 subjects of the WHO standardages was identified from randomlyselected schools. The schools were

chosen from at least three loca-tions in each province and districtand in urban and rural areas,respectively. For the present study,the survey comprised 8,800 partici-pants, i.e. 4,400 in each age groupand the final sample was balancedby gender and urbanisation.

Oral epidemiological data werecollected by clinical examinationsaccording to WHO methodologyand criteria and all examiners weretrained and calibrated to accept-able standard17,24. Examinations

were carried out in daylight. Inaddition, structured questionnaires

were used for self-administration whereby the participants wereasked about demographic back-ground, oral health knowledge andattitudes, self-care practices, andutilisation of dental services. Thequestionnaires were filled out bythe respondents themselves in theclassroom and the data collection

was supervised by survey staffspecially trained for this activity.

The supervisors had at least tertiaryeducation level and they were care-fully instructed in the rationality andmeaning of questions. Prior to thedata collection the questions werepre-tested among comparablegroups of children in order toassess reliability and validity. In each

province one dentist was in chargeof the organisation of clinicalexaminations as well as administra-tion of questionnaires.

Processing of data was performedby use of EPI-INFO v5.0 (Chinese

version) whereby data were checkedfor logical errors. The data entrytook place in every province andthe staff members were carefullytrained on how to use the datainput program. Double data entry

was carried out. All questionnaires were collected from each prov-ince, checked for logical errors byuse of EPI-INFO and the files were

then transferred to the NationalCommittee for Oral Health inBeijing for central data analysis. Thenational data file was constructedby the Department for Epidemi-ology, Peking University, Faculty

of Medical Science, Beijing. Thedata were finally converted foranalysis by means of the StatisticalPackage for the Social Sciences(SPSS 10.0) in the WHO Collabo-rating Centre for Community OralHealth Programmes and Research,University of Copenhagen. Bivariateand multivariate analyses of the dataon oral health knowledge, attitudesand behaviour were based onfrequency distributions. The Chi-square test was used in the statisticalevaluation of the bivariate frequencydistributions. For the assessment ofthe relative effect of behaviouralfactors on dental caries experience,multiple dummy regression analy-sis and logistic regression analysis

were performed. Dental cariesexperience index (DMFT) was thedependent variable in the dummyregression analyses. In the logisticregression model the dependent

variable was represented by thedichotomous presence or absenceof caries (i.e. DMFT=1 or more,or DMFT=0); thereby the regres-sion coefficient indicates the OddsRatio (OR=P/1-P) of caries. Forthe statistical evaluation of theregression coefficients, the t-test wasused in the dummy regression

whereas the Wald-test was chosenin the logistic regression.

Results

Oral hygiene habits

Tables 12summarise the findingsconcerning tooth brushing habitsof 12- and 18-year-olds. No signifi-cant differences in tooth brushingbehaviour were found accordingto gender. In all, nearly half of therespondents claimed to brush theirteeth at least twice a day and such

practice was reported more oftenin urban than in rural areas. Themajority of children and adoles-cents brushed their teeth in the


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Table 1 The percentages of 12- and 18- year-old Chinese according to frequency of tooth brushing,

occasion of brushing, use of toothpaste and age of starting brushing in relation to urbanisation

12 years 18 years

Urban Rural Total Urban Rural Total

(n=2200) (n=2200) (n=4400) (n=2200) (n=2200) (n=4400)

Frequency of tooth brushing

seldom or no brushing 7.2 26.3 16.8 2.0 9.5 5.8

brushing once a day 33.7 42.8 38.2 45.8 54.9 50.3

brushing at least twice a day 59.1*** 31.0 45.0 52.1*** 35.6 43.9

Occasion of tooth brushing

in the morning 94.9 88.6 91.8 94.0 88.8 91.4

in the evening 64.6*** 43.6 54.2 60.4*** 51.6 56.1

after meals 13.6 1.4 16.0 14.2 20.4 17.3

after dessert/sweets 21.0 14.5 17.8 17.0 21.0 18.9

Use of toothpaste

non-fluoridated 77.3 89.1 83.2 87.5 92.6 90.0

fluoridated 22.7*** 10.9 16.8 12.5*** 7.4 10.0

Started brushing teeth

before schooling 70.6 29.0 50.0 54.3*** 18.7 36.7

when attending primary school 28.9 69.8*** 49.1 41.0 69.6*** 55.2after completing primary school 0.5 1.2 0.9 4.7 11.6 8.1

*** p


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Table 3 The distribution (pct) of 12- and 18- year-old Chinese according to awareness of where

dental plaque tends to stick and the intervals for exchange of toothbrush in relation to urbanisation

