A cross-sectional questionnaire survey was conducted amongst 1027 secondary level school students, in Chandigarh, India. A simple random sampling was done to select the students for the purpose of the study and the duration of study was 3 months (April- June, 2013).

A list of schools in Chandigarh was obtained from Education Department and their location noted down. Initially the city was divided into four zones; north, south, east and west as done by Municipal Corporation of Chandigarh for development purposes. Then a school from each zone was selected by simple random sampling to get a representative sample. All students with good general health at secondary school level between the ages of 13-15 years were assessed. Those students with severe general health problems that affect oral health and those with dental emergencies were excluded.

Ethical Approval and Official Permission: Before starting the survey ethical approval was obtained from the institutional ethical committee and official permission was obtained from the authorities (Principal/Director) of the schools included in the study.

Survey Form: A pretested self administered questionnaire containing 37 questions was administered to all study participants. The format of questionnaire was adapted from questionnaire used in the study conducted by Al- Omiri (2006) and language of questionnaire was in English [26]. Pre-testing of the questionnaire was carried out by initially administering the questionnaire to 10 students. Feedback was obtained from participants on any difficulty faced by them in interpretation of questions and any ambiguity within responses was checked. The questionnaire was then modified accordingly and administered to all participants. Questions were divided in to four domains addressing demographics, knowledge, attitudes and practice behaviours of the participants. Item responses were multiple choices.

Methodology: Informed consent was obtained from each participant before the administration of the questionnaire, explaining the need and the purpose of the study.

The response format included multiple choice questions in which the students who agreed to participate and available on the days of survey were instructed to choose only one response from provided list of options. The students were given instructions regarding filling the questionnaire. Furthermore, the investigator was present while the questionnaire was being filled and all queries of participants were addressed by the investigator. The students were asked to fill in the questionnaire without discussion with each other within half an hour time.

Assessment of a participant’s oral health–related practices included questions on frequency, duration and time of cleaning, cleaning aids used and replacement, type of toothbrush and brushing technique if used, use of fluoridated toothpaste and amount of dentifrice used. Assessment of participant’s oral health–related attitude included items on frequency of visits to a dentist and reasons for visiting and not going to dental office. Assessment of a participant’s oral health–related knowledge included questions on benefits of fluoride, necessity of regular dental visits, the role of sugar in causing dental caries, the importance of teeth in the health of body, effects of smoking, alcohol, tobacco, oral habits, misalignment of teeth on oral health, plaque and its effect on gingival and periodontal health and importance of regular dental check-ups.

The data so obtained was compiled and analysed using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 15.0 for windows). Frequency analysis was done using descriptive statistics.

The age of study population ranged between 13 to 15 years with a mean age of 14 years. Data pertaining to the oral hygiene habits among the study population (n=1027), is summarized in [Table/Fig-1]. The survey revealed that approximately 54% of the population studied, brushed their teeth once daily, while 40% respondents brushed twice a day. Tooth brush with dentrifice was the most frequent method of oral hygiene amongst study population. In all 1.7% of study sample reported using floss and 20% used either mouthwash and tongue cleaner as extra aids for oral hygiene. In regard to knowledge about toothbrush and the brushing technique, approximately 93.9% of the subjects were aware that it was important to choose the right toothbrush. Soft bristle toothbrush was used by 53.8% and 32.8% replaced their brush every month. A total of 63.7% were not aware of the type of dentifrice being used and approximately half of the study population did not know the purpose of fluoride (49.9%) and were using full bristle length amount of the toothpaste. Among sample subjects 28.7% were brushing according to the dentist directed brushing method, where as 71.3% of subjects were using non-directed brushing method. A combination of brushing strokes was used by 59.7% subjects during brushing and about 32.7% brushed for more than 2 minutes [Table/Fig-1].

