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173]

Original Article

Influence of Oral Health Literacy on the Oral Health Status of

School Teachers in Mangalore, India
Arun K. Simon, Ashwini Rao, GuruRaghavendran Rajesh, Ramya Shenoy, Mithun B. H. Pai
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Mangalore, Karnataka, India

Abstract
Background: The problem of low oral health literacy (OHL) is often neglected which may lead to poor oral health outcomes and underutilization
of oral care services. Objectives: The aim of this study was to determine the influence of OHL on the oral health status of school teachers in
Mangalore, Karnataka. Materials and Methods: A cross‑sectional survey of 260 school teachers presently working in schools at Mangalore
was undertaken. Details regarding demographics, medical, and dental history, oral hygiene practices and habits, diet history, and decay
promoting the potential of school teachers were obtained using face‑to‑face interview method. The Rapid Estimate of Adult Literacy in
Dentistry‑99 (REALD‑99) was used to assess their OHL. An oral examination was conducted following the administration of the questionnaire
at the school campus using the WHO Oral Health Assessment Form‑1997. Results: The mean age of the study population was 39 ± 10.42 years.
The OHL was high in the school teachers with the REALD‑99 scores ranging from 45 to 95 with a mean score of 75.83 ± 9.94. There was
a positive correlation between the OHL and filled teeth (FT) (r = 0.195, n = 260, P = 0.002). This study found that there was a statistically
significant difference between OHL and education (F [3,256] = 9.62, P < 0.001), frequency of brushing (t[258] = −2.253, P = 0.025), and the
FT (t[258] = −3.200, P = 0.002). Conclusions: Although this study indicated high OHL levels among school teachers in Mangalore, Karnataka,
the magnitude of dental caries in this population was also relatively high and very few had a healthy periodontium.

Keywords: Health promotion, oral health literacy, questionnaires, school teachers

Introduction Health promotion and disease prevention approach is the

most effective way to attain good oral health, and oral health
Low health literacy has been described as “the silent health
literacy (OHL) should be seen in this context. OHL is defined
epidemic,” where there is limited ability to negotiate complex
as “the degree to which individuals have the capacity to
healthcare systems and understand health information.[1] A health
obtain, process, and understand basic oral health information
literate person should be able to comprehend directions on
and services needed to make appropriate health decisions.”[9]
prescription drug bottles, appointment cards, health brochures,
Low literacy skills are likely to impact oral health disparities,
doctor’s directions, and consent forms.[2] Health literacy is defined
which are potential hurdles in attaining better oral health
by the WHO (1998) as: “The cognitive and social skills which
outcomes.[10] An increasing body of evidence explains how
determine the motivation and ability of individuals to gain access
low OHL is associated with poor oral health outcomes such
to, understand, and use information in ways which promote and
as dental neglect, irregular dental attendance, and worse oral
maintain good health.”[3] Underutilization of healthcare services
health status.[10‑12] In 2007, Richman et al. developed and
is common in persons with low health literacy skills, who often
evaluated a 99‑item questionnaire called the Rapid Estimate
have a higher rate of hospitalizations, high emergency room use,
and ultimately poorer health outcomes.[4‑6] Health literacy plays
the role of a moderator between socioeconomic factors, such as Address for correspondence: Dr. Ashwini Rao,
Department of Public Health Dentistry, Manipal College of Dental
race and education, health behaviors and health outcomes, partly Sciences, Manipal Academy of Higher Education, Light House Hill Road,
explaining health disparities.[7,8] Mangalore ‑ 575 001, Karnataka, India.
E‑mail: ashwini.rao@manipal.edu

Received: 02-02-2018  Accepted: 3-04-2018

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DOI: How to cite this article: Simon AK, Rao A, Rajesh G, Shenoy R, Pai MB.
10.4103/jiaphd.jiaphd_40_18 Influence of oral health literacy on the oral health status of school teachers
in Mangalore, India. J Indian Assoc Public Health Dent 2018;16:127-32.

