This descriptive cross-sectional study aimed to assess the risk behaviors and practices among children in rural and urban public primary schools in Rwanda, with a comparison of results between the two settings. The study results revealed that the highest proportion (51.3%) of children were females living in rural areas (51.3%). This aligns with the Rwandan Demographic Health Survey (RDHS), which showed that females are predominant among the Rwandan population, with most respondents living in rural areas.[13]
In this study, most of the respondents (51.3%) were studying in grades P1 to P3, indicating that the attitude and knowledge of risk behaviors can be influenced by the child’s level of understanding toward the promotion of good dental health. Similarly, a cross-sectional study conducted among primary school children in Ethiopia stated that the prevalence of dental caries was 21.8%, and poor habits of tooth cleaning, as well as studying in grades one to four, were significant risk factors associated with dental caries.[12]
The results of this study demonstrated that most of the participants (61%) brush their teeth once per day, and among them, 90% brush their teeth in the morning. While professional dentists recommend brushing teeth twice a day.[15] Only 32.3% of the participants reported brushing their teeth twice a day. Brushing teeth twice a day, preferably in the morning after breakfast and before bedtime, is crucial as it helps to clean out food debris after breakfast and decreases the number of bacteria that cause dental decay during the night. Similarly, a study conducted in Madagascar in 12-year-old school children reported that only 8.6% cleaned their teeth twice a day, with 55.1% cleaning their teeth once per day, while 36.2% reported cleaning their teeth less than once per day.[15] Brushing two times a day has been described to considerably decrease the prevalence of caries compared to brushing only once per day.[2] Similar beneficial effects of brushing twice daily have also been found in terms of gingival health. Despite this clear scientific evidence and strong support of twice-daily brushing from dental professionals through bodies such as the WHO, the FDI, and dental associations, significant participant still only brush their teeth once a day or even less.[2]
This study revealed that 41% of the participants drink sugary containing drinks once per week, 59.5% of them reported taking sugary drinks at night, while 60% of the participants reported eating sweets and candies 1 to 3 times per day. An increase in sugar and sweets candies consumption associated with a lack of parental control over the number of sweets or chocolate that children consume and poor tooth brushing after sugar consumption are important factors contributing to teeth erosions, cavities formation, and dental decay in children. Similarly, studies have shown the same results, like a study conducted in Indonesia in school children, found that the majority of the respondents (90%) used to eat sweet candies and drink sugary containing drinks every day, including nighttime.[16]
The study reported that 44% of the participants have never visited a dentist in their lifetime. Yet, dental consultation is crucial for better dental and oral health as it helps to rule out any abnormality for early prevention and treatment. Based on the American Academy of Pediatric Dentistry (AAPD), the first examination is recommended at the time of the eruption of the first tooth and no later than 12 months of age. Regular visits every six months should be followed for the developing dentition, including a complete oral health assessment of general health/growth, pain, extraoral soft tissues, temporomandibular joints, intraoral soft tissues, oral hygiene, periodontal health, and caries risk behavior of the child.[17]
The results of the study showed that 69.2% of the participants use a toothbrush and toothpaste in brushing their teeth, 10.8% reported using charcoal, 8.7% reported using a toothpick, while 11.3% use fingers to clean their teeth. Similarly, a study conducted in Asia revealed that only 65.7% used a toothbrush to clean their teeth, and others used other items such as charcoal, miswak, and fingers[16] A toothbrush was not commonly used in Ethiopian children, where one study revealed that 67.6% of children clean their teeth using a small stick of wood [11].One systematic review has shown that the use of standard fluoride toothpaste reduces approximately 24–29% of the incidence of dental caries in children’s permanent teeth.[18]
The time spent during tooth brushing is also an important factor that impacts dental health. For this study, 44.6% reported spending 1 minute, 36.9% spent 2 minutes, while only 10.3% reported spending 3 minutes and more in brushing their teeth. The more time spent brushing the teeth, the more food debris and bacteria are removed, enhancing the activity of fluoride on the teeth. Contrarily, a study conducted in Indonesia found that more than half (63.8%) of the respondents reported brushing their teeth for more than 3 minutes, and 34.8% reported brushing teeth for less than 3 minutes.[19]
