Influence of Oral Health Related Behavior on Oral Health of Adolescents in Belgrade

Oral and general health status depend on dynamic interplay of many factors including individual’s personal character­ istics, behaviors, and perceptions. Oral health behavior is closely related to oral health outcome, and can be considered important determinant of health. Oral self­care practices based on personal choice are considered an important as­ pect of oral health behavior [1]. Children and adolescents represent the group of special interest for developing ad­ equate oral health related knowledge, attitudes and behav­ ior. Due to dynamic physical and psycho­emotional de­ velopment during adolescence, previously established oral health related habits tend to change whereas new attitudes and behavioral patterns which might increase the risk of oral diseases and are influenced by adolescents’ environ­ ment, peers and informal group are developing. Smoking, unhealthy diet, lack of time or “forgetting’’ to perform oral hygiene and underestimating risk of inadequate health re­ lated behavior negatively affect adolescents’ oral health [2]. To investigate dental health attitudes, perceptions, and behaviors, Kawabuta et al. [3] developed the Hiroshima University – Dental Behavioral Inventory (HU­DBI) ques­ tionnaire. HU­DBI questionnaire consists of twenty ques­ tions primarily associated with tooth­brushing behavior. All questions have a dichotomous response format: Agree/ Disagree. Quantitative estimate of oral health attitude and behavior is provided by the total number of appropriate agree/disagree responses with the maximum score of 12. Higher scores indicate better oral health related attitudes and behavior [4]. The score for each question which relates to oral health attitude and behavior was based on analytical research in which a statistical model was developed [5]. Re­ cently, this questionnaire was used to compare oral health attitudes and behaviors among dental and dental hygiene students [6, 7, 8].Considerable differences were found in dental health attitudes and behavior among students from different countries and cultural groups, as well as among dental students during the course of their dental education. For the purpose of our study, English version of HU­ DBI questionnaire was translated into Serbian language. Three additional questions regarding oral hygiene and smoking habits were included in the final version of our HU­DBI questionnaire. Serbian Dental Journal, vol. 60, N 2, 2013


INTRODUCTION
Oral and general health status depend on dynamic interplay of many factors including individual's personal character istics, behaviors, and perceptions. Oral health behavior is closely related to oral health outcome, and can be considered important determinant of health. Oral selfcare practices based on personal choice are considered an important as pect of oral health behavior [1]. Children and adolescents represent the group of special interest for developing ad equate oral health related knowledge, attitudes and behav ior. Due to dynamic physical and psychoemotional de velopment during adolescence, previously established oral health related habits tend to change whereas new attitudes and behavioral patterns which might increase the risk of oral diseases and are influenced by adolescents' environ ment, peers and informal group are developing. Smoking, unhealthy diet, lack of time or "forgetting'' to perform oral hygiene and underestimating risk of inadequate health re lated behavior negatively affect adolescents' oral health [2].
To investigate dental health attitudes, perceptions, and behaviors, Kawabuta et al. [3] developed the Hiroshima University -Dental Behavioral Inventory (HUDBI) ques tionnaire. HUDBI questionnaire consists of twenty ques tions primarily associated with toothbrushing behavior. All questions have a dichotomous response format: Agree/ Disagree. Quantitative estimate of oral health attitude and behavior is provided by the total number of appropriate agree/disagree responses with the maximum score of 12.
Higher scores indicate better oral health related attitudes and behavior [4]. The score for each question which relates to oral health attitude and behavior was based on analytical research in which a statistical model was developed [5]. Re cently, this questionnaire was used to compare oral health attitudes and behaviors among dental and dental hygiene students [6,7,8].Considerable differences were found in dental health attitudes and behavior among students from different countries and cultural groups, as well as among dental students during the course of their dental education.
For the purpose of our study, English version of HU DBI questionnaire was translated into Serbian language. Three additional questions regarding oral hygiene and smoking habits were included in the final version of our HUDBI questionnaire.
The aim of our study was to investigate epidemiologic relationship between oral health attitudes and behavior measured by the HUDBI questionnaire and dental caries status using the DMFT index in the sample of 15 years old adolescents from Belgrade.

