Assessment of Oral Hygiene Knowledge, Attitude, and Practices among Medical Students in a Medical College in the State of Telangana: A Cross-sectional Survey.
Oral health is a vital component of the general health of an individual that influences on one's general quality of life and well-being.  According to the World Oral Health report 2003, the prevalence of periodontitis is 86% in India. Oral health has been neglected for long in India.  Enhanced oral health can be achieved with increased awareness and better practices. 
A knowledge, attitude, and practices (KAP) survey is a quantitative method (pre-defined questions formatted in standardized questionnaires) that provides access to quantitative and qualitative information. KAP survey essentially records an "opinion" and is based on the "declarative" (i.e., statements). The survey reveals what was said, but there may be considerable gaps between what is said and what is done. 
KAP study tells us what people know about certain things, how they feel, and also how they behave. The knowledge possessed by a community refers to their understanding of any given topic oral hygiene in this case. Attitude is an acquired characteristic of an individual. People demonstrate a wide variety of attitudes toward dental care and dentists.  These attitudes naturally reflect their own experiences, cultural perceptions, familial beliefs, and other life situations, and they strongly influence the health status of the oral cavity.  Practice refers to the ways in which they demonstrate their knowledge and attitude through their actions. 
Keeping a healthy oral profile requires joint efforts from the dentist as well as the patient himself. One of the most important factors that decide the dental health of a population is the outlook of its people toward their dentition.  Students play a vital role in health promotion and preventive information dissemination among their family and their society, and therefore, their oral health attitude and practices conform to the expectations of the population. The booming young medical students are not exposed to health-care knowledge as dental professionals.  Understanding the levels of KAP will enable a more efficient process of awareness creation as it will allow the program to be tailored more appropriately to the needs of the community. Hence, the present study was aimed to assess the KAP of oral hygiene among medical students aged 17-35 years.
An observational, descriptive, cross-sectional survey study was conducted at Kamineni Institute of Medical Sciences, Nalgonda. This proposed study was reviewed by the Institutional Ethical Committee, and their clearance was obtained. A total of 500 students were selected using a convenience sampling technique. A informed consent was obtained from each patient.
Study Sample and Sampling Technique
A cross-sectional study using a 20-item structured was conducted to assess oral hygiene KAP in a sample of medical students (n = 500) [Graph 1].
All the semester students who were present on the day of survey were included in the study. Permission to conduct this study was obtained from the concerned authorities of the college, who in turn, through a circular, notified students about the intent of the study. Pilot study was conducted on 50 students for pre-testing of the questionnaire and to determine feasibility of the study.
The study involved self-administration of pre-tested structured closed-ended questionnaire, to each student in their classrooms. Questionnaire consisted of 20 multiple choice questions to evaluate knowledge (5 questions) and attitude (5 questions); students received a full explanation on how to fill in the questionnaire. Students were asked to fill in the questionnaire without discussing with each other, and an average time of 15 min was taken to complete the procedure. It was made sure that none of the questions were left un-attempted. Anonymity of the respondents was assured. The students were then provided with health education regarding oral hygiene practices. The study was completed within a period of 2 weeks.
The data collected were compiled using Microsoft Office Excel and was subjected to statistical analysis using the statistical software package, Statistical Package for the Social Sciences version 19.0 for MS Windows, and P < 0.05 was considered statistically significant. Frequency distribution, number, and percentage were calculated. The descriptive statistics and statistical significance of any difference between the two genders were determined using Chi-square test.
The present study was carried out on 500 students. Among them, 40% were males and 60% were females [Graph 2].