12 years 18 years


Where does dental plaque stick

to in the mouth

on the tongue 1.5 1.5 1.5 0.5 0.5 0.5

on the gums 9.6 9.0 9.3 12.8 12.5 12.7

on the teeth 13.8 10.2 12.0 11.1 8.9 10.0

all the above mentioned 6.8 7.5 7.1 14.3 17.9 16.1

never heard about plaque 30.2 34.7 32.5 25.0 26.4 25.7

dont know 38.1 37.0 37.6 36.4 33.8 35.1

Intervals for exchange of toothbrush

13 months 53.2*** 38.9 46.1 46.3*** 43.3 44.8

46 months 20.4 18.7 19.6 29.3 27.7 28.5

712 months 6.4 7.7 7.0 8.1 11.2 9.7

more than one year 2.7 4.1 3.4 2.3 3.6 2.9

dont know 17.4 30.6 23.9 14.0 14.2 14.1

*** p


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Table 5 The percentages of 12- and 18-year-old Chinese with certain self-care

practices in oral health according to province

Province Tooth brushing at least Recommended methods Use of fluoride

twice a day of brushing toothpaste

12 years 18 years 12 years 18 years 12 years 18 years

Beijing 40 50 49 54 38 10

Shanghai 48 41 66 48 31 17

Tianjin 33 36 66 48 13 4

Gansu 32 19 55 53 8 3

Shandong 43 31 60 47 7 2

Yunnan 62 59 56 40 6 5

Liaoning 47 32 79 67 26 8

Zhejiang 40 48 58 46 19 12

Hubei 24 43 30 42 6 7

Guangdong 77 72 40 34 35 28

Sichuan 50 53 54 48 22 11

Total 45 44 46 42 19 11

Table 6 The distribution (pct) of 12- and 18-year-old Chinese according to how many times they had

seen a dentist during lifetime (n=7897), time since last dental visit (n=5862) and preventive servicesreceived within the recent two years (n=5861) in relation to urbanisation

12 years 18 years


Number of times having seen a dentist

never 30.0 53.2*** 41.7 41.4 62.7*** 52.2

12 times 38.4 30.1 34.2 30.2 22.5 26.3

3 or more times 31.5 16.8 24.1 28.4 14.9 21.6

Time since last visit to the dentist

less than 1 year 28.6 34.8 31.3 22.0 23.3 22.5

12 years ago 30.7 24.7 28.1 17.0 16.6 16.8

3 or more years ago 31.7 19.0 26.1 46.6 31.5 40.0

never seen a dentist 9.0 21.6*** 14.5 14.5 28.6*** 20.6Preventive services received during

the recent two years

check-up of teeth 37.1* 32.9 35.3 18.7 22.2* 20.2

topical application of fluoride 5.4*** 8.3 12.3 11.2*** 6.9 9.3

fissure sealing 9.7*** 5.3 7.8 8.3*** 4.7 6.7

scaling of teeth 20.8 23.9* 22.2 11.9 16.0** 13.7

*** p


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Table 7 The percentages of 12- and 18-year-old Chinese with use

of professional dental services according to province

Province Saw a dentist within Dental check-up during

the last year the recent two years

12 years 18 years 12 years 18 years

Beijing 36.6 24.9 31.4 15.7

Shanghai 34.0 21.8 39.0 19.5

Tianjin 39.2 24.0 33.7 33.7

Gansu 22.8 12.5 28.8 13.3

Shandong 32.1 24.0 28.6 9.9

Yunnan 29.4 18.7 9.8 12.1

Liaoning 32.0 22.5 72.0 56.3

Zhejiang 32.2 29.3 30.8 17.5

Hubei 28.4 30.1 22.4 12.6

Guangdong 28.3 24.5 24.7 5.5

Sichuan 33.5 24.1 44.2 15.9

Total 31.3 22.5 35.3 20.2

Table 8 The percentages of 12- and 18-year-old Chinese who reported certain actions when having bleeding from gums

or signs of caries in relation to urbanisation

12 years 18 years


If gums are bleeding what do you do

stop brushing 10.0 12.5 11.2 16.9 16.9 16.9

pay more attention to gums when brushing 30.6 32.1 31.3 39.6 40.4 40.0

brush more frequently 35.0 39.0*** 37.0 45.2 52.3*** 48.8

go to see a dentist 36.7*** 29.1 32.9 23.5 23.4 23.5

ignore bleeding 9.3 16.1*** 12.7 25.4 26.8 26.1

never had this problem 32.2 28.0 30.0 19.7 21.8 20.8

dont know what to do 12.7 21.6*** 17.1 24.3 26.6 25.5

If having signs of tooth decay what do you do

dont care if no pain 12.8 22.0*** 17.4 40.8 42.0 41.4take pills for pain killing 16.7 27.6*** 22.1 24.8 29.0** 26.9