© 2018 Journal of Indian Association of Public Health Dentistry | Published by Wolters Kluwer ‑ Medknow 127
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Simon, et al.: Oral health literacy and oral health status of school teachers
of Adult Literacy in Dentistry‑99 (REALD‑99) which by the
authors’ own admission is simple and easy to carry out and
score, and requires minimal training since lengthy evaluation
tools are not practical in clinical practice.[13]
The goals of any OHL strategy would be to reduce oral health
disparities and to reduce the barriers to dental care. Even though
literature linking literacy to general health continues to grow, very
few studies have examined the role of literacy on dental outcomes,
and none has measured dental health literacy, especially among
school teachers. School teachers own perceptions about health
and their feeling about their own competency in health‑related
matters may affect the school going children.[14] The fact that
school teachers are among the most important influences in the
lives of school‑aged children and that they can also influence
their oral health decisions cannot be denied.[15] Thus, this study
was contemplated to determine the influence of OHL on the oral
health status of school teachers in Mangalore city in the Indian
state of Karnataka.
Materials and Methods
School teachers, teaching in schools of Mangalore city during
the study (October 2012–January 2013) were part of this
cross‑sectional study.
Ethical clearance
Data collection was started after obtaining the approval from
the Institutional Ethics Committee (MCODS/198/2012)
and was completed over a period of
4 months (October 2012–January 2013).
Sampling methodology
Records obtained from the Block Education Office, Mangalore
City, listed 170 city schools. Based on the pilot study, the mean
REALD scores were 71.8, and the standard deviation was
8.02, considering 10% permissible error at 95% confidence
interval, the minimum sample size was estimated to be 247.
Table of random numbers was employed to select the schools,
and the final sample consisted of 260 respondents from 22
schools.
Calibration of the examiner
Before conducting the survey, calibration was done to
establish intraexaminer reliability for WHO Oral Health
Assessment Form‑1997 and the REALD‑99 scores.
Pronunciations from the Dorland’s Illustrated Medical
Dictionary[16] and Oxford Advanced Learner’s Dictionary[17]
were taken as the standard for calibration of REALD‑99
scores. The assessment of intraexaminer reliability
using the Kappa statistic showed there was almost total
agreement (κ = 0.99 and κ = 0.94). The REALD‑99
instrument is a prevalidated instrument for measuring
OHL. However, the investigators checked the 99 items
in the instrument for face and content validity by expert
evaluation and group discussions among the investigators
and few schoolteachers and were found to be valid.
128 Journal of Indian Association of Public Health Dentistry  ¦  Volume 16  ¦  Issue 2  ¦  April-June 2018
Organizing the survey
The initial visit was made by the principal investigator
to meet the Principal/School Incharge to explain about
the study and to obtain permission. One day before the
designated day of interview and examination, a reminder
was sent to the selected school through the telephone. On the
allocated day, after introduction to the principal investigator,
eligible school teachers were asked to participate in the
survey in a designated area within the school premises. All
the subjects were provided with a patient information sheet
explaining the survey procedure, and a written informed
consent was obtained from them before the examination.
A minimum of three visits were made to include all the
willing teachers from that school. In case of teachers absent
even on the third visit to the school, he/she was excluded
from the study.
Information collected and methods used
The principal investigator collected the data from the
respondents’ using a questionnaire, REALD‑99 instrument
and by conducting an oral examination.
The questionnaire
Face‑to‑face, interview method was employed to obtain
demographic details, medical history, dental history, oral
hygiene practices, habits, diet history, and decay promoting
potential.
Rapid estimate of adult literacy in dentistry
Respondents’ read the REALD‑99 instrument aloud and the
principal investigator scored them based on pronunciation.
Respondents were advised to only read those words for which
they believe they knew the correct pronunciation. A single
investigator carried out the REALD‑99 assessment. In
calculating overall scores for REALD‑99, correct pronunciation
was assigned one point and summed. REALD‑99 scores have
a possible range of 0 (low literacy) to 99 (high literacy).[13]
WHO basic oral health assessment form
The format was reproduced from the “Oral Health
Survey – Basic Methods 4 th Edition” and was printed.
Clinical examination was done using natural light with the
subject sitting on a chair. A trained recorder accompanied the
investigator to help in recording the data.[18]
Statistical analysis
The data were coded and analyzed using the Statistical Package
for the Social Sciences (SPSS, version 16.0; SPSS Inc.,
Chicago, IL, USA). One‑way analysis of variance (ANOVA),
Student’s t‑test (two‑tailed, independent) and the Pearson
product‑moment correlation coefficient were used for analysis
of collected data. The level of statistical significance was kept
at P < 0.05.
Results
The mean age of the study population was 39 ± 10.42 years.
Table 1 gives the sociodemographic characteristics of the
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Simon, et al.: Oral health literacy and oral health status of school teachers