MATERIAL AND METHODS
This cross sectional study included 404 randomly selected high school students (1516 years old) of grade one from 10 randomly selected high schools in different municipalities of Belgrade. Data on oral health related behavior was col lected using modified Serbian version of English HUDBI questionnaire. HUDBI questionnaires were administered by school teachers and students filled in the questionnaires during the classes. For the calculation of the HUDBI ques tionnaire score, one point was given for each agreed re sponse for items 4, 9, 11, 12, 16 and 19, and one point for each disagree response for items 2, 6, 8, 10, 14 and 15. The number of healthy, decayed, filled and missing teeth (DMFT index) and the presence of visual signs of gingival inflammation were recorded after clinical examination performed in classrooms by two previously trained and calibrated dentists.
The SPSS 17.0 (SPSS, Inc., Chicago, IL, USA) was used to analyze data. Simple frequency tables and descriptive statistics (means and standard deviations) were processed and analyzed by chisquare (χ 2 ) and Fisher's exact tests. Differences in the DMFT score and its components in re lation to agree/disagree responses of HUDBI question naire were assessed using independent samples ttest.

RESULTS
HUDBI score ranged from 2 to 11, with the mean of 6.27±0.27. Girls had higher mean HUDBI score (6.28±1.45) compared to boys (6.22±1.45; p<0.05). The DMFT score ranged from 0 to 23 (average 5.84±0.20). There were 35 participants (8.66%) with all healthy teeth (DMFT=0). Less than one third of subjects (119 patients, 29.46%) had none untreated tooth decay at the time of examination (DT=0). Untreated dental caries score was 2.65±0.14 (DT). The F factor, which represented filled teeth, was 2.71±0.14 denoting low dental treatment rate. Dental treatment, calculated by the F/DMF (filled/dis eased teeth) index, was 46.40%, whereas the decay com ponent calculated by the D/DMF index (decayed/diseased teeth) was 45.37% (Table 1). Gingival inflammation (red ness, swelling and/or bleeding from marginal gingiva) was   Table 2. Dental visits at least once a year reported 67.3% of adolescents, more often girls than boys (p<0.05). Bleeding gums were reported in 18.4% of the participants; 65.1% answered that it was not possible to prevent gum disease with tooth brushing only. Majority of subjects (70.7%) reported that they have been thought by a professional how to brush teeth, girls more frequently than boys (p<0.05). Tooth paste was considered necessary for brushing in 91.8% of subjects, more often among girls but with no significant difference. Almost half of the subjects used toothbrush with hard bristles and brushed with hard strokes, girls more often than boys (p<0.05). Emergency dental visits only were reported by 47.1% of adolescents. Majority of subjects reported brushing twice a day or more (86.2%), girls more often than boys (p<0.001), but only 13.4% reported regular flossing and 30.3% daily use of mouth rinses. Nearly one quarter of adolescents (23.3%) reported smoking cigarettes every day.
Agreement with the statement "I go to see the dentist at least ones a year" was associated with significantly lower DMFT (p<0.01) and FT (p<0.05). Agreement with the statement "My gums bleed when I brush my teeth" was related to higher DMFT score, DT and MT components (p<0.05). Association was observed between negative at titude "I think that I cannot help having false teeth when I am old" and high MT component (p<0.05). Subjects who agreed with the statement "I think my teeth are get ting worse despite my daily brushing" had higher DMFT score and higher DT component (p<0.01). Relation was also observed between agreement with the statement "I put off going to the dentist until I have a toothache"and lower FT component. Subjects who reported use of dye to see how clean their teeth are had high DMFT score (p<0.01). Subjects who agreed with the statement "I don't feel I've brushed well unless I brush with strong strokes" had higher DT (p<0.05) and MT component (p<0.01). Subjects who received feedback from their dentist re garding their brushing efficacy had lower DMFT score, DT and MT components (p<0.01). Those who were satis fied with the appearance of their teeth had significantly lower DMFT score, DT, MT and FT components (p<0.01). Subjects who had positive habit to use mouthwashes regu larly had higher DMFT score (p<0.01).
Mother's educational level significantly affected num ber of healthy (F=3.156; p=0.44) and decayed teeth (F=3.021; p=0.05), as well as mean DMFT score (F=3.090; p=0.047). Adolescents whose mothers received only ele mentary education had significantly less healthy and more decayed teeth and higher DMFT score compared to adolescents whose mother were highly educated. Ado lescents whose mothers were less educated rated their oral health as poor or moderate compared to adolescents whose mothers were highly educated (χ 2 =9.45; p=0.051).
