J Dent Res 76(9): 1602-1609, September, 1997
Oral Hygiene Habits of 11-year-old
Schoolchildren in 22 European Countries
and Canada in 199311994
S. Kuuselal*, E. Honkala2, L. Kannas3, J. Tynjalai3, and B. Wold4
lInstitute of Dentistry, PO Box 41, FIN-00014 University of Helsinki, Finland; 2Department of Cariology, University of Helsinki, Finland;
3Department of Health Sciences, University of Jyvaskyla, Finland; and 4Research Center for Health Promotion, University of Bergen, Norway;
*to whom correspondence should be addressed
Abstract. This study is part of the Cross-National Survey on
Health Behaviour in School-aged Children-a WHO
Collaborative Study, which started in 1982. The aim of the
study was to describe the oral hygiene habits
(toothbrushing and flossing) of 11-year-old schoolchildren
in 22 European countries (Austria, Belgium, the Czech
Republic, Denmark, Estonia, Finland, France, Germany,
Greenland, Hungary, Israel, Latvia, Lithuania, Northern
Ireland, Norway, Poland, Russia, Scotland, the Slovak
Republic, Spain, Sweden, and Wales) and Canada. The data
were collected from standardized anonymous
questionnaires in school classrooms during the 1993-1994
school year. At least 1300 schoolchildren, representing the
whole country, participated in the study in each country.
Oral hygiene habits were analyzed according to gender, age,
country, school performance, and family economy. The
children brushed most favorably in Sweden, Denmark,
Germany, Austria, and Norway (83-73% brushed twice a
day). More-than-once-a-day toothbrushing was especially
uncommon (from 26 to 33%) among boys in Finland,
Lithuania, Russia, Estonia, and Latvia. Toothbrushing
frequency differed significantly according to school
performance in Canada, the Czech Republic, Scotland,
Poland, Northem Ireland, and Wales and between different
socio-economic groups in Northern Ireland, Wales, the
Czech Republic, Scotland, Poland, and Russia. Use of dental
floss was rare. In general, flossing was less frequent among
boys than among girls. Daily flossing was most common
among Canadian adolescents (25%). In conclusion, there are
considerable differences in toothbrushing frequency among
children in European countries.
Key words: toothbrushing, flossing, health behavior,
Europe, Canada, schoolchildren.
Received July 23, 1996; Revised December 16, 1996;
Accepted March 10, 1997
1602
Introduction
Research on schoolchildren's health behavior and lifestyle
has demonstrated how strongly behavioral patterns are
formed, influenced, and changed by social and societal
conditions (Honkala, 1993). The immediate social
environment strongly predicts health behaviors; and the
economic, organizational, political, and cultural processes
within the wider environment directly or indirectly
influence the choices and decisions young people make
concerning health behavior (Nutbeam et al., 1989). Thus,
results that indicate the differences in health behaviors
between and among different groups are not unique or
surprising, but serve as a reminder of the need for health
promotion programs which are focused not only on the
individual child and his/her immediate social groups, but
also on the broader environment (Nutbeam et al., 1989).
Because oral health promotion focuses on improvement
of oral health behaviors, description of current habits is
crucial. The most important oral health habit is regular
toothbrushing, and the recommendation for frequency is
twice a day (Sheiham, 1977). Only when the appropriate
frequency has been reached can efforts to improve the
technical performance of brushing lead to good oral hygiene.
Despite considerable information about additional
toothcleaning aids, typical individual toothcleaning consists
of only brushing. Use of dental floss has not been widely
accepted (Honkala et al., 1990), although it is the only
practical method for cleaning proximal surfaces. Both of
these oral health habits are strongly determined by the social
environment of a child (Honkala, 1984), and therefore cross-
cultural differences could be expected to exist between
children in different countries. However, only a few
European countries have conducted nationally
representative studies concerning oral health habits (Kostlan,
1979; WHO, 1985). Different epidemiological surveys have
been conducted in European countries (Table 1), but the
methods of data collection have varied considerably.
For health habits in different countries to be compared,
and especially for the associations of these habits with
different determinants to be determined, studies with
j Dent Res 76(9) 1997 Oral Hygiene Habits in 23 Countries 1603