About knowledge and awareness towards general oral health, most of sample subjects were aware that sweets (92.7%) and soft drinks (67.8%) have negative impact on dental health [Table/Fig-2]. Approximately 77.1% of the sample was aware that smoking was not good for dental health. 56.5% and 92.3% of the respondents knew about the detrimental effect of alcohol and paan/ tobacco respectively on oral health. About half the respondents were aware that maligned teeth could affect oral health. A variable proportion of respondents were aware of the adverse effects of various habits e.g., thumb sucking (35.3%), mouth breathing (31.4 %) and nail biting (53.1%). Approximately half of the study population (50.2%) knew health of mouth and dentition had an impact on health of the body also [Table/Fig-2].

Regarding awareness in relation to periodontal diseases 50% respondents did not know the significance of bleeding from gums though most (58%) were aware that infrequent brushing lead to stains, caries and periodontal disease [Table/Fig-3].

[Table/Fig-4] reveals the information about participants’ attitudes towards professional dental care. About 97% of the respondents thought care of the teeth were necessary and 77.6% of the study population felt the necessity of regular dental check-up. Thirteen percent respondents visited the dentist regularly after every 6-12 months whereas 48% of the respondents had visited the dentist only in case of dental pain. Approximately 24.9% of the respondents had visited the dentist in the last 6 months and the reason for the last dental visit was dental pain for 33% of the sample. Driving factor for not visiting the dentist for most of respondents was fear of pain (38.5%) or needle (34.2%) and 20.9% reported to have been scared and reluctant at their first visit.

[Table/Fig-5] provides comparative analysis of the oral hygiene habits of study population, who were/ were not regularly visiting dentists.

Present investigation aimed to provide a comprehensive overview of the oral health behaviour, knowledge and attitudes among secondary level school students of Chandigarh, which can help the planning and evaluation of the oral health promotion program in this region. This survey found that a high percentage of the children in this study brush their teeth at least once daily (54%) or twice daily (40%). There is consensus in literature that meticulous tooth brushing once per day is sufficient to maintain oral health and prevent caries and periodontal diseases. But most of people are not able to achieve optimum plaque removal. Therefore, tooth brushing twice daily is recommended by most dentists in order to improve plaque control [27]. The frequency of subjects brushing twice a day is quite in concordance with Humagain, who studied the similar population in rural Nepal, but is quite less than reported by Al Omiri et al., and Zhu et al., [13,26,28]. Twice-a-day tooth brushing seems to be an established practice in several industrialized countries [1,29–31], whereas, in others like Tanzania, Iran and Thailand many studies have reported once-a-day tooth brushing by majority of their participants [32–34]. In India Gupta et al., reported 61.9 % while Harikiran et al., reported 38.5% frequency of twice a day brushing. This wide variation when compared to present study can be attributed to varied social and economic conditions within India [17,18]. The use of other recommended oral hygiene methods such as dental floss and mouthwashes was found to be rare. The findings are in concurrence with Al-Omiri et al., and Mathur and Gupta and could be attributed to the lack of oral health education, the cost of such aids socioeconomic status, parental influences or traditional/ religious beliefs of the population concerned [26,35].

On the knowledge on how the teeth should be properly brushed, majority of the respondents used a non-directed brushing method with a combination of brushing strokes. Thus there is need to educate school children on the correct motion for teeth brushing to ensure that the teeth are thoroughly brushed which will reduce or eliminate the chance of oral diseases.

There was lack of awareness regarding periodontal diseases as compared to dental caries as, almost half of the respondents did not know the significance of bleeding from gums and were unaware of the term "dental plaque". The response was quite limited as compared to previously reported by Al Omiri et al., and Humagain in similar populations in North Jordan and Nepal respectively though similar to what has been reported by Gupta et al., [13,17,26]. High awareness of dental caries including its impact on the dentition (86.5% knew dental caries affected aesthetics), cause (56% reported that sweets lead to dental caries) and prevention (93% knew caries could be prevented) in comparison with periodontal health could be attributed to the fact dental caries is more prevalent among children than periodontal disease [13]. This could have had been the reason for the improvement in the respondents’ knowledge concerning dental caries as, while attending dental clinics for treatment of the same, they must have obtained more professional counselling in this matter.

