Prevalence of Acute Tonsillitis and Its Association With Oral Hygiene Among the Population of Taif City, Saudi Arabia

Introduction Dental surfaces have dense bacterial deposits, and poor oral hygiene can exacerbate bacterial infections, causing acute tonsillitis. The study aims to quantify acute tonsillitis prevalence and assess its association with oral hygiene practices. Methods A descriptive cross-sectional study aimed to assess the prevalence of acute tonsillitis and its association with oral hygiene was conducted among adults aged 20 and above in Taif City, Saudi Arabia. Illiterates and those unwilling to participate were excluded. We employed an Arabic online self-administered questionnaire that was disseminated conveniently via Google Forms to social media assessing oral hygiene such as last dental visit, age at starting dental care, number of toothbrushes per day, frequency of toothbrush change, and duration of brushing teeth, and acute tonsillitis characteristics of the participants. Results About 393 participated in the study. Of them, 54% were aged 20-30, 53% were males, and 70% had a university education. The prevalence of acute tonsillitis was 64%. Approximately 28% reported dental clinic visits within three months, and 21% initiated oral hygiene practices at age 20. Among participants, 43% brushed twice daily, with 33% spending one minute and 43% two minutes. About 31% replaced toothbrushes every three months, while 23% acknowledged having bad breath. Experiencing bad breath, changing toothbrushes every three months, and having dental visits within less than three months were associated with having acute tonsillitis (p<0.05). However, regression analysis revealed that experiencing bad breath (OR: 2.11, 95% CI: 1.23, 3.70) was associated with a higher risk of acute tonsillitis, while less frequent toothbrush changes correlated with a lower risk (OR: 0.54, 95% CI: 0.30, 0.94). Conclusion This study revealed a substantial prevalence of acute tonsillitis among adults in Taif City. Oral care practices need improvement. There are significant associations between oral hygiene practices, bad breath, and the occurrence of acute tonsillitis. Addressing oral hygiene practices could be a key focus for preventative measures.


Introduction
Tonsils at the upper aerodigestive tract serve as mucosa-associated lymphoid tissues, playing a crucial role in defending against numerous airborne and dietary pathogens by primarily engaging in humoral immune responses [1][2][3].Tonsillitis, an inflammation of the tonsils, is mainly attributed to viral or bacterial infections, with viruses being the predominant cause [4].
Although there is not enough data on the global incidence of tonsillitis [5], in primary care, sore throat makes up 1.3% of outpatient visits [6].
Chronic tonsillitis (CT) is a long-term infection that occurs as a result of several repeated episodes of acute tonsillitis or as a result of a persistent infection that leads to chronic inflammation that is long-lasting and slowly progressing [7].Acute tonsillitis is characterized by visible streaks of pus or cheesy material on the tonsillar surface, and the entire tonsil may become enlarged and hyperemic, suggesting an inflammatory process [8].
Dental surfaces, characterized by dense bacterial deposits and non-shedding plaque or calculus, signify poor oral hygiene linked to caries, gingivitis, and periodontitis [10].Poor oral hygiene is associated with internal and external disorders in the oral and oropharyngeal cavities [11].Tonsillar actinomycosis, reported by Priyadharshini et al., suggests a potential link between dental plaque-related infections and tonsil issues [12][13][14].
Oral hygiene significantly prevents infections.Regular practices, including brushing and flossing, reduce bacterial load in the oral cavity.This directly relates to acute tonsillitis, where poor oral hygiene can exacerbate bacterial infections, impacting the frequency and severity of cases.Our study aims to quantify acute tonsillitis prevalence and assess its association with oral hygiene practices among adults in Taif City, Saudi Arabia.Through this exploration, we aim to provide insights into healthcare strategies tailored to this demographic, highlighting the critical role of oral hygiene in preventing acute tonsillitis.

Study design, population, and setting
A descriptive cross-sectional study aimed to determine the prevalence of acute tonsillitis and its correlation with mouth hygiene was conducted in Taif City.It is a city in the Makkah Region of Saudi Arabia.It is located at an elevation of 1,879 m on the slopes of the Hijaz Mountains.Taif City has a hot desert climate with hot summers and mild winters.
The study included adults aged 20 years and above who lived in Taif City during the data collection period, regardless of gender and nationality, excluding illiterates and those who didn't have smartphones due to the online nature of the questionnaire and who refused to be involved in the study.The sample size was calculated using the Raosoft sample size calculator.Considering a margin of error of 5%, an expected proportion of 50%, a 95% confidence interval, and a total population of 913,374 according to the 2022 Census [15], the minimum required sample size was 384.