Table 1. Toothbrushing frequency and daily flossing of children in different countries

Author & Year Country Study Sample Age Toothbrushing Daily
Year Frequency (%) > 1 /day Flossing (%)
Aleksejuniene, 1995 Lithuania 1990 737 12 72a
Bauch et al., 1991 Germany (West) 1989 452 13/14 27b
Borutta et al., 1993 Germany (East) 1992 492 13/14 29b
Hescot and Roland, 1994 France 1993 1331 12 62
Honkala et al., 1990 Austria 1985/86 1240 11 53 4
Belgium (French-
speaking region) " 1250 11 34 3
Finland 1183 1 33 4
Hungary 1601 11 59 1
Israel (Jerusalem,
except eastern sector) 934 11 58 6
Norway " 1395 11 68 28
Scotland
(Lothian region) " 1306 11 69 8
Spain " 1295 11 31 6
Sweden " 747 11 81 9
Wales 2098 11 55 6
Kostlan, 1979 Canada 1977 936 13-14 69
Poland 1974 1033 13-14 44
O'Brien, 1994 UK (including
Northern Ireland) 1993 7407 12 72
Petersen, 1992 Denmark 1992 212 6 88
Ranka et al., 1992 Latvia 1990 631 11 36
a
Brushing once or more/day and interdental cleaning.
b Toothbrushing twice a day and duration of 2 min.

