Assessment of Differences in Oral Health Knowledge, Attitudes, and Behavior Among Preclinical and Clinical Dental Students

Aim To assess and compare differences in oral health knowledge, attitudes, and behavior among preclinical and clinical dental students of Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India. Material and methods A total of 175 students responded to a total of 37 questions regarding their knowledge, attitudes, and behavior regarding dentistry and oral health. The mean percentage scores and standard deviation were calculated to assess the relation between knowledge, attitude, and behavior. Results It was observed that the students in the clinical phase had significantly better knowledge and attitude towards oral health than preclinical undergraduates. There was no significant difference in mean and SD among clinical and preclinical students in behavior while statistically significant differences were observed in their responses to questions related to knowledge (p = 0.000) and attitude (p = 0.007). Female students had better knowledge than male students (p = 0.029). Conclusion Clinical dental students of the institute showed a marginally higher KAP regarding oral health than preclinical students. This might reveal an ineffective transition of the students from the preclinical to the clinical stage. On intergender comparison, the females were better oriented than males towards oral health.


Introduction
Oral health is a fundamental aspect of overall health and well-being, encompassing not only the teeth and gums but also the broader craniofacial complex.It plays a crucial role in one's quality of life, affecting speech, nutrition, and self-esteem [1].Dental professionals bear the responsibility of ensuring that individuals receive adequate oral healthcare, which includes prevention, diagnosis, and treatment of oral diseases [2][3][4][5].Consequently, dental education programs serve as the cornerstone for training future dental practitioners, equipping them with the necessary knowledge, attitudes, and behavior required to provide effective oral healthcare [6,7].
The distinction between preclinical and clinical dental students is pivotal in dental education [8].Preclinical dental students, typically in their first two years of dental school, are primarily engaged in foundational coursework, including the study of oral anatomy, dental materials, and the basic sciences.In contrast, clinical dental students, often in their third and final years and internship, transition to the clinical phase of their education, where they gain hands-on experience treating patients under the supervision of licensed dental faculty.This phase is essential for integrating theoretical knowledge into practical clinical skills and developing attitudes necessary for patient care.Previous studies assessing the difference in attitude and behavior between preclinical and clinical dental students have reported conflicting results, while some studies found better awareness amongst clinical students [9,10], others have reported no difference between them [11,12].
As the demand for dental care continues to rise, it becomes increasingly imperative that dental education programs are not only comprehensive but also attuned to the evolving needs of the healthcare landscape [13].It is within this context that this study aims to assess and compare oral health knowledge, attitudes, and behavior among preclinical and clinical dental students.The assessment of oral health knowledge, attitudes, and behavior among these two distinct groups of dental students is of paramount importance [14].
It provides insights into the efficacy of dental education programs in equipping students with the requisite competencies and values essential for their future roles as oral healthcare providers [14,15].Additionally, understanding the differences and similarities in these aspects between preclinical and clinical dental students can inform curriculum development, teaching strategies, and interventions aimed at improving oral health education [16].
Therefore, this research aims to shed light on the following key question: How do the oral health knowledge, attitude, and practice (KAP) of preclinical dental students compare to that of their clinical counterparts?

Materials And Methods
The present study was conducted among 175 undergraduate dental students of Dental Institute, Rajendra Institute of Medical Sciences, Ranchi after obtaining clearance from the ethics committee vide Memo 47, IEC, RIMS, Ranchi dated 3/6/2020.

Sample size
A purposive sampling technique was employed to select participants.The sample size was determined to be 164, taking into account an 80% confidence interval and a 5% margin of error.However, a total of 175 participants were recruited to account for any attrition.
All 175 participants were invited to participate in this survey comprising 37 questions in English regarding oral health knowledge, behavior, and attitudes.The questions were sourced from previous studies [9][10][11][12].The questionnaire was transformed into an online survey using a web-based survey tool (Google Forms) and the survey link was shared amongst all dental students by their class representatives.A link to the survey was mailed to all students.All the undergraduate students of the institute were included to participate in the study while no exclusion criteria were defined.

Statistical analysis
SPSS statistical software (v.20;SPSS/IBM, Armonk, NY) was used to analyze the data.Since the data had a non-normal distribution according to the Shapiro-Wilk test, non-parametric tests were used.Chi-squared test was used to evaluate variations in responses to each questionnaire item.The Mann-Whitney test was used to compare the mean score of knowledge, attitude, and practice-related items between gender (males and females) and academic level (pre-clinical and clinical).Each correct response was given a score of 1, while erroneous responses were given a value of zero, to create an overall score for the items that tested knowledge, attitude, and behavior (where there were correct answers), giving knowledge-based items a maximum score of 21, attitude-related items a maximum score of 5, and practice-related items a maximum score of 11.A p-value of 0.05 or less was considered statistically significant.