just try to cope with the problem 11.2 19.8*** 15.5 26.0 29.5** 27.7

go and see a dentist only when in pain 28.0 31.3* 29.6 42.4* 38.7 40.5

go and see a dentist immediately for dental filling 49.2*** 27.2 38.2 31.5* 28.0 29.8

go and see a dentist for extraction of tooth 18.8 19.2 19.0 9.5 10.5 10.0

brush teeth more often when having pain 12.8 17.5*** 15.1 18.0 19.9 19.0

*** p


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Table 9 The percentages of 12- and 18- year-old Chinese with certain habits of consuming

sweets and frequency of eating sweets in relation to urbanisation

12 years 18 years

Urban Rural Total Urban R ural Total

Have sweets in-between-meals

every day

desserts or candy 46.3 48.9* 47.6 54.1* 52.0 53.0

sugary drinks 45.1*** 34.5 39.8 46.0*** 35.9 40.9

sweets before sleeping 13.3 18.5*** 15.9 19.9 26.0*** 23.0

Frequency of eating sweets

13 times per day 69.4 63.9 66.8 68.3 64.9 66.6

46 times per day 6.8 9.1 7.9 6.5 4.1 5.3

710 times per day 1.4 1.4 1.4 0.9 0.5 0.7

do not have such habits 22.4 25.6** 24.0 24.3 30.5*** 27.4

*** p


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were inserted as independent vari-ables and the regression analyses

were carried out for the two agegroups separately. The mostimportant factors of the cariesexperience index were frequency

of dental visits, use of fluoridatedtoothpaste and frequency of eatingsweets. The logistic regressionmodel indicated higher odds ofdental caries (OR) if the respond-ents had frequent dental visits andfrequent consumption of sweets.

Discussion

In China, socio-epidemiologicaldata on oral health status are scarce;in particular, systematic data on oralhealth behaviour of children andadolescents are not available atnational level. The present studyintended to provide such informa-tion with regard to 12- and 18-year-olds of urban and rural areas.

The emphasis was placed ondescribing the level of oral healthknowledge, attitudes and behav-iour of children and adolescents indifferent regions of China and high-lighting the impact of the nationalmass oral health education pro-grammes, such as the national Love

Teeth Day campaign17,25. Themultistage random cluster samplingprocedure was applied for selec-tion of participants. Relatively moreurban respondents took part in thesurvey, although the epidemiologi-cal part of the study may beconsidered representative of the

general population17

. The sociological data werecollected by means of self-admin-istered questionnaires and due tothe school-based approach a highresponse rate was obtained. Severalinitiatives were made to ensure the

validity and reliability of data. Thequestionnaires used in this study

were evaluated for optimal constructand face validity of variables by anexpert panel of oral health research-

ers of the Chinese National Com-mittee for Oral Health (NCOH).The test-retest method was carriedout in a sub-sample of each prov-

ince and retest within one monthafter the questionnaire was completedinitially; the consistency rate of thetwo sets of responses was morethan 70 per cent23. However, thedata collection method may have

certain limitations26. First, theparticipants may tend to givesocially desirable responses by over-estimating the frequency of dental

visits or tooth brushing. Second,participants may underestimatenegative behaviour such as consump-tion of sugar. Third, some over-reporting would be consideredlikely with respect to the answerson knowledge and attitudes towardsdental care.

In China, several efforts havebeen made to implement preven-tive oral care programmes and oralhealth education since the late1980s. In 1988, the National Com-mittee for Oral Health (NCOH)

was established in order to preventdental diseases and improve oralhealth behaviour of the public. TheLove Teeth Day campaign (LTD)has been organised as a mass oralhealth education programme bythe NCOH and annually variousactivities were carried out through-out the country in order to encour-age the implementation of commu-nity-based oral health education atprovince level25. The LTD campaignsintended to pass on the followingmessages for preventive practicesby the public: regular tooth brush-ing at least twice a day, performanceof standard methods of brushing,

tooth brushing from early child-hood as well as the use of standardtoothbrushes and fluoridatedtoothpaste. The present studyrevealed that about half of childrenand adolescents performed therecommended practice of brush-ing teeth twice a day or more. Thislevel is similar to that observed insome industrialised countries of eastEurope2729 but low as compared

with most western industrialised

countries27,28

. Moreover, oral self-care practices of Chinese youthsseemed to be more frequent thanobserved in the Middle East13,30,31,

while the proportion of childrenbrushing twice or more per day inthe Chinese study is somewhatlower than found in similar studiesin Asia, such as in Thailand12.