standardized methods are needed. For this purpose, a
special WHO research program, the Cross-National Survey,
was developed, which also included oral health habits. The
first data for this survey were collected in four European
countries (Austria, England, Finland, and Norway) in
1983/1984 (Aar0 et al., 1986). In the second phase
(1985/1986), 11 European countries and in the third phase
(1989/1990) 15 countries participated in the survey
(Nutbeam and Aar0, 1991). The oral health habits in the first
survey (Honkala et al., 1988) and in the second survey
(Honkala et al., 1990) have been reported earlier.
The overall aim of the Cross-National Survey was to
increase understanding of the health behavior and lifestyles
of young people. Further objectives of the study were to
promote cross-disciplinary research into young people's
health behavior and to support international networking
that promotes scientific progress (Aar0 and Wold, 1985;
Aar0 et al., 1986).
The aim of this study was to describe the oral hygiene
habits (toothbrushing and flossing) of 11-year-old
schoolchildren in 22 European countries or regions (Austria,
Belgium, the Czech Republic, Denmark, Estonia, Finland,
France, Germany, Greenland, Hungary, Israel, Latvia,
Lithuania, Northern Ireland, Norway, Poland, Russia,
Scotland, the Slovak Republic, Spain, Sweden, and Wales)
and Canada. A further aim was to compare the associations
between these habits and gender, age, country, school
performance, and family economy in these countries.
Materials and methods
This study is part of a large, international comparative survey of
schoolchildren's health and life-styles (Health Behaviour in
School-aged Children-A WHO Cross-National Survey, the
HBSC Study). The philosophy and methods of the project have
been described in more detail elsewhere (Aar0 and Wold, 1985;
King et al., 1996).
Study design
In the fourth phase of this study program, 1993/1994, 24
European countries (Austria, Belgium, the Czech Republic,
Denmark, Estonia, Finland, France, Germany, Greenland,
Hungary, Israel, Latvia, Lithuania, Northern Ireland, Norway,
Poland, Russia, Scotland, the Slovak Republic, Spain, Sweden,
Switzerland, the Netherlands, and Wales) and Canada took part
in the study program (Wold et al., 1994). However, the
Netherlands and Switzerland were excluded because the
common guidelines for data collection were not followed. In
some countries, the sample represented only certain regions: in
France, the regions of Toulouse and Nancy; in Germany, the
state of Nordrhein-Westfalen; and in Russia, the St. Petersburg
region. In Belgium, two samples were drawn, one (n = 1733)
representing the Flemish-speaking population (57% of the whole
population) and the other (n = 1935) the French-speaking
population (43% of the whole population). For Belgian data,
weighted mean figures were used. In all other countries, the
sample was collected according to the research protocol (Wold et
al., 1994) and was therefore nationally representative. A cluster
sample design was used, in which the first level of sampling
occurred at school or school class level, and then all students in
appropriate age groups were surveyed (King et al., 1996).
The data were collected by means of standardized
questionnaires administered to 11-, 13-, and 15-year-old
schoolchildren in school classrooms. Pupils responded
anonymously during a class period, with either a teacher or
researcher overseeing the process. The ethical clearance for the
study was obtained by each national participant from the
1604 Kuusela et al.
ethical committees of their respective institutions. Overall, in
every participating country, each age category was to consist of
about 1300 schoolchildren, except in Greenland (sample was
about 450). Since the population of Greenland is relative small,
the entire in-school population for each age group was
surveyed (King et al., 1996).
Variables
Oral hygiene habits were determined with two structured
questions. To the question "How often do you brush your
teeth?", five alternatives were given: more than once a day, once
a day, at least once a week but not daily, less than once a week,
never. In the analyses, the answers were recoded into three
categories: more than once a day, once a day, and less than once
a day. To the question "How often do you use dental floss?",
three altematives were given: daily, weekly, rarely or never. No
information about flossing was gathered in Scotland and Wales.
One group of countries needed an alternative-"Don't know
what flossing is"-in their questionnaires for flossing. The
proportions of don't-know answers were quite high (from 32 to
77%) in Belgium, France, Germany, Lithuania, and Poland; thus,
those countries were excluded from the analyses. Estonia,
Latvia, and Russia were also excluded because of the high
proportions of reported daily users (from 17 to 46%), even
though dental floss is not commonly available in those
countries.
The study also included information about age, gender,
school performance, and family economy as indicators of socio-
economic status, because all of these factors are known to
associate with dental health habits (Honkala, 1984). This study
was based on only 11-year-olds for age to be controlled as a
confounding factor. However, we used the two oldest age
groups for calculating the odds ratio for age. The 13-year-olds
and 15-year-olds did not differ very much from each other in
their brushing habits. Only in Hungary, Poland, and Spain was
the difference between the proportions of twice-a-day brushers
greater than 10%. Therefore, the older adolescents were
compared together with the 11-year-olds. The question
concerning school performance was: "In your opinion, what
does your class teacher think about your school performance
compared with your classmates'? He/she thinks I am: very
good, good, average, below average." In the analyses, answers
were recoded into three categories: good, average, and poor.
Self-reported school performance in different countries with
different school systems might mean different things. However,
despite differences between and among countries in terms of
school systems, economic development, or spending power, the
adolescents face many of the same difficulties, to which they
seem to react similarly (Piette et al., 1993).
Family economy was asked in the question: "How well off
do you think your family is?" The alternatives given were: very
well-off, well-off, average, not very well-off, not at all well-off, I
don't know. In the analyses, the following categories were used:
good, average, and poor. There were no data available from
Spain concerning family economy. For self-reported and self-
evaluated family economy, the expression "well-off" has been
used for clarifying the socio-economic status of families. In
English, "well-off" could be interpreted more broadly than in
j Dent Res 76(9) 1997
purely economic terms to mean something more holistic, such
as family well-being (Piette et al., 1993).
Validity and reliability
In studies involving several countries in the management of the
survey, there are problems in ensuring consistency in data
collection, and therefore direct comparisons of behaviors
between and among countries have to be made with caution
(Nutbeam and Aar0, 1991). If valid international comparisons
are to be made, it is of the utmost importance that the data be
comparable. Special concern should be exercised with
prevalence figures based on only single questions. To make the
comparisons as reliable as possible in the HBSC study program,
we applied the standardized methods for procedures of
sampling and data collection (Aar0 et al., 1986; King et al., 1996).
Terms used to describe behaviors like toothbrushing frequency
are easy to translate and are understood similarly everywhere
(King et al., 1996). Several separate studies or set procedures
have been undertaken for the examination of both the reliability
and the validity of the national and cross-national data (Piette et
al., 1993). The relevance of the questions was studied during the
pilot surveys. The validity of all the studied questions has also
been studied earlier in Finland (Honkala, 1984).
Analyses
All data were cleaned and re-ordered where necessary to a
consistent format at the co-ordinating center in the University of
Bergen, Norway. The cleaning implied exclusion of cases that
did not meet the age criteria and cases where more than 25% of
the answers were missing across selected key behavioral
questions (Nutbeam and Aar0, 1991). The proportion of pupils
excluded through this process varied from 3% to 7% among the
participating countries. The final population of the cleaned data
consisted of 102,641 schoolchildren (Table 2), the number of 11-
year-olds being 35,138 (King et al., 1996).
The variations in the distributions of the variables studied in
this study were analyzed by cross-tabulations according to
gender, age, child's self-reported school performance, and self-
reported family economy. Statistical significances were
measured by the chi-square test. A logistic regression model
was used to estimate the odds ratios for brushing teeth less than
twice a day according to gender (males compared with
females), age (11-year-olds/13- to 15-year-olds), family
economy (poor and average/good), and school performance
(poor and average/ good).
Non-respondents
There were two sources of non-response in the study: (1)
schools or classes that refused to participate and (2) individual
pupils who refused to participate (informed consent) or were
absent on the day the questionnaire was administered
(Nutbeam and Aar0, 1991). No attempt was made to follow up
with pupils who were absent on the day of the survey. In those
countries where it was possible to calculate the number of
pupils who did not participate, the response rates varied
between 75% and 90%.
j Dent Res 76(9) 1997 Oral Hygiene Habits in 23 Countries 1605