Nevertheless, they reported dental visits less than once a year (χ 2 =11.752; p=0.001), more often worried about the color of their teeth (χ 2 =9.58; p=0.003), noticed the presence of white sticky deposits on their teeth (χ 2 =7.54; p=0.012) and less frequently received professional Table 3. Mean DMFT scores and their DT, MT and FT components in relation to the agreement/disagreement to the HU-DBI items Ta be la 3. Pro seč ne vred no sti in dek sa KEP i nje go vih kom po ne na ta (K, E i P) u od no su na od go vo re "Sla žem se/Ne sla žem se" na pi ta nja u upit ni ku HU-DBI feedback regarding their level of oral hygiene (χ 2 =6.74; p=0.018) compared to adolescents whose mothers had high school education or higher. Compared to adolescents whose father's education level was higher than elementary school, adolescents whose fathers had lower education more often worried about the color of their teeth (χ 2 =9.80; p=0.002), more often reported white deposits on their teeth (χ 2 =18.77; p=0.0001) and less frequently rated their oral health as "good" (χ 2 =9.37; p=0.009).

DISCUSSION
Health related behavior forms during the process of so cialization by adopting and developing attitudes, habits, values and beliefs, and learning communication skills. Knowledge, skills and abilities that a person acquires on cognitive and affective levels, under sociocultural and developmental influences of the environment affect an individual's ability to make decisions regarding health related behavior.
In the study of brushing behavior in children from 32 European countries and North America, authors reported that percentage of children who brushed their teeth more than once a day ranged from 16% to 80% among boys and from 26% to 89% among girls, with tendency to increase with child age in some countries, and decrease in other countries [9]. The mentioned study reported strong re lationship between brushing teeth more than once a day and family income and parents' occupation, while the re lationship between behavior and family structure (single parent family) as well as parental control of child's oral hygiene, was inconsistent and relatively weak.
Our research also confirmed that sociodemographic factors, namely parental educational level, affected ado lescents' perceptions and oral health related habits, as well as oral health status of adolescents, in sense that low educational level of parents contributed to poor oral health related behavior and higher levels of oral disease. Our results showed that most of 15 years old subjects in our sample had established regular brushing behavior, but relatively small percentage of participants reported use of supplemental oral hygiene means, such as dental floss and mouthwash rinses, and thus they could not pro vide adequate control of oral biofilms. High percentage of fluoride toothpaste use, on the other hand, is a significant factor in the prevention of dental caries. High incidence of attitude that the use of toothpaste was necessary for brushing was desirable finding among adolescents.
The Serbian Population Health Survey conducted by the Serbian Ministry of Health in 2006 [10] showed de crease in dental visits once a year from 36.8% to 30.7% for the period 20002006, but also increase in the number of regular dental checkups. However, compared to the year of 2000, the percentage of children and young who visited dentist in the previous year, increased from 58.9% to 63.7%. Our findings are consistent with this data.
Adolescenats' oral health status determined in this study, in terms of realized risk of developing caries and periodontal disease, was characterized by high prevalence of dental disease (91% of adolescents had DMFT>0) with 45% of untreated dental decay (DT/DMFT). In total sample, mean DMFT score was 5.84. Some other studies reported average DMFT score in the group of 15 years old subjects 1.8 in Germany [11], 3.19 in Greece [12], 4.3 in Slovenia [13], and 6.6 in Bosnia [14].
In Central and Eastern European countries, increased prevalence of dental caries in school children and ado lescents is associated with inconsistent implementation of preventive measures and lack of organized health pro motion activities [15]. Also, high prevalence of caries in developing countries may be partly explained by the fact that the health system of these countries is still in transi tion [16]. Unfortunately, since health promotion activities in Serbia are not systematically and consistently imple mented, and the health care system is oriented toward treatment rather than prevention of oral diseases, high DMFT score in 15 year old adolescents is not surprising.
No significant correlations were found between total mean HU DBI score and number of healthy, decayed, missing and extracted teeth. However, significant differ ences in DMFT score or its DT, MT and FT components were obtained in relation to agree/disagree responses of HUDBI questions 1, 2, 5, 6, 13, 14, 16, 18, 19 and 22. Inter esting finding was that subjects who reported regular use of mouth rinses or use of plaque disclosing solution had higher DMFT score. This could be the result of received professional advice after they experienced problems with their teeth or gums. In general, better oral health related behaviors were associated with better dental status.