Traditionally, Chinese people

have tended to practice an unsyste-matic or horizontal method ofbrushing. In order to encouragethe Chinese population to adoptproper oral hygiene habits, the

vertical, rolling or Bass-methodswere considered most appropriateby the LTD programme. Thepresent survey indicated that onlyhalf of the respondents performedthe recommended methods ofbrushing. The results may suggestthat growing numbers of Chinesechildren adopt regular tooth brush-ing in early childhood since abouthalf of the 12-year-olds reportedtooth brushing before they startedat school. In comparison, for 18-year-olds who were born beforethe LTD was introduced, thefigure was only about one-third.Furthermore, it is worth noting thatthe use of fluoridated toothpaste

was relatively seldom. If brushingwas performed only once a day, itapparently tended to take place inthe morning rather than in theevening, despite the LTD messagesemphasising tooth brushing to becarried out in the evening. This mayindicate that such habits are diffi-cult to change merely through masshealth education33.

The children and adolescentsliving in urban areas had regular

oral hygiene habits more often thanin rural areas. This may be due tofactors such as better coverage ofthe LTD programme in urbanareas, higher socio-economic statusand adoption of modern lifestyle.In addition, the use of a standardtoothbrush was significantly lessfrequent in rural areas than inurban areas, and this pattern maybe explained by the restricted avail-ability of such brushes from the

market. Moreover, the differencesin oral hygiene habits by locationwere reflected in other dimensionsof oral health behaviour when

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responses were analysed accordingto the province; for example, theGuangdong province had highscores on tooth brushing at leasttwice a day.

About half of the respondents

had never visited a dentist at all.and this confirms findings fromthe Wuhan19 and Guangdong20 stud-ies carried out in the mid-1990s.However, less than one third ofthe respondents reported a dental

visit in the previous 12 months, afigure much lower than in previousChinese studies19,20 or as reportedfor children of industrialised coun-tries2730, the Middle East13,29,31,32andSouth-East Asia12. In agreement

with a previous Chinese study33 onethird of respondents reportedpreventive dental visits within theprevious two years and the resultsdemonstrated that utilisation ofdental services among Chinesechildren and adolescents is highlysymptoms-oriented. Meanwhile, theanalysis revealed that if the partici-pants had frequent dental visits they

were more likely to perform regu-lar self-care practices, and thismay suggest that they had beeninstructed in oral self-care by thedentist. Furthermore, the responsesto the questions on illness behav-iour revealed that most childrencope with symptoms throughintensified oral hygiene or by seek-ing help from dentists when havingbleeding from gums or signs oftooth decay. In parallel to theobservations on oral hygiene habits,

the level of utilisation of dentalservices varied significantly acrossprovinces and between urban andrural areas and this pattern mayreflect socio-economic backgroundsand different availability of dentalservices or hospitals. It is remarkablethat sugar consumption habits ofchildren showed minor differencesaccording to location.

Multivariate regression analyseswere carried out in order to predict

the dental caries experience fromindependent variables related tooral health care. After controllingfor confounders, the most impor-

tant factors of caries experiencewere frequency of dental visit, useof fluoridated toothpaste, andfrequency of eating sweets whereasthe frequency of tooth brushing hadminor impact on dental caries

experience. Such pattern was alsofound in the previous studiescarried in China19,20 and in Thai-land12. One reason of the limitedimpact of tooth brushing may bethat oral self-care practices ofChinese children and adolescentsare more problem-oriented ratherthan performed for preventivereasons. The problem-orienteddental visiting habits also explainthe higher caries index amongdental visitors.

In general, attitudes to preventionof dental caries and periodontaldiseases seem positive in Chineseyouth, nevertheless, the informationon oral health knowledge indicatesthat most young Chinese havesomewhat diffuse understanding ofthe major oral diseases, especiallyin rural areas. This may be seen inlight of the fact that nearly half ofthe population had never receivedany oral health education instruc-tion. Although the LTD campaignpresumably has had some positiveimpact on the oral health practicesof young Chinese, the study indi-cates that systematic community-oriented oral health promotionprogrammes are needed to targetlifestyles and the needs of children,particularly for those living in ruralareas. In light of the scarce resources

and the current pattern of oraldiseases in China, a prevention-oriented oral health care policy

would seem more advantageousthan the present curative approach.Oral health education would playthe most important role and theprimary and secondary schools mayprovide effective settings for oralhealth education programmes. Theprovince health authorities shouldbe encouraged to develop targeted

community-oriented oral health carepromotion strategies aimed atfurther improvement of oral self-care practices, regular dental visiting

habits of youth and better controlof oral disease.

Acknowledgement

This survey was conducted by an

expert group under the Ministry ofHealth and the National Committeefor Oral Health; it was supportedfinancially by the China Oral HealthFoundation and technical assistance

was provided by the WHOCollaborating Centre for Commu-nity Oral Health Programmes andResearch (University of Copenha-gen, Denmark).

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