Most of the respondents were aware of detrimental effects of sweets, smoking, paan/tobacco on dental health though there was not as much awareness regarding adverse effects of various oral habits. More enlightenment activities need to be done in this area as much of the damage could be prevented by intercepting these habits at young age.

Earlier it was believed that oral infections were localized to the oral cavity and had no association with other systemic systems except in the case of some associated syndromes and untreated odontogenic abcesses. As evidence of periodontal infection’s influence on chronic inflammatory disease states continues to mount, a change in paradigm has dispelled this notion, and a whole new concept of the status of the oral cavity and its link to systemic health and disease has evolved. The participants demonstrated limited awareness of the link between oral health and systemic well-being (50%) which is very less as compared to studies done by Al Omiri et al., Farsi et al., El-Qaderi et al., and Humagain [13,26,36,37]. It is important to lay emphasis on the association between oral health and general health of the rest of the body because this might be helpful in promoting oral health and self-care practice among students as well as the community.

Most of the study subject reported irregular dental attendance (48%) and this finding is consistent with findings of similar studies [10,13,17,18,26]. An astounding finding in this regard was that most participants were aware of importance of regular dental attendance (77%). Some findings in this study might offer an explanation for the irregular dental attendance among the participants. A high proportion of the subjects did not attend or disliked visiting dentists due to fear of needle (34%) or pain (38%). Oral disease has a slow path which can be detected on time by the dentist hence, educating the students in this regard is vital. Frequency of visiting dentist is also determined by the parents of these children and dental attitudes displayed by parents might also offer an explanation of the lack of regular attendance. Thus, parents too should be made to understand why it is important to take the children for routine dental check-up.

These observations can be ascribed to the deficiency of appropriate oral health education programs which might have made the dental treatment redundant.

Better oral hygiene knowledge and practices were found in students who visited dentists regularly which might be due to individual level oral health education and motivation received by them. Thus, key to an informed and motivated public lies in the hands of the profession, as well as the authorities. Our study is limited in the fact that the generalizations from this study may not be applicable to other areas as Chandigarh is unique in its social and demographic factors. Further, there is a need for follow-up to find if the survey itself had any influence on the attitude or knowledge of participants.

Health promotion, with its core ideas of equity and equality, empowerment and advocacy, provides a novel though a complex approach to improve not only general health but oral health also. It shifts the responsibility for health from the formal health care system to individuals, communities and decision- makers at all levels of society. Dental health education should be incorporated into the existing school curriculum. The program for dental health education and various didactic activities should be structured in such a manner as to gain the student’s interest and obtain a high priority of social acceptance. The objective should be to maintain that level of acceptance throughout the student’s lifetime. The education programs should thus be motivating, vibrant, and closely matched to the learning aptitude established by the child at each educational level. Community group effort can also reinforce interventions to endorse improved oral health. Efforts should be synchronized between school personnel, dental health care professionals, as well as parents to make certain long-term remuneration. In future more surveys on larger scale like that on state level or national surveys should be carried out and the data obtained be used to formulate better dental health programs for our country.

This survey furnishes the background data to get insight into the status of awareness of secondary level school students regarding oral health. The clinical implication of this survey was to emphasize on the need for the oral health education of the school children aiming at improving oral health knowledge and continuous implementation of school oral health promotion programs. As, school age is the right time when the behaviour can still be molded, secondary level students would be the appropriate target group to receive the first organized intervention leading towards correct knowledge along with a positive attitude which is essential to bring about a change in their oral health behaviour. However, the efficacy of such education will be limited if health programs are not able to directly affect theattitudes, and take into consideration various socio-economical and environmental factors of targeted population.