Table 1: Rapid Estimate of Adult Literacy in Dentistry‑99 Table 2: Rapid Estimate of Adult Literacy in Dentistry‑99
scores and its relation to sociodemographic scores and its relation to personal habits and dietary
characteristics among study participants characteristics among study participants
Characteristic Participants REALD‑99 score P Characteristic Participants, REALD‑99 score P
(n=260), n (%) (mean±SD) n (%) (mean±SD)
Age quartiles Diet
(years) Vegetarian 53 (20.4) 77.42±8.34 0.143
21-30 61 (23.5) 74.36±10.54 0.138 Mixed 207 (79.6) 75.42±10.28
31-40 81 (31.1) 76.70±10.77 Frequency of tooth
41-50 71 (27.3) 77.38±8.86 brushing
51-60 47 (18.1) 73.87±8.83 Once 47 (18.1) 72.89±10.75 0.025*
Gender Twice or more 213 (81.9) 76.47±9.65
Male 33 (12.7) 73.76±8.65 0.201 Brushing method
Female 227 (887.3) 76.13±10.09 Horizontal 56 (21.5) 74.88±9.30 0.702
Income per Vertical 50 (19.2) 76.38±9.32
month (INR) Combination 154 (59.3) 75.99±10.38
0-10,000 91 (35.0) 74.07±9.10 0.156 Frequency of
10,001-20,000 110 (42.3) 76.95±10.96 changing toothbrush
20,001-30,000 34 (13.1) 77.38±8.31 Within 3 months 136 (52.3) 75.02±10.60 0.172
30,001 and above 25 (9.6) 75.16±9.65 >3 months 124 (47.7) 76.71±9.12
Teaching Other oral hygiene
experience (years) aids used
1-15 164 (63.0) 76.04±10.07 0.747 None used 236 (90.7) 75.67±10.01 0.308
16-30 80 (30.8) 75.74±8.37 Dental floss 3 (1.2) 85.00±3.00
31 and above 16 (6.2) 74.06±9.78 Mouthwash 10 (3.8) 78.50±10.16
Education Tongue cleaner 11 (4.3) 74.27±8.41
High school 40 (15.4) 69.78±9.15 <0.001* ANOVA, Student’s t‑test. *Significant. REALD‑99 – Rapid
Diploma 17 (6.5) 70.47±14.90 Estimate of Adult Literacy in Dentistry‑99, SD – Standard deviation,
Graduate 143 (55.0) 77.91±8.82 ANOVA – Analysis of variance
Postgraduate 60 (23.1) 76.42±9.30
ANOVA, Student’s t‑test. *Significant. ANOVA – Analysis of variance, prosthetic need in the upper and lower arch was 19.8% and
REALD‑99 – Rapid Estimate of Adult Literacy in Dentistry‑99, 28.9%, respectively.
SD – Standard deviation, INR – Indian rupees
The OHL was high in the school teachers with the REALD‑99
respondents. Among the respondents, about 15.4% had never scores ranging from 45 to 95 with a mean score of 75.83 ± 9.94.
had a dental visit. All the respondents used toothbrush and The REALD‑99 scores were distributed almost evenly between
toothpaste for cleaning of teeth, but 90.7% of the population different age groups, gender, income groups and according to
did not use any other oral hygiene aids [Table 2]. teaching experience. A Pearson product‑moment correlation
coefficient was computed to assess the relationship between
The dental caries experience of the respondents was calculated
the OHL levels and DMFT and caries experience. There was
from the dentition status of the WHO Oral Health Assessment
a statistically significant positive correlation only between the
Form. The mean decayed, missing, filled teeth  (DMFT)
OHL and FT (r = 0.195, n = 260, P = 0.002) [Table 4].
among school teachers were 6.18 ± 4.35. The mean number
of DMFT observed in this population were 2.84 ± 2.50, Among the sociodemographic characteristics, there
0.95 ± 1.61, and 2.37 ± 3.44, respectively. The caries was a statistically significant difference between
prevalence in this population was 79.2%. The prevalence OHL and education as determined by one‑way
of root caries was 11.5% (30). The periodontal status of the ANOVA (F [3,256] = 9.62, P < 0.001). A Tukey post hoc
school teachers was recorded using Community Periodontal test revealed that the high OHL levels were statistically
Index (CPI) and loss of attachment (LOA) scores. The significant in graduates (77.91 ± 8.82, P < 0.001) and
analysis showed that Code 2 was the highest score for CPI, postgraduates (76.42 ± 9.30, P = 0.004) compared to high
which indicated that majority (60.1%) of the school teachers school group (69.78 ± 9.15) and also high OHL levels were
had calculus deposits and with 20.7% of the school teachers statistically significant in graduates (77.91 ± 8.82, P < 0.01)
presenting with the pocket formation. Bleeding on probing and postgraduates (76.42 ± 9.30, P = 0.03) compared to
was a finding among 8.8% of the school teachers [Table 3]. diploma group (70.47 ± 14.90). There were no statistically
Out of the 260 school teachers, about 1.9% had questionable significant difference between the high school and diploma
fluorosis, 5.4% had very mild fluorosis, 3.1% had mild, 1.2% groups (P = 0.994) and between graduate and postgraduate
had moderate fluorosis, and 1.2% had severe fluorosis. The groups (P = 0.736) [Table 5].