CONCLUSION
Poor oral health of adolescents and DMFT index of 5.84 are caused by their inadequate attitudes and habits. Thus, emphasis should be placed on educating patients who are receiving dental treatment to improve their oral health attitudes and behavior.

UVOD
Oral no i ce lo kup no zdra vlje za vi se od di na mič kog od no sa broj nih fak to ra ko ji ob u hva ta ju in di vi du al ne oso bi ne, po na ša nja i shva ta nja po je din ca. Po na ša nje u ve zi s oral nim zdra vljem je bli sko po ve za no s is ho dom po zdra vlje i mo že se sma tra ti zna čaj nom de ter mi nan tom zdra vlja. Na vi ke sa mo stal ne kuć ne ne ge zu ba ko je po či va ju na lič nim iz bo ri ma po je din ca sma tra ju se zna čaj nim aspek tom po na ša nja u ve zi s oral nim zdra vljem [1]. De ca i ado le scen ti pred sta vlja ju gru pu po seb no zna čaj nu za sti ca nje zna nja i stva ra nje na vi ka i sta vo va u ve zi s oču va njem oral nog zdra vlja. Zbog di na mič nog fi zič kog i psi ho lo škoemo tiv nog raz vo ja, u pe ri o du ado le scen ci je me nja ju se do tad usvo je ne na vi ke, a pod uti ca jem ne po sred nog okru že nja, vr šnja ka i ne for mal nih gru pa stva ra ju se no vi obra sci po na ša nja i si stem vred no sti, ko ji če sto po ve ća va ju ri zik od na ru ša va nja zdra vlja. Pu še nje, neo d go va ra ju ća is hra na, ose ćaj ne do stat ka vre me na ili "za bo ra vlja nje" da se odr ža va oral na hi gi je na, kao i ne ra zu me va nje ri zi ka ko ji pro iz la zi iz po sto je ćih ob li ka ne pri me re nog zdrav stve nog po na ša nja, mo gu lo še uti ca ti na oral no zdra vlje ado le sce na ta [2].
Za iz u ča va nje sta vo va, opa ža nja i po na ša nja po ve za nih s oral nim zdra vljem Ka va ba ta (Ka wa ba ta) i sa rad ni ci [3] su sačinili Upit nik o po na ša nju u ve zi s oral nim zdra vljem Uni ver zi te ta u Hi ro ši mi (engl. Hi ros hi ma Uni ver sity -Den tal Be ha vi o ral In ven tory -HU-DBI). Upit nik HUDBI sa dr ži dva de set pi ta nja ko ja se pr ven stve no od no se na na vi ke u ve zi s hi gi je nom usta i zu ba. Sva pi ta nja ima ju dva mo gu ća od go vo ra: "Sla žem se" i "Ne sla žem se". Kvan ti ta tiv no oce nji va nje sta vo va i po na ša nja u ve zi s oral nim zdra vljem mo gu će je na osno vu utvr đe nog ukup nog bro ja od go va ra ju ćih od go vo ra, sa mak si mal nim zbi rom od 12 bo do va. Ve ći skor ozna ča va pri me re ni je sta vo ve i po na ša nje u od no su na oral no zdra vlje [4]. Bo do va nje sva kog pi ta nja ko je se od no si na od re đe ni stav ili po na ša nje u ovom upit ni ku za sni va se na ana li tič kom is tra ži va nju u okvi ru ko jeg je raz vi jen sta ti stič ki mo del [5]. U sko ri je vre me ovaj upit nik je ko ri šćen u is tra ži va nji ma u ko ji ma su po re đe ni sta vo vi i po na ša nje u ve zi s oral nim zdra vljem stu de na ta sto ma to lo gi je i den tal nih hi gi je ni ča ra ši rom sve ta [6,7,8]. Utvr đe no je da po sto je zna čaj ne raz li ke kod stu de na ta iz raz li či tih ze ma lja i kul tu ro lo ških gru pa, kao i raz li ke me đu stu den ti ma u od no su na go di nu stu di ja.