Table 1 reveals that 96.6% of the participants agree that there are two sets of dentition in human beings, only 1% of the participants did not know about it, and 2.4% disagree with it. 91.8% of the participants had knowledge about the number of permanent teeth in an adult's mouth, whereas the remaining 8.2% of the participants did not have correct knowledge. 38.2% of the participants had knowledge about dental deposits, whereas 22.8% did not know about it and the rest of the participants, i.e., 39% assume it to be the food particles or stains. The difference between males and females regarding knowledge of dental deposits was statistically significant (P= 0.004), and females had better knowledge regarding it. 72.6% of the participants had knowledge about interdental aids, whereas 27.4% of the students had no knowledge regarding it. The difference between males and females regarding knowledge about interdental aids was statistically significant (P = 0.003), and females had better knowledge regarding it. 75.4% of students knew that bleeding gums are related to our general health conditions, whereas 21.6% of the students disagree with that and 3% of them had no knowledge about it. The difference between males and females regarding the knowledge about bleeding gums corresponding to the general health condition was statistically significant (P = 0.038), and males had better knowledge regarding it.
Table 2 shows that most of the study population (95.4%) think that oral health is important for overall health, whereas the remaining 4.6% do not think that it is important. 56.8% of the participants visit the dentist only in problem, whereas 19.6% of them never visited the dentist. Of the study population, 10.8% prefer scaling as the reason for visiting the dentist, 29.6% said as a routine visit, and 45.2% said for other reasons such as bleeding gums and orthodontic treatment ... According to 51.4% of the study population, they never had a problem, it is the main reason for not having routine dental visits, 5.6% of the participants think that dental treatment is expensive, and 26.8% of the students could not visit the dentist due to lack of time. The difference between males and females regarding the reason for not having routine dental visits is statistically significant (P < 0.05). 96.8% of the participants had a good attitude of using toothbrush and toothpaste to clean the teeth, and 2% of the individuals prefer toothbrush and toothpowder.
Table 3 reveals that 69.4% of the participants brush their teeth once daily, 28.4% of them brush twice daily, and 1.6% of the individuals brush occasionally. The difference between males and females regarding the frequency of tooth-brushing was statistically significant (P = 0.032). 64.0% of the participants prefer the combined type of motion; 7.6% of the individuals use vertical motion; 9.4% of the individuals prefer horizontal motion; and 19.0% of the individuals prefer circular motion while brushing. 48.8% of the population had a practice of using medium bristled toothbrush; 37.2% used soft-bristled toothbrush, whereas only 4.4% used hard-bristled toothbrush and 9.6% of the individuals never noticed the particular type of toothbrush. Majority 49.0% of individuals change their toothbrush once in 2-3 months, whereas 30.8% change it monthly and 6.4% change when it is spoilt.
The difference between males and females, regarding the practice of changing toothbrush, was statistically significant (P = 0.002). 92.2% of the participants clean their tongue and prefer to use a tongue cleaner for this. 80.8% of the people had a good practice of rinsing their mouth after eating. Only 33.8% of the individuals had a practice of using mouthwash; 66.2% of the participants do not use mouthwash, and the difference between males and females, regarding the use of mouthwash, was statistically significant (P = 0.047). 60.8% of the individuals never noticed smell from their mouth. In addition to toothbrush, 32.0% used tooth pricks, only 13.0% had a good practice of using dental floss, and 5.2% used interdental brushes. Only 27.6% of the participants noticed bleeding in their gums; of them, 31.8% had a good practice of visiting the dentist and 28.8% of the participants waited for bleeding to reoccur. The results of the study have pointed out that educational level was one of the important factors that governed the knowledge, attitude, and oral hygiene practices of the people.
It has been observed that oral hygiene has mostly remained as an ignored and unrealized major social problem. 
According to the consumer usage and attitudes study done in 2010, the most shocking observation is that nearly half of the Indian population does not use a toothbrush and only 51% brushed their teeth using a toothbrush and toothpaste. 
Over the past 20 years, a significant amount of emphasis has been made on prevention of diseases rather than the treatment aspect. Healthy teeth can last us a lifetime with the proper preventive dental care. Preventive oral health knowledge, attitude, and its practice are the important ways of keeping our teeth healthy.  Hence, in the present study, attempts were made to evaluate preventive oral health knowledge, practice, and attitude of the population of medical students in a private medical college.
In the present study, the knowledge regarding oral hygiene was satisfactory except knowledge about dental floss, whereas poor knowledge on the perception of oral health was reported among engineering students of Tiruchengode. 