Data collection
The data was collected using an online self-administered questionnaire designed according to study objectives and relative literature and validated by a pilot study after a thorough revision of a dentist and family medicine specialists.The questionnaire was disseminated conveniently via Google Forms to social media platforms, including only Taif City residents.
The questionnaire contains three sections: the first includes demographic characteristics such as gender, age, marital status, nationality, and educational level.The second one assesses the oral hygiene of the participants, including last dental visit, age at starting dental care, number of toothbrushes per day, the use of mouthwash, frequency of dental floss use, frequency of toothbrush change, and duration of brushing teeth.The third section identifies acute tonsillitis characteristics such as history of acute tonsillitis, frequency of acute tonsillitis at age 20 years or above, antibiotic prescriptions, throat culture, fever with acute tonsillitis, swallowing difficulty, and the effect of acute tonsillitis on daily activity.The data was collected between June and August 2023.

Data analysis
Data was analyzed using the R statistics (R Foundation for Statistical Computing, Vienna, Austria).Means and standard deviations were calculated for numerical data, while frequencies and percentages were used to present categorical data.Fisher's exact and Pearson's chi-squared tests assessed the association between acute tonsillitis and oral hygiene.In contrast, multiple logistic regression with a backward selection method was used to identify if oral hygiene was a determinant of acute tonsillitis.A p-value less than 0.05 was set as the significance level of the study.

Ethical consideration
Ethical approval was obtained from Taif University, which is accredited by the National Committee for Bioethics (HAO-02-T-105) with application no.44-298.

Characteristic N (%) 1
Does taking care of oral hygiene prevent some diseases?Experiencing bad breath was associated with having acute tonsillitis; however, changing toothbrushes every three months and having dental visits within less than three months was associated with having acute tonsillitis (p<0.05)(Table 3).Among the 250 participants with acute tonsillitis, 13 participants (5.2%) reported never having acute tonsillitis when they were over 20 years, while 49 (19.6%)experienced it twice, 11 (4.4%) three times, and 96 (38.4%) more than three times.When seeking a medical diagnosis for acute tonsillitis, 99 participants (40%) visit a doctor each time.Of those diagnosed, 198 (79%) received antibiotic treatment, with 42 (21%) receiving it once, 58 (29%) twice, and 39 (19%) three times.Thirty-eight (15%) had a throat swab taken among those diagnosed with acute tonsillitis.A significant majority, 87%, experienced fever during acute tonsillitis, and 238 (95%) had difficulty swallowing.Regarding the impact on daily life, 41 (16%) reported not missing any work/school days, 84 (34%) missed three days or less, and 41 (16%) missed more than three days (Table 4).

Characteristic N (%) 1
How many times have you had acute tonsillitis when you were over 20   Approximately 64% of the participants had or experienced acute tonsillitis (Figure 1).

FIGURE 1: Prevalence of acute tonsillitis
Most participants (67.9%) recognize the immunologic function of tonsils.However, 15% needed to recognize its role (Figure 2).