Za po tre be ovog is tra ži va nja en gle ska ver zi ja upit ni ka HU DBI pre ve de na je na srp ski je zik. U ko nač nu ver zi ju upit ni ka uklju če na su još tri pi ta nja ko ja se od no se na oral nu hi gi je nu i na vi ku pu še nja.
Cilj ovog is tra ži va nja bio je da se utvr di po ve za nost sta vo va i po na ša nja utvr đe nih po mo ću upit ni ka HUDBI i oral nog zdra vlja (iz ra že nog po mo ću in dek sa KEP) u gru pi pet na e sto go di šnja ka iz Be o gra da.

MATERIJAL I METODE RADA
Stu di ja pre se ka je ob u hva ti la 404 slu čaj no oda bra na uče ni ka pr vog raz re da sred nje ško le (uz ra sta 15-16 go di na) ko ja su po ha đa la jed nu od de set na su mič no oda bra nih sred njih ško la iz raz li či tih op šti na na pod ruč ju gra da Be o gra da. Po da ci o po na ša nju u ve zi s oral nim zdra vljem pri ku plje ni su po mo ću mo di fi ko va ne srp ske ver zi je en gle skog upit ni ka HUDBI. Upit ni ke su na stav ni ci po de li li oda bra nim uče ni ci ma da ih po pu ne za vre me škol skog ča sa. U iz ra ču na va nju HUDBI sko ra, je dan bod je do de ljen za sva ki od go vor "Sla žem se" za pi ta nja 4, 9, 11, 12, 16 i 19, kao i za sva ki od go vor "Ne sla žem se" za pi ta nja 2, 6, 8, 10, 14 i 15.

KRATAK SADRŽAJ
Uvod Ado le scen ci ja je pe riod in ten ziv nih fi zič kih, psi ho lo ških i emo ci o nal nih pro me na ko je mo gu da uti ču na do tad stvo re ne na vi ke u ve zi s oral nim zdra vljem i do ve du do is po lja va nja no vih ri zič nih ob li ka po na ša nja. Cilj ovog ra da je bio da se utvr di po ve za nost na vi ka i sta vo va ado le sce na ta ko ji ži ve na te ri to ri ji gra da Be o gra da i nji ho vog oral nog zdra vlja, iz ra že nog po mo ću in dek sa KEP. Ma te ri jal i me to de ra da Is tra ži va nje je ura đe no kao stu di ja pre se ka i ob u hva ti lo je 404 uče ni ka pr vog raz re da sred njih ško la na te ri to ri ji gra da Be o gra da. Dva ob u če na sto ma to lo ga su na osno vu sto ma to lo škog pre gle da oba vlje nog u uči o ni ca ma utvr di la sta nje oral nog zdra vlja ado le sce na ta (in deks KEP i po sto ja nje vi dlji vih zna ko va za pa lje nja gin gi ve). Po da ci o na vi ka ma i sta vo vi ma u ve zi s oral nim zdra vljem pri ku plje ni su po mo ću mo di fi ko va ne ver zi je upit ni ka o po na ša nju u ve zi s oral nim zdra vljem Uni ver zi te ta u Hi ro ši mi (Hi ros hi ma Uni ver sity Den tal Be ha vi or In ven tory -HU-DBI), ko ji je pro ši ren sa tri pi ta nja. Re zul ta ti Pro se čan HU-DBI skor bio je 6,22±1,45 kod is pi ta nih mla di ća, a 6,28±1,45 kod is pi ta nih de vo ja ka (p<0,05). Naj ma nje jed nom go di šnje sto ma to lo ga je po se ći va lo 67,3% ado le sce na ta, i to su če šće či ni le de voj ke (p<0,05). Na vi ku od la ga nja od la ska stoma to lo gu do po ja ve zu bo bo lje na ve lo je 47,1% ado le sce na ta. Ve ći na is pi ta ni ka (86,2%) pra la je zu be dva pu ta dnev no, pri če mu su de voj ke to či ni le če šće ne go mla di ći (p<0,001). Sa mo 13,4% is pi ta ni ka ko ri sti lo je ko nac za zu be, a 30,3% ras tvo re za is pi ra nje usta. Uku pan KIP je bio 5,84±0,20, sa 45% ne sa ni ra nih ka ri je snih zu ba u struk tu ri KEP. Za klju čak Neo d go va ra ju ći sta vo vi i na vi ke ado le sce na ta uti ca li su na nji ho vo lo še oral no zdra vlje. Da bi se una pre di le na vi ke ne ge zu ba i oral nog zdra vlja, po treb no je da ado le scen ti bu du ob u hva će ni pro gra mom zdrav stve no va spit nog ra da usme re nim ka raz vija nju od go va ra ju ćih zna nja, sta vo va i ve šti na u oču va nju zdra vlja usta i zu ba. Ključ ne re či: ado le scen ti; oral no zdra vlje; oral na hi gi je na; po na ša nje u ve zi s oral nim zdra vljem; sta vo vi u ve zi s oral nim zdra vljem; upit nik HU-DBI Dva pret hod no ob u če na is tra ži va ča oba vi la su sto ma to lo ški pre gled u škol skim uči o ni ca ma i utvr di la broj zdra vih, ka ri je snih, plom bi ra nih i iz va đe nih zu ba (in deks KEP), te ima li vi dlji vih zna ko va za pa lje nja gin gi ve.