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Simon, et al.: Oral health literacy and oral health status of school teachers

Table 3: Rapid Estimate of Adult Literacy in Dentistry‑99 Table 4: Correlation of Rapid Estimate of Adult Literacy
scores and its relation to dental characteristics among in Dentistry‑99 scores with dental caries experience
study participants REALD‑99 scores DT MT FT Caries
Characteristic Participants, REALD‑99 score Test experience DMFT
n (%) (mean±SD) score Pearson correlation −0.071 −0.024 0.195* −0.044
OHL Significance 0.254 0.699 0.002* 0.482
REALD‑99 score 260 (100.0) 75.83±9.94 Nil (two‑tailed)
Visit to dentist *Significant. REALD‑99 – Rapid Estimate of Adult Literacy in
Dentistry‑99, DMFT – Decayed, missing, and filled teeth, FT – Filled
Never 40 (15.4) 74.08±10.66 0.226
teeth, MT – Missing teeth, DT – Decayed teeth
Yes 220 (84.6) 76.15±9.79
DT
Absent 54 (20.8) 77.20±8.81 0.254
to examine the association between OHL and the overall oral
Present 206 (79.2) 75.47±10.20
health status in school teachers using REALD‑99. Since the
MT participants were not recruited from a clinical environment,
Absent 149 (57.3) 76.03±9.42 0.699 selection bias was avoided which is a unique asset of this study.
Present 111 (42.7) 75.55±10.63 Although recent studies have highlighted the importance of
FT OHL, they have focused mainly on the self‑reported oral health
Absent 120 (46.2) 73.73±10.28 0.002* status which may not represent the actual status.[10,12,19,20] High
Present 140 (53.8) 77.62±9.30 prevalence of dental caries (79.2%) was noted in this study
Caries experience population that was higher than the caries levels (50%–60%)
(DMFT) reported for India by Shah.[21] The mean DMFT levels for this
No caries 17 (6.5) 77.47±7.50 0.482 population was 6.18 ± 4.35 which was higher than the DMFT
experience
values 5.7 ± 4.7 as reported by Patro et al.[22] for an urban Indian
Caries experience 243 (93.5) 75.71±10.09
CPI
population. A total of 89.6% of the study subjects in this study
Score 0 27 (10.4) 78.85±9.51 0.144 had one or the other periodontal diseases, these figures were
Score 1 23 (8.8) 76.48±12.54 comparable to the results of the study done by Singh et al. in
Score 2 156 (60.1) 76.15±9.86 Ludhiana, India.[23]
Score 3 44 (16.9) 73.25±9.09 In chronic diseases such as dental caries and periodontal
Score 4 10 (3.8) 72.50±7.20
diseases, the patient compliance and comprehension play a role
Loss of attachment
in the successful long‑term maintenance of good oral health.[24‑26]
Score 0 200 (76.9) 76.22±9.70 0.331
A surprising finding from this study was that dental visit,
Score 1 40 (15.4) 74.88±10.49
Score 2 18 (6.9) 74.89±11.24
caries experience (DMFT) and periodontal status (CPI scores
Score 3 2 (0.8) 64.50±7.77
and LOA scores) were not found to be associated with OHL
ANOVA, Student’s t‑test. *Significant. OHL – Oral health literacy, despite the fact that these factors were predictors of dental
REALD‑99 – Rapid Estimate of Adult Literacy in Dentistry‑99, caries and periodontal disease in other populations.[24‑26] All the
SD – Standard deviation, CPI – Community Periodontal Index, participants reported brushing with toothpaste and toothbrush,
DMFT – Decayed, missing, and filled teeth, FT – Filled teeth,
MT – Missing teeth, DT – Decayed teeth
with the majority of the population brushing twice or more
daily (81.9%). This suggests previous education regarding
plaque control from multiple sources which may have led to
Among the oral hygiene practices, a statistically significant
increased OHL levels among the study population.
difference was found between OHL and the frequency
of tooth brushing as determined by an independent Results from this study reveal that the REALD‑99 scores ranged
t‑test (t[258] = −2.253, P = 0.025). No statistically significant from 45 to 95. A study by Jones et al. found almost one‑third of
difference was found in an independent t‑test used to compare the subjects had low OHL (REALD‑30 score <22) and reported a
the effect of diet (t [96.64] = 1.477, P = 0.143] and frequency mean score of 23.9 (standard deviation [SD] = 1.3).[10] Lee et al.
of changing toothbrush (t [96.64] = 1.477, P = 0.143) on OHL reported a mean score of 19.8 (SD = 6.4) using REALD‑30.[11]
levels [Table 2]. Among the oral health findings, a statistically Miller et al. reported a mean score of 20.7 (SD = 5.5).[19] D’Cruz
significant difference was also found between OHL and the and Shankar Aradhya reported that about 60.4% of the adult
FT as determined by an independent t‑test (t[258] = −3.200, patients seeking oral health care in a private dental hospital in
P = 0.002) [Table 3]. India had low health literacy level.[27]
High level of OHL (mean REALD‑99 score = 75.83) among
Discussion participants in the current study was significantly associated
The present study was an attempt to assess the influence of with the education level. The discrepancy of low OHL in
OHL on the oral health status of school teachers in Mangalore, previous studies versus the current study may be due to the
Karnataka. To the best of our knowledge, this was the first study very high level of education among the school teachers. The