Table 2. Number of 11-year-old children in the sample Table 3. Percentages of children who brush their teeth more than
once a day (gender-standardized) in different countries
Country Total Sample Sample of 11-year-olds
Austria 5,217 1,614 Country Toothbrushing > 1/day
Belgium 9,702 3,668 Sweden 83
Canada 6,758 2,289 Denmark 82
Czech Republic 3,585 1,094 Germany 76
Denmark 3,912 1,219 Austria 74
Estonia 3,516 1,170 Norway 73
Finland 4,187 1,714 Czech Republic 63
France 4,004 1,461 Israel 63
Germany 3,275 1,104 Canada 61
Greenland 1,322 457 France 61
Hungary 5,775 2,072 Poland 60
Israel 4,299 1,301 Northern Ireland 59
Latvia 3,818 1,307 Scotland 59
Lithuania 5,428 1,783 Wales 59
Northem Ireland 3,970 1,346 Greenland 56
Norway 4,988 1,614 the Slovak Republic 56
Poland 4,527 1,473 Hungary 46
Russia 4,001 1,353 Spain 45
Scotland 4,959 2,007 Belgium 45
the Slovak Republic 3,374 1,088 Estonia 40
Spain 4,570 1,507 Latvia 38
Sweden 3,584 1,225 Finland 34
Wales 3,870 1,272 Lithuania 34
Russia 34
TOTAL 102,641 35,138