Do bi je ni po da ci su ob ra đe ni u pro gra mu SPSS 17.0 (Či ka go, Ili no is, SAD). Pri ka za na di stri bu ci ja fre kven ci ja i de skrip tiv na sta ti sti ka (sred nja vred nost i stan dard na de vi ja ci ja) ana li zi ra ne su pri me nom χ 2 te sta i Fi še ro vog te sta. Za po re đe nje in dek sa KEP, kao i pro seč nog bro ja ka ri je snih, iz va đe nih i plom bi ra nih zu ba iz me đu is pi ta ni ka ko ji su raz li či to od go vo ri li na po je di nač na pi ta nja u upit ni ku, ko ri šćen je Stu den tov ttest ne za vi snih uzo ra ka.
Pi ta nja u okvi ru upit ni ka HUDBI i di stri bu ci ja od go vo ra "Sla žem se" i "Ne sla žem se" pri ka za na su u ta be li 2. Na vi ku od la ska sto ma to lo gu naj ma nje jed nom go di šnje ima lo je 67,3% ado le sce na ta, i to če šće de voj ke, ali ova raz li ka ni je bi la sta ti stič ki zna čaj na. Kr va re nje de sni pri li kom pra nja zu ba na ve lo je 18,4% is pi ta ni ka, a 65,1% je od go vo ri lo da za pa lje nje gin gi ve ni je mo gu će spre či ti sa mo pra njem zu ba. Ve ći na is pi ta ni ka (70,7%), ali če šće de voj ke (p<0,05), na ve la je da ih je struč no li ce ob u či lo ka ko da pra vil no pe ru zu be. Ve ći na is pi ta ni ka (91,8%) sma tra la je da je za pra nje zu ba neo p hod no ko ri sti ti pa stu za zu be, pri če mu je ovaj stav za stu pa lo zna čaj no vi še de vo ja ka, ali bez sta ti stič ki zna čaj nih raz li ka. Vi še od po lo vi ne is pi ta ni ka (če šće de vo jke) na ve lo je da ko ri sti tvr du čet ki cu za zu be i da pri li kom pra nja vr ši sna žan pri ti sak na zu be (p<0,05). Sko ro po lo vi na ado le sce na ta (47,1%) iz ja sni la se da od la že od la zak sto ma to lo gu dok se ne ja vi zu bo bo lja. Ve ći na is pi ta ni ka (86,2%) se iz ja sni la da pe re zu be dva pu ta dnev no, pri če mu je uče sta lost ove na vi ke bi la zna čaj no ve ća kod de vo ja ka (p<0,001). Sa mo 13,4% is pi ta ni ka je na ve lo da ko ri sti ko nac za zu be, a 30,3% da re dov no pri me njuje ras tvo r za is pi ra nje usta. Go to vo če tvr ti na ado le sce na ta (23,3%) iz ja sni la se da sva ko dnev no pu ši ci ga re te.