The study found that 42% of the participants reported brushing their teeth horizontally, while 47.7% have no systematic method in brushing their teeth. The technique used to clean the teeth is also crucial in dental health because it allows the removal of bacteria and food debris and promotes the fluoride to be absorbed well within the gums. Similarly, various studies revealed the methods of brushing teeth used by children. In India, different methods of tooth brushing were reported by respondents, including horizontal strokes (26.1%), up and down strokes (55.5%), and no systematic method (24% [6]. In Sudan, 40.4% of respondents reported brushing their teeth from all directions, while 39.6% reported brushing their teeth from top to bottom and bottom to top.[16]
For good teeth brushing, a gentle scrub technique with very short horizontal movements starting with outer and inner surfaces, and brushing at a 45-degree angle in short, half-tooth-wide strokes against the gum line is recommended. Move on to chewing surfaces, hold the brush flat and brush back and forth along these surfaces and inside surfaces of your front teeth, tilt the brush vertically and use gentle up-and-down strokes with the tip of the brush, and finally, brush gently along the gum line. Toothbrushes must be changed every 3 months.[9]
The study results revealed that there is a statistically significant difference in the frequency of dentist visits between urban children and rural participants (p = 0.026). Participants from rural areas (48%) reported never having visited a dentist compared to 40% from urban areas. For rural children, 11% reported consulting occasionally compared to 25.3% from urban areas. This means that geographical location in terms of city, region, and social status poses a barrier to achieving good dental health, in terms of dental health care services access. Similarly, a study conducted on 478 children in Brazil revealed that only 112 (23.68%) were found to have visited a dentist; 67.77% of those had seen the dentist for preventive care, and the majority (63.11%) used public rather than private services. The use of dental services and the sugar consumption habit are linked to parental socioeconomic status, where children from low socioeconomic backgrounds and those whose parents rated their oral health as “poor” used dental services less frequently and consumed sugary diets less frequently.[20]
The study found a statistically significant difference in the frequency of sugar consumption (p = 0.002) between children from urban areas than rural areas. It showed that 25% of the participants from urban areas drank sugary drinks every day, while only 6% of rural participants drank sugary drinks every day. Children from urban areas are exposed to accessibility to sweets and sugary candies more than rural areas, and their differences in economic status. Similar studies have shown the same results, like a study conducted in India in school children, found that the majority of the respondents (90%) used to eat sweet candies and drink sugary drinks every day, including nighttime, and 62.3% of them were from urban areas.[16]
The results of this study also reported that there is a statistically significant difference in materials used to brush teeth among children from rural compared to children from urban (p = < 0.001). Children from urban areas (78%) reported cleaning their teeth with toothbrushes and toothpaste compared to 57% from rural areas. In rural areas, 17% reported using charcoal, 15% reported using toothpicks, and 15% reported using other methods. Similarly, in a study from Zimbabwe, it was reported that only 65.7% used a toothbrush to clean their teeth, and others used other items such as charcoal, fingers, and others, while only 68.6% used toothpaste while cleaning their teeth. Toothbrushes were not commonly used in Ethiopian children, where one study revealed that 67.6% of children clean their teeth using a small stick of wood[11], where participants report poor socioeconomic status of their family.
This study also revealed that there is a statistically significant difference in changing the toothbrush time (p = 0.011). Children from urban areas (42.1%) change their toothbrushes within 1 to 3 months compared to 33% of children from rural areas. The good status of the toothbrush promotes effective tooth brushing. A similar study conducted in Australia found that rural/remote children in this study had worse oral health than either state or national averages in both the 5-6-year-old and 11-12-year age groups. Socioeconomic status, tooth-brushing, and indigenous statuses were significantly associated with caries in these communities.[21] There were no differences in time spent on brushing and the technique to brush teeth among children from urban compared to children from rural areas. As limitation, the sample size was not big enough to generalize the findings to the whole country, further studies are needed with bigger sample size to reflect the situation in Rwanda. Moreover, another limitation is that our study only involved children who were at school. Future study could also include those in community or who do not attend schools.