Results toothbrushing (Table 4) and the age of 11 years was found in

Most children (83-73%) brushed their teeth twice a day in
Sweden, Denmark, Germany, Austria, and Norway (Table
3). More-than-once-a-day toothbrushing frequency was
especially uncommon, from 26 to 33%, among boys in
Finland, Lithuania, Russia, Estonia, and Latvia (Fig. 1).
Toothbrushing was less frequent among boys than among
girls (p < 0.001) in all countries except in France, where 61%
of both boys and girls brushed their teeth twice a day (Figs.
1, 2). The gender difference was large in Northern Ireland
(25%), Hungary (20%), the Slovak Republic (19%), Finland
(18%), and Poland (18%) and quite small in Sweden (5%),
Denmark (8%), Norway (9%), and Latvia (10%).
Age (11-year-olds compared with 13- to 15-year-olds)
was strongly associated (p < 0.001) with less-than-twice-a-
day toothbrushing frequency in Canada, Finland, Hungary,
Northern Ireland, Sweden, and Wales. In Austria and in
Lithuania, the situation was reversed (OR 0.5 and 0.6,
respectively). Children's self-reported school performance
(poor and average compared with good; p < 0.001) was
strongly associated (p < 0.001) with less-than-twice-a-day
toothbrushing frequency in Austria, Canada, the Czech
Republic, Denmark, France, Hungary, Israel, Lithuania,
Norway, the Slovak Republic, and Spain; and with self-
reported family economy (poor and average compared with
good) in Austria, Canada, Hungary, Israel, Latvia,
Lithuania, Northern Ireland, Poland, Russia, Scotland, the
Slovak Republic, and Wales. Family economy was not a
statistically significant risk factor for less-than-twice-a-day
brushing in Denmark, Norway, Sweden, and France. School
performance was not a statistically significant risk factor in
Latvia and Belgium.
The strongest association between infrequent
Sweden (OR 3.4) and Hungary (3.0); between infrequent
toothbrushing and poor/average family economy in Austria
(3.5), Wales (3.0), Estonia (2.6), and Greenland (2.6); and
between infrequent toothbrushing and poor and average
school performance in Poland (5.7), Canada (3.6), Greenland
(3.6), Norway (3.6), and the Slovak Republic (3.2).
Use of dental floss was rare. More Canadian
schoolchildren flossed their teeth daily than in other
countries. Children in Hungary, Finland, and the Slovak
Republic rarely flossed (Table 5). Girls used dental floss
more frequently than boys did. There were significant
differences between boys and girls in Canada (30 and 20%,
respectively), Norway (20 and 13%, respectively), and
Northern Ireland (18 and 11%, respectively).
Discussion
International comparisons are especially important for
adding to existing knowledge of dental hygiene practices of
schoolchildren in those countries where there is no history
of monitoring preventive dental practice. In this study, the
descriptive figures for those countries where previous
epidemiological surveys of dental behavior existed
corresponded quite well with the earlier studies. This could
well justify comparisons of the possible strength of the
associations between toothbrushing frequency and its
expected determinants. Cross-cultural comparisons are
interesting and necessary in considerations of the possible
factors affecting this important oral health habit.
The validity and reliability of the questions used in this
study have been tested in earlier studies (Heloe, 1972;
Ahlstrom-Laakso, 1975; Norheim and Heloe, 1977; Honkala,
1984), and the possible factors causing bias were well-
 .
1606 Kutu5sela et al. j Dciit Res 76(9) 1997
about the toothbrushing habit
Sweden .I would be "spying in the
bathroom", which is quite
Denmark --i impossible in practice. Ob-
servation and even interview
Germany - Ill"
,methods would make na-
,, , , .........tionally
, , representative and
Norway - , .,..,..,,.,,.,,.international
surveys diffi
cult. Actual brushing per-
France - formances have been studied
.........

-I"
earlier by videotape, but these
Austria -L "'
, ,have little relevance if the re-
commended frequency has
Czech Rep ,
not been adopted (Honkala et
-7-7-7X al., 1986). From the behavioral
Canada standpoint, the most import-
,,-,,,,ant aspect of brushing is its
-.,,
Israel - frequency. Only after the
twice-a-day brushing habit
Scotland -
f"I

"I= was established could efforts

be directed to adequate tech-
Wales nique and the duration of
brushing. Use of dental floss
Poland is still rare among children in
Greenland Europe. Flossing does not
seem to be a well-known
N Ireland =_habit,
,.ZE,.,,., , and therefore there
might be more bias in the
Slovak Rep _._.... . answers toward expected
behavior than in the answers
Spain ,,concerninig toothbrushing
frequency.
Hungary While the social environ-
ment (values, attitudes, be-
Belgium "I", liefs), traditions of behavior,
-.ZI Z..
I

.,, Xand responses to questions

Latvia -II"
-C o>/ :differ considerably in different
...