Sa gla snost s iz ja vom "Od la zim sto ma to lo gu naj ma nje jed nom go di šnje" bi la je po ve za na sa zna čaj no ni žim vred no sti ma KIP (p<0,01) i bro jem ka ri je snih zu ba (p<0,05). Sa gla snost s iz ja vom "De sni mi kr va re ka da pe rem zu be" bi la je po ve za na s ve ćim vred no sti ma in dek sa KEP i nje go vih kom po nen ata K i E (p<0,05). Za pa že no je da je sa gla snost s od rič nim sta vom da je ne mo gu će iz be ći ve štač ke zu be u sta ro sti po ve za na s vi so kom vred no šću kom po nen te E (p<0,05). Vi ši KIP i broj ka ri je snih zu ba utvr đen je kod is pi ta ni ka ko ji su bi li sa gla sni sa iz ja vom "Mi slim da se sta nje zdra vlja mo jih zu ba po gor ša va upr kos sva ko dnev nom pra nju" (p<0,01). Ta ko đe je uoče no da is pi ta ni ci ko ji su sa gla sni sa iz ja vom "Od la žem od la zak sto ma to lo gu dok se ne ja vi zu bo bo lja" ima ju ma nji broj sa ni ra nih zu ba. Is pi ta ni ci ko ji su na ve li da ko ri ste sred stvo za bo je nje pla ka ka ko bi vi de li da li su im zu bi či sti ima li su vi ši KIP (p<0,01). Is pi ta ni ci ko ji su na ve li da sma tra ju da ni su do bro opra li zu be uko li ko ih ne tr lja ju sna žno ima li su ve ći broj zu ba za hva će nih ka ri je som (p<0,05) i eks tra ho va nih zu ba (p<0,01). Is pi ta ni ci ko je je struč no li ce ob u či lo ka ko da pe ru zu be ima li su ni že vred no sti KIP i kom po ne na ta K i E (p<0,01). Oni ko ji su bi li za do volj ni iz gle dom svo jih zu ba ta ko đe su ima li ni že vred no sti KIP i kom po ne na ta K, E i P (p<0,01). Utvr đe no je da su is pi ta ni ci ko ji su ima li po zi tiv nu na vi ku da ko ri ste ras tvo re za is pi ra nje usta ima li vi ši skor KEP (p<0,01).

DISKUSIJA
Zdrav stve no po na ša nje se for mi ra to kom pro ce sa so ci ja li za ci je, usva ja njem i iz grad njom sta vo va, na vi ka, vred no sti, ve ro va nja i shva ta nja, ali i uče njem ko mu ni ka ci je s okru že njem. Zna nja, ve šti ne i spo sob no sti ko je je oso ba ste kla na kog ni tiv nom i afek tiv nom ni vou pod so ci o kul tur nim i raz voj nim uti ca ji ma okru že nja uti ču na spo sob nost po je din ca da do no si od lu ke u ve zi s po na ša njem u po gle du zdra vlja.
Is tra ži va nje u ko jem je upo re đi va na uče sta lost pra nja zu ba kod de ce raz li či tog uz ra sta u 32 ze mlje Evro pe i Se ver ne Ame ri ke po ka za lo je da je uče sta lost pra nja zu ba vi še od je dan put na dan u ra spo nu od 16% do 80% kod de ča ka i od 26% do 89% kod de voj či ca, te da se u ne kim ze mlja ma po ve ća va sa uz ra stom de ce, dok se u dru gi ma sma nju je [9]. Po me nu to is tra ži va nje je utvr di lo ja ku vezu iz me đu za stu plje no sti na vi ke pra nja zu ba vi še od jed nom dnev no i po ro dič nih pri ho da i za ni ma nja ro di te lja, dok je po ve za nost po na ša nja sa struk tu rom po ro di ce (po ro di ca s jed nim ro di te ljem) i ro di telj skom kon tro lom oral ne hi gi je ne de te ta bi la ne kon zi stent na i re la tiv no sla ba.
U ovom is tra ži va nju ta ko đe je po tvr đen uti caj so ci jal node mo graf skih fak to ra, od no sno obra zov nog ni voa ro di te lja na per cep ci ju i na vi ke ado le sce na ta u ve zi s oral nim zdra vljem, kao i na sa mo sta nje oral nog zdra vlja. Na i me, ni zak obra zov ni ni vo ro di te lja do pri no si lo ši jim na vi ka ma po ve za nim s oral nim zdra vljem i iz ra že ni joj oral noj pa to lo gi ji. Re zul ta ti ovog is tra ži va nja su ta ko đe uka za li na to da je na vi ka re dov nog pra nja zu ba ve o ma če sta u is pi ti va nom uzor ku pet na e sto go di šnja ka. Me đu tim, re la tiv no ma li broj is pi ta ni ka ko ri sti do dat na sred stva za oral nu hi gi je nu, kao što su ko nac za zu be i ras tvo ri za is pi ra nje usta, te se ne obez be đu je do volj no te melj na kon tro la oral nog bi o fil ma. Pri me na pa ste za zu be s flu o rom u vi so kom pro cen tu, s dru ge stra ne, pred sta vlja zna ča jan fak tor u pre ven ci ji ka ri je sa, pa je vi so ka uče sta lost sta va da je pri me na pa ste za zu be neo p hod na pri li kom pra nja zu ba po želj na u is pi ti va noj po pu la ci ji ado le sce na ta.