Results
A total of 175 students participated in the survey.A basic demographic detail of the students is depicted in Table 1.The responses of the participants on questions related to knowledge, attitude, and behavior are charted in Tables 2-4 respectively.

TABLE 4: Proportion of participants with acceptable responses to questions on Behavior
There was an insignificant difference in mean and SD among clinical and preclinical students in behavior while we observe statistically significant differences in their responses to questions related to knowledge and attitude.It was observed that the clinical students had superior knowledge and attitude than preclinical undergraduates (Table 5).On intergender comparison (Table 6), it was observed that female students had better knowledge than males while in questions related to attitude and behavior, their responses were almost similar with insignificant statistical differences.

Discussion
The present study was conducted to compare the knowledge, behavior, and attitude among preclinical and clinical undergraduate dental students studying at the Dental Institute, Rajendra Institute of Medical Sciences, Ranchi.Within the limitations of this study, it was observed that there is an insignificant difference between clinical and preclinical students in behavior while we observe statistically significant differences in their responses to questions related to knowledge and attitude.It was observed that the clinical students had superior knowledge and attitude than preclinical undergraduates.Our results are in agreement with the results of studies by Kawamura et al. [17], Tseveenjav et al. [18], and Rong et al. [19].The difference appears to reflect the variation in the student's educational level.
On intergender comparison, it was observed that female students had better knowledge than males while in questions related to attitude and behavior, their responses were almost similar with insignificant statistical differences.Our findings were in agreement with the results of Polychronopoulou et al. [20], who inferred that females had better knowledge while Muthu et al. [21], Ostberg et al. [22], and Fukai et al. [23] found that female dental students had better oral health attitudes and take better care of their teeth than their male colleagues.Tseveenjav et al. [18] reported no differences between male and female students of Mongolia in terms of KAP.Students of clinical batches had better knowledge of plaque control and gingivitis and were more aware of the role of diet in the prevention of dental caries.
Results from our study emphasized the fact that both the clinical and preclinical students realized the importance of dental treatment with almost 98% of them saying that treatment of toothache is as important as treatment of any other body part.While all the preclinical students advocated regular checkups from dentists, only 70.8% of them had information regarding the use of artificial teeth.In comparison, 91.3% of the clinical students said that a lost missing tooth should be replaced by an artificial one.All the participants realized that the use of tobacco and its products was bad for oral and general health similar to the results of the previous study [24].
In the present study, both the preclinical and clinical undergraduate students were adequately oriented toward the importance of maintaining good oral hygiene.The students knew about the importance of regular brushing and maintaining oral hygiene.Almost 86.8% of the preclinical students and 82.6% of clinical students brushed twice a day using toothpaste and brush.Neeraja et al. [25] reported that 74% of the dental students brushed their teeth twice daily.Similarly, a study assessing oral health attitude and behaviour of dental students of four different Asian countries reported that more than 60% of students brushed their teeth twice daily [26].In the present study, a total of 86.8% of preclinical students and 92.8% of clinical students used fluoridated toothpaste while only 75.4% of clinical students used additional aids to maintain oral hygiene.This number was less in preclinical students where only 72.6% of preclinical students used other aids to maintain oral health.Our observations were in agreement with the findings of the previous studies [24,27].The preclinical students were more aware of the importance of tongue cleaning.In our study, almost 98% of the participants used tobacco in some form or the other.Balogh et al. [28] reported that students from other nations like Germany (11.30%), Bangladesh (22%), Holland (24%), Norway (24%), Greece (47%), Serbia (43%), Hungary (34%), France (33%), Italy (33%) and Turkey (26%) had lower smoking rate.Conflicting results from other studies might be attributed to religious, social, and demographic differences.
While the results of the present study offer valuable insight into our understanding of differences in oral health knowledge, attitudes, and behavior among preclinical and clinical dental students it is important to recognize certain limitations.The findings of this study may not be true representative of other dental institutes in the country, and caution should be exercised in extending their applicability to other dental students in India.Future studies should try to address this problem and include multiple institutes and a larger sample size for better external validity.

Conclusions
Within the limitations of the study, it could be concluded that clinical dental students of the institute showed a marginally higher KAP regarding oral health than preclinical students.This might reveal an ineffective transition of the students from the preclinical to the clinical stage.On intergender comparison, the females were better oriented than males towards oral health.
The students need to have adequate knowledge and attitude about oral health so that they can fulfill their role as oral health educators.For a smooth and successful preclinical-clinical transition, a review and modification of the academic curriculum might be warranted.Moreover, counseling students to develop empathy could also help them to be good oral health educators.Clinical assessment of the students might help to explore the status of oral health in both groups.