Discussion
This cross-sectional study aimed to assess the prevalence of acute tonsillitis and the relationship between acute tonsillitis and oral hygiene among the population in Taif City.Males represent about 53% of our study participants, and the majority were in the age group 20-30 years (54%).Ninety percent were Saudi and 70% had a university level of education.
The frequency of acute tonsillitis reported by our participants is about 64%; about 38% reported experiencing acute tonsillitis more than three times.A study by Hidaya et al. among the Saudi pediatric population found that the incidence of acute tonsillitis was higher among the age group 6-12 years (69%), followed by 13-18 years (18%), and finally the age group 4-5 years (17%).The occurrence of tonsillitis was found to vary according to socioeconomic status, where the incidence decreases with increasing economic status.The incidence of tonsillitis in the low-income group was 66%, the middle-income group was 34%, and 7% among the high-income group [16].A retrospective study that investigated the incidence of tonsillitis in the Al-Baha region, Saudi Arabia, reported that the incidence is more observed among males (60%) than females (40%).The most commonly isolated organisms were GAS infections, group A betahemolytic Streptococci (Streptococcus pyogenes) [17].
A prospective study in Saudi Arabia surveying children with acute tonsillitis with throat swabs found evidence of GAS infection in about 40% of participants, and less than 50% were sensitive to penicillin [18].Nevertheless, a review article reported the pooled prevalence of 37% of GAS infection among children.It was observed that GAS infection and carriage among under-five children was less than that among older children, with a pooled prevalence of 24% among those under five [19].
In a retrospective study in Libya, the prevalence of tonsillitis among patients who came with a sore throat to otolaryngology clinics was found to be 34%, and the majority of tonsillitis patients were females (65%), from the age group 15-45 years (48%) [20].
Regarding oral hygiene practices by our participants, 95% believed that taking care of oral hygiene can prevent some diseases.The majority (43%) reported brushing their teeth twice per day.The majority (38%) didn't use mouthwash, and 44% didn't use dental floss.Most of our participants (43%) take about 2 minutes to brush their teeth.A review article concluded that there is a relationship between oral hygiene and CT [21].A case-control study conducted in Iraq found a strong positive correlation (p < 0.001) between dental caries and CT in children [22].
The majority of our study participants (79%) indicated that they were treated with antibiotics when diagnosed with acute tonsillitis, and 20% had antibiotics prescribed more than five times.Nevertheless, more than three-quarters (85%) got the diagnosis of acute tonsillitis on a clinical basis with no throat swab taken for the diagnosis.Regarding symptomatology of acute tonsillitis, 87% of our participants experienced febrile episodes, and 95% had difficulty swallowing when they were sick.However, 34% missed about three days of school/work as a consequence of their illness.In the cross-sectional study by Hidaya et al. in Al-Riyadh, fever was reported in 74% of participants.Another symptom observed was odynophagia, which was reported in 33% of the tonsillitis patients [17].The aim of the treatment in tonsillitis cases is to decrease symptoms (pain and fever) and to decrease complications.Thus, the treatment is usually supportive, especially with viral infections.GAS infection could be treated with penicillin; if there is resistance or allergy to penicillin, cephalosporins and macrolides are good alternatives.Corticosteroids are helpful in case of infectious mononucleosis pharyngitis [23,24].However, an interesting meta-analysis article by Mirza et al. found a statistically significant deficiency of vitamin D in patients with recurrent tonsillitis [25].
This study is limited by the pure cross-sectional approach with no involvement of a comparative control group.Yet, the relatively larger sample size could adjust for any potential bias that might be encountered in this study.

Conclusions
In our survey, 64% reported acute tonsillitis prevalence, with most acknowledging the impact of oral hygiene.Despite quick teeth brushing being common, these habits may contribute to the prevalence.Participants who had bad breath were at more risk for developing acute tonsillitis.Reducing the frequency of toothbrush changes was associated with a lower risk of having acute tonsillitis.
Antibiotic treatment was common, especially with 20% prescribed more than five times.Surprisingly, over three-quarters received a clinical diagnosis without a throat swab.Symptomatically, 87% experienced febrile episodes, and 95% had difficulty swallowing.Acute tonsillitis, seemingly simple, led to frequent school and work absences, emphasizing the need for heightened attention and further research in this area.Addressing oral hygiene practices could be a key focus for preventative measures.

TABLE 1 : Demographic characteristics of the participants
1 N (%): number (percentage), and the total number of participants is 393.

TABLE 2 : Participant oral hygiene practice
1 N (%): number (percentage), and the total number of participants is 393.

TABLE 3 : Association between acute tonsillitis and oral hygiene
1Response is expressed as a number (percentage).The participants who had tonsillitis (Yes) = 250.The participants who did not have tonsillitis (No) = 143.2Fisher'sexact test; Pearson's chi-squared test.

TABLE 4 : Characteristics of participants with acute tonsillitis
1 N (%): number (percentage), and the total number of participants is 393.

TABLE 6 : Questionnaire Additional Information
How many times do you brush your teeth per day?Once.☐ Twice.☐ Three times.☐ Never.☐