U is tra ži va nju zdra vlja sta nov ni štva Sr bi je ko je je Mi ni star stvo zdra vlja spro ve lo 2006. go di ne [10] za be le že no je sni že nje uče sta lo sti od la ska sto ma to lo gu jed nom go di šnje sa 36,8% u 2000. go di ni na 30,7% u 2006. go di ni, ali je po ras tao broj po se ta zbog re dov ne kon tro le oral nog zdra vlja. Me đu tim, u od no su na 2000. go di nu po ve ćan je pro ce nat de ce i omla di ne ko ja su u po sled njih go di nu da na po se ti la sto ma to lo ga sa 58,9% na 63,7%. Ovo is tra ži va nje je u skla du sa na šim po da ci ma.
U ze mlja ma cen tral ne i is toč ne Evro pe ve ća pre va len ci ja ka ri je sa kod de ce škol skog uz ra sta i ado le sce na ta do vo di se u ve zu s ne kon zi stent nom pri me nom pre ven tiv nih me ra i iz o stan kom or ga ni zo va nih pro gram skih ak tiv no sti pro mo ci je zdra vlja [15]. Ta ko đe, vi so ka pre va len ci ja ka ri je sa u ze mlja ma u raz vo ju mo že se pri pi sa ti či nje ni ci da se si stem sto ma to lo ške zdrav stve ne za šti te u po me nu tim ze mlja ma na la zi u tran zi ci ji [16]. Ka ko i Sr bi ja, na ža lost, pri pa da gru pi ze ma lja gde se zdrav stve no va spit ne ak tiv no sti pri me nju ju u ne do volj nom obi mu, a zdrav stve ni si stem je ori jen ti san ka te ra pi ji a ne ka pre ven ci ji oral nih obo lje nja, ne iz ne na đu ju vi so ke vred no sti KIP u is pi ti va nom uzor ku pet na e sto go di šnja ka.
U ovom is tra ži va nju ni je utvr đe na po ve za nost ukup nog HU DBI sko ra i bro ja zdra vih, ka ri je snih, eks tra ho va nih i plom bi ra nih zu ba. Me đu tim, zna čaj ne raz li ke u vred no sti ma KIP ili kom po ne na ta K, E i P in dek sa KEP utvr đe ne su u od no su na po tvrd ne i od rič ne od go vo re na pi ta nja 1, 2, 5, 6, 13, 14, 16, 18, 19 i 22 u upit ni ku HUDBI. Za ni mlji vo je da su is pi ta ni ci ko ji su na ve li da ko ri ste ras tvo re za is pi ra nje usta i sred stva za bo je nje den tal nog pla ka ima li vi še vred no sti in dek sa KEP. Ovo se ve ro vat no mo že sma tra ti re zul ta tom struč nog sa ve ta ko ji je dat od re đe nim is pi ta ni ci ma na kon što su se ja vi li sto ma to lo gu zbog pro ble ma sa zu bi ma ili de sni ma. U ce li ni, utvr đe no je da su pri me re na po na ša nja u po gle du zdra vlja usta i zu ba bi la po ve za na sa bo ljim sta njem oral nog zdra vlja ado le sce na ta.

ZAKLJUČAK
Neo d go va ra ju ći sta vo vi i na vi ke ado le sce na ta uti ca li su na lo še oral no zdra vlje ado le sce na ta, a uku pan in deks KIP bio je 5,84. Zbog to ga ak ce nat tre ba sta vi ti na edu ka ci ju ado le sce na ta u sklo pu sto ma to lo škog le če nja, ka ko bi se una pre di li nji ho vi sta vo vi i po na ša nje u ve zi s oral nim zdra vljem.