........ countries, inter-cultural com-

Estonia ...... ..-., ... parisons are difficult, and the
results can be only indicative.
Russia ........,, However, for the context of
behavior to be understood,
Lithuania inter-cultural comparisons
-
-/ZIIZ / :? i could help in the development
Finland .% of new models of the
determinants of behavior,
0 20 40 60 80 1 00 concomitantly providing new
methods of behavioral change
- >1 iyIdc Ewi/day] through health promotion.
International comparisons
could also provide
the unique
timinguo
Figure 1. 1'ercentages of 11-year-old boys who brush tl ieir teeth more than once a day/once a day in ig so of
different countries. insights into the timiing
dental education, the content,
and the need to ensure that
education efforts reach all
controlled in this study design (see "Materials and Imethods"). sections of the population. Based on the results of this study, it
The methodology has been discussed in more det, iiI in other seems to be a universal finding that health behavior models
reports (Ahlstrom et al., 1979; Honkala, 1984; Aaro et al., 1986; should include at least background factors such as family
Eder, 1990). All methods for collecting data on c)ral health economy, school performance, age, and gender. In almost all
behavior have limitations. The only reliable in formation countries, more efforts are needed for younger adolescents
j Dent Res 76(9) 1997 Oral Hygiene Habits in 23 Counltries 16()7

than for older adolescents. It

has also been shown that the
toothbrushing habit is quite
Denmark 'I ....I
..

stable after it is adopted Sweden

(Kuusela et al., 1996), and it
is more difficult to change Germany
later on.
The countries where the Norway
highest proportions of children
brushed according to the Austria
recommendation were in
Northern Europe. Those count- N Ireland
ries with the lowest pro-
portions were in Eastern Israel
Europe and in Spain, Belgium,
and Finland, where special Czech Rep
health education programs
should be developed. Possible Poland
socio-cultural factors should
also be studied if the programs Canada
are to be correctly targeted. An
increase of health education in Slovak Rep
oral hygiene does not ne-
cessarily improve the behavior Wales I I I I I I I I I I I I

of adolescents, if the methods

have not been developed Scotland
(Laiho et al., 1993). This has
Greenland
I I I I I I I I I I

been observed in Finland,

where improvements in
toothbrushing frequency France
have been quite slow (Kuu-
sela et al., 1997). Hungary
The results of this study
correspond well to those found Spain
in earlier surveys (Table 1). On
the contrary, in Hungary and Estonia ...........
.........

Scotland, the figures were low

compared with those reported Belgium
in earlier studies. However, in
Scotland, the earlier study Latvia .............

sample was from only the ,III III III III

Lothian region. In Austria and Russia ---------- 921.050211121

I"" " I .I
..........