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Simon, et al.: Oral health literacy and oral health status of school teachers
Table 5: Tukey post hoc test for comparison between
Rapid Estimate of Adult Literacy in Dentistry‑99 scores
and education
Education SE
High school
Diploma 2.744
Graduate 1.695
Postgraduate 1.935
Diploma
Graduate 2.431
Postgraduate 2.604
Graduate
Postgraduate 1.458
*Significant, SE – Standard error
REALD 99 score was significantly associated with the FT
component of DMFT. Interestingly, there was also a positive
correlation between REALD 99 scores and FT component of
DMFT, which may be considered as a proxy to a dental visit,
although it was surprising that the dental visit component per se
did not show any association with the REALD 99 scores. This
may be explained by the fact that persons who required fillings
may have had multiple appointments within a short time frame
that might have given the opportunity to learn about oral health.
This study found an association between OHL and frequency
of tooth brushing which may be attributed to the fact that
those respondents are more concerned with their oral health.
A minimal number of studies of respondents seeking care have
been the basis for research in OHL, but the present study was
community‑based. The results of this study provide insights
into the dimension of OHL in relation to sociodemographic
characteristics, personal habits, dietary practices and dental
utilization patterns. With this data, interventions can be
targeted to those being at risk for low OHL and health‑related
knowledge, behaviors and practices can also be studied.
Limitations
The cross‑sectional study design was employed, and therefore
no casual inferences can be made. Next, the REALD‑99
instrument has been validated in English only, so our study
population was limited to school teachers from English medium
schools of Mangalore, Karnataka, who may have limited
generalizability to school teachers in non‑English medium
schools, but this population is crucial to examine. It should be
noted that REALD‑99 is a reading recognition test and was
intended only as a screening tool for basic OHL, which has
some disadvantages. Another limitation of a word recognition
test such as the REALD‑99 is mispronunciation by the Indian
population who are nonnative speakers embracing many
different languages and dialects, and each of which brings
different problems to English pronunciation. In addition, an
objective test of fluency in the English language was not used.
Future research
The primary area will be an attempt to establish cutoff points
for REALD‑99 to determine the clinical relevance of score
Journal of Indian Association of Public Health Dentistry  ¦  Volume 16  ¦  Issue 2  ¦  April-June 2018
differences. Future studies can include patients in the different
background including community health centers with more
diversified educational levels. The effectiveness of various
methods of communication aimed at increasing a subject’s
P OHL can be undertaken. Studies to develop interventions for
improving OHL and to establish a causal relationship to oral
0.994 health status. In addition, studies should examine approaches
<0.001* that can help people to overcome barriers to health literacy.
0.004*
Recommendations
<0.01* Low OHL when recognized can alert dental care providers, so
0.03* that focussed efforts can be taken to improve communication
with such patients. The patient’s literacy level appropriate
0.736 interventions may be effective in patient compliance in
dental programs. The threat of low health literacy should
be acknowledged in all surveys because of the participant’s
difficulty in reading and comprehending informed consent
forms and survey questions. Oral health informational tools
comprising commonly used terminologies can improve
population OHL levels.
Conclusions
Although this study indicated high OHL levels among school
teachers in Mangalore city, the magnitude of dental caries in
this population was also relatively high, and very few had a
healthy periodontium. The influence of OHL was associated
with and limited to education, the frequency of brushing and
the number of FT among the school teachers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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