The 4th Chinese National Oral Health Survey showed that people's oral health knowledge and attitudes had been greatly improved, but caries and periodontal diseases remained serious problems, and people's OHB was far from standard. OHE focused on behaviour for undergraduates, with the aim of helping them improve themselves and indirectly helping children and elderly people, might be an efficient way of addressing this issue.
A previous study showed that the oral healthcare knowledge and behaviour of dental students were better than those of non-dental students [34]. For dental students at Sichuan University, they underwent oral health education starting in their first year. Some clinical research or practice was open to them, such as the university students' innovation and entrepreneurship training programme. Additionally, some of them had opportunities to get in touch with seniors and obtain additional information. The third year is the first year of professional dental education. Preclinical education and practice can enhance dental students’ knowledge and behaviour of oral health. For non-dental students who had similar general education backgrounds as those of dental students, the difference might come from pre-clinical oral health education. Therefore, we used the dental group as a reference to identify the differences or gaps in OHB between the two groups. Additionally, we explored the role of OHE focused on OHB in both dental and non-dental students by comparing their oral health knowledge and attitudes before and after the course. Regarding the behaviour guidance part of the course, non-dental students experienced the same content and degree of difficulty as did dental students. Although this relatively-professional education was more difficult than usual, it was helpful for non-dental students to understand aetiology-based knowledge and might also be helpful for behavioural education.
Toothbrushing frequency was well known among all the students. However, half of the non-dental students did not meet the recommended brushing time of two minutes. Additionally, non-dental students faced difficulty in selecting a tooth brushing method. The (modified) Bass method, Roll method, Fones method and horizontal method are the most widely used brushing methods [35]. A study has shown that the (modified) Bass technique is effective in controlling dental plaque and alleviating gingival inflammation [36]. The horizontal method, which could result in wedge-shaped defects, is not recommended. However, it is a common method used in China. In this survey, less than one-fifth of the non-dental students used the Bass method, but more than two-fifths of them used incorrect methods. From these results, we concluded that although non-dental students had good brushing frequency, their brushing time and actual brushing methods may not be appropriate.
Interproximal cleaning was extremely overlooked by both dental and non-dental students. It was surprising that few dental students floss daily. The findings revealed signs of ignorance concerning interproximal cleaning in China. Using floss in addition to toothbrushing may reduce gingivitis, plaque, or both, more than toothbrushing alone [37]. However, floss is comparably difficult to use, which may limit its application [38]. Moreover, toothpicks have a history of more than a thousand years in China and are deeply rooted in Chinese people’s minds [39]. Toothpicks are quite popular in China and can easily be found in restaurants and take-away cutlery. Interestingly, the tendency to use toothpicks increased among non-dental students after the course. OHE on avoiding the use of toothpicks should be strengthened to minimize the periodontal damage caused by improper use.
Function and price were the most important considerations when students chose toothbrushes. A study confirmed that electric toothbrushes were more effective than manual toothbrushes [40]. Before the course, more than half of the students in both groups thought electric toothbrushes were better than manual toothbrushes. However, the actual use rate was much lower, especially in the non-dental group. Furthermore, nationwide usage was much lower. A report showed that the penetration rate of electric toothbrushes in China was only 5%, while in some developed countries, it was more than 15% and even up to 40% [41]. Price might be a possible reason for this result. After the introduction of electric toothbrushes during the course, more students realized their advantages and intended to use them, even at a higher price. If electric toothbrushes are not popular because of their high price, then we should strengthen OHE on the use of manual toothbrushes instead of emphasizing the use of electric toothbrushes.
When choosing toothpaste, function and price were the first two considerations. Interestingly, more non-dental students than dental students were willing to use Chinese herbal toothpaste before and after the course. As a part of traditional Chinese medicine, Chinese herbal toothpaste may have some effects in alleviating gingival inflammation [42] and preventing caries [43]. Chinese have partiality for Chinese herbal toothpaste. Its correct usage should be addressed in future OHE courses; for example, when facing gingival bleeding caused by periodontitis, relying on herbal toothpaste instead of scaling may worsen the disease.
One issue that cannot be ignored is that some students cared about popularity when choosing toothpaste and toothbrush. This suggests a new method of OHE: new media. Recently, a large number of popular media platforms have emerged. WeChat, an interactive social media platform in China, has a wide range of young users and is used every day [44]. A study showed that the passive acquisition (moments, public accounts, and group chat) of health information through WeChat is an important medium for college students [45]. Taobao, a large online shopping platform, is preferred by young people and carries many traditional and emerging oral care products endorsed by celebrities, which is very attractive to young people who are starstruck and pursuing popularity. At the same time, it contains a wealth of pictures, videos and instructions for the products. In addition to traditional classes, WeChat groups, WeChat public accounts and Moments can be used for regular OHE as a reminder to floss and as an update to new knowledge that is not included in textbooks. Taobao links can provide vivid information about oral hygiene products, making OHE much more convenient and cost-effective.
Overall, the majority of students realized their shortcomings in OHB and had a strong willingness to improve. Our OHE course focused on behaviour and had a positive effect on university students. Dental students had much better performance than non-dental students in terms of toothbrushing frequency, method, and time and floss use. This suggests that dental students know more details about oral healthcare. Future OHE should pay more attention to flossing, toothbrushing methods, toothpicks, Chinese herb toothpaste and modifications to adopt new media.
Limitations
As a quasi-experimental study, the grades and sample numbers of dental and non-dental students were different. The post-course survey was conducted within a short period of time. The long-term change in students' knowledge, attitudes and behaviours is unknown. Furthermore, our survey did not include clinical examinations.