Poland, on the other hand, the

present results indicate a Finland ""." . " ." ." ."
'-"'" "' -
I I

marked improvement. There Z - I/ Z

/ Z E
was an intensive TV campaign
of dental hygiene products, and
Lithuania 1..............
I%
education programs were 0 20 40 60 80
1 00
introduced to schools in Poland
a few years before this study.
The factor most consist- rm>1/day ELi7/dayl
ently associated with tooth-
brushing frequency seemed Figure 2. Percentages of 11-year-old girls who brush their teeth more than once a day/once a day in
different countries.
to be gender. The better
toothbrushing behavior of
girls seemed to be universal,
except in France. It seems that boys require more targeted the behavior of boys than of girls, because girls tend to have
health education programs than girls in almost all countries. more health-directed behavior than boys (Helakorpi ct (l.,
In general, girls are more concerned about their personal 1995; King et al., 1996).
hygiene than boys. It might also be more difficult to change The second most common factor associated with
1608 Kuusela et al. j Dent Res 76(9) 1997
Table 4. Odds ratios for less-than-twice-a-day toothbrushing frequenicy associated with gender, age, indicator of socio-economic
school performance, and family economy among children in different cotuntries background. Those who
Country Gender Age School Perforn iance Family Economy perform well at school are, in
(boys/girls) (1 1/13-15 yrs) (poor+average/'good) (poor+average/good) general, also more likely to
Austria 2.0a
follow other behavioral
0.5a 1.8a
Belgium 2.1a 1.6 0.9 2.0a expectations. (Ahlstr6m et al.,
Canada 2.Oa 2.2a 3.6a 1.9a 1979; Kunst, 1994). The
Czech Republic 2.9a 1.4 2.7a 1.9 improvement of welfare and
Denmark 2.2a 0.8 2.8a 1.3 school performance would
Estonia 2.Oa 1.3 1.8 2.6a evidently also improve tooth-
Finland 2.8a 2.Oa 1.7
France 1.8a 1.4 1.8a 1.7 brushing frequency as a
Germany 2.4a 0.7 2.0 2.5a consequence of environ-
Greenland 2.6a 1.0 3.6 2.6 mental or individual devel-
Hungary 2.8a 3.0a 2.4a 1.9a opment However if the
Israel 2.5a 1.3 2.0a 2.1 opmentraoevr if the
Latvia 1.9a 0.7 1.2 2.5a high-risk strategy is pre-
Lithuania 1.8a 0.6a 2.0a 2.1a ferred, the most efforts of
Northern Ireland 3.1a 1.8a 2.0 2.1a health education should be
Norway 1.9a 1.6 3.6a 1.3 directed to the children in
Poland 2.8a 1.2 5.7a 2.4a lower socio-economic groups
Russia 2.4a 1.6 1.6
Scotland 2.0a 1.4 2.7a 2.2a and those not performing
the Slovak Republic 2.5a 1.1 3.2a 1.9a well at school. Also, inter-
Spain 2.2a 0.9 2.4a - vention efforts should be
Sweden 2.2a 3.4a 1.7 2.2 targeted especially at meth-
Wales 2.5a 2.5a 1.7 3.0a ods to affect the children of
a p < 0.001. disadvantaged groups.
In conclusion, the differ-
ences in toothbrushing
toothbrushing frequency was family economy. Only in frequency of children differ considerably between and among
Denmark, Norway, France, and Sweden was this not a European countries. In eight countries, less than half of the
statistically significant risk factor. In this study, family economy children reported brushing according to recommendations. In
was a subjective measure-the child's own perception of the most of the countries, the same factors (gender, school
family economy. However, it could be expected to measure performance, family economy, and age) seemed to be
family economy quite reliably, and several other associated with toothbrushing behavior. Proximal hygiene
epidemiological surveys have also shown the importance of with flossing was very rare among the European children.
socio-economic background for determining children's
toothbrushing behavior (Honkala et al., 1981; Macgregor and
Balding, 1987; Bedi et al., 1990; Addy et al., 1994). School Acknowledgments
performance was also consistently associated with The World Health Organization's Regional Office for Europe
toothbrushing in all countries except Latvia and Belgium. This has adopted this project as a WHO collaborative study. The
association has also been observed in earlier studies (Honkala et international coordinators of the 1993-94 study were Chris
al., 1981; Traeen and Rise, 1990). Better school performance Tudor-Smith, Health Promotion, Wales, and Bente Wold,
could, to some extent, predict better socio-economic status in University of Bergen, Norway. The study was carried out in
the future and therefore may be considered as just another collaboration with Anselm Eder and Wolfgang Dur
(Austria), Danielle Piette and Lea Maes (Belgium), Alan King
and Mary Johnston (Canada), Dzamila Stehlikova (the Czech
Table 5. Percentages of children who floss their teeth daily
Republic), Bj0rn E. Holstein (Denmark), Mai Maser (Estonia),
(standardized for gender) in different countries Lasse Kannas (Finland), Christiane Dressen (France),
Country Daily Flossing (%) Elisabeth Nordlohne (Germany), Anna Aszmann and Rozsa
Mandoki (Hungary), Yossi Harel (Israel), Ilze Kalnins and
Canada 25 Ieva Ranka (Latvia), Apolinaras Zaborskis (Lithuania), Bente
Norway 17
Wold and Oddrun Samdal (Norway), Barbara Woynarowska
Northern Ireland 15
Greenland 12 (Poland), Aleksander Komkov (Russia), Candace Currie
Israel 10 (Scotland), Miro Bronis (the Slovak Republic), Ramon
Denmark 9 Mendoza (Spain), Ulla Marklund (Sweden), and Chris
Spain 9
Tudor-Smith and Laurence Moore (Wales, UK).
Austria 7
Sweden 6 The study program was supported by the authorities of
the Czech Republic 6 each participating country-most often, the Ministry of
the Slovak Republic 4 Health-but in some countries, the support was provided
Finland 3 by the responsible research institute only. No commercial
Hungary 2
support was accepted in any country.
j Dent Res 76(9) 1997 Oral Hygiene Habits in 23 Countries
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