In the present study, only 28.4% [Table 3] of the medical students reported of brushing their teeth twice daily and it was in contrary with the results of Peltzer and Pengpid who reported it to be 67.2% in university students of 26 low-, middle-, and high-income countries.  On the contrary, Rimondini et al.  described a much higher percentage (92.1%) in Italian University students, whereas Prasad et al.  and Gasgoos et al.  reported small percentage 30.7% and 15.4%, respectively. The present observation may be due to the occupancy of the students in their curricular activities and ignorant attitude toward oral hygiene, considering it as less important.
In the present study, males brush their teeth more frequently than females [Table 3] which were statistically significant (P = 0.05), and it was contrary with the result of El-Qaderi and Taani,  Gasgoos et al.,  and Prasad et al.,  where females brush their teeth more frequently. This difference can attribute to a higher regarding personal hygiene and health care among males.
Hamilton and Coulby found that a high percentage (44%) studied in North Eastern Ontario used dental floss; in contrast, this current study reported only 13% [Table 3] of students used dental floss.  Reason for this may be the significant resource allocation to health education programs that are carried out in Canada. This emphasizes the urgent need for educating and motivating the public to use this efficient method for oral health care. Majority of the studied population showed that they clean their tongue either with toothbrush or tongue cleaner. Furthermore, 80.8% [Table 3] of the sample population rinses their mouth after eating food. This very basic method of maintaining oral hygiene is a clear indication of good awareness.
It is noteworthy that 64% [Table 3] of the respondents brushed their teeth using combined motion, which is in contrary to the horizontal motion causing jeopardize of the tooth structure. This finding is in contrary with that of the study done by Zhu et al.,  where 60% of the sample used horizontal motion. Only 37.2% [Table 3] of the subjects use soft brush, which is more than that observed among Zhu et al.'s subjects where 27% of the sample use the same.  49% change their toothbrush once in 3 months [Table 3], and surprisingly 6.4% [Table 3] change their brush only when it is useless. 33.8% [Table 3] of subjects used a mouthwash. Interestingly enough, they used it to treat malodor. Furthermore, 39.7% reported halitosis. The present study is in contrast with that of an epidemiologic survey of the general population of Japan where 24% of the individuals examined complained about bad breath.
27.6% [Table 3] of the total subjects reported bleeding gums. The present study is in contrary with the studies of Gilbert and Nuttal and Buhlin et al. who showed that self reported bleeding gums were high in percentage. [12,13] The present study is in agreement with the studies of Tervonen and Knuttila and Kallio et al. who showed that most of the patients did not notice bleeding from gums. [14,15]
Visiting a dentist is still not considered a preventive dental behavior, and at present, it only depends on the treatment needs.  The present study shows that around 75% [Table 2] of the patients visited the dentist only in problem and only 10% [Table 2] of the population visited the dentist on regular basis after every 6 months. These results are similar to the study done by Jain et al., where 54% of the subjects visited the dentists when there is a problem. [R] These results are also equivocal with the study conducted by Maryln et al. in which 67.9% of the study population reported having had a dental checkup at least once a year in the past 5 years. 
Student's self-reporting of behaviors may have resulted in over-reporting of proper hygiene practices. Determination of causality is difficult using this cross-sectional study design.
The present study presented a comprehensive overview of oral health-related KAP among medical students in a private medical college in Nalgonda. The awareness about the oral health of the studied subjects stands acceptable. Knowledge about dental floss and frequency of visiting the dentist and brushing frequency was inadequate. More concentration needs to be undertaken regarding oral health care in terms of health education programs.
We, as dentists, will have to keep reinforcing the importance of correcting all aspects related to brushing and flossing along with the importance of regular checkups.
The authors wish to thank all the medical students participated, for their kind cooperation throughout the survey.
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G. Jagadish Reddy (1), K. Suchithra (2), A. Abhinav (3), V. Ravikiran (4)
Department of Periodontics, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Telangana, India
Email for correspondence: email@example.com
Caption: Graph 1: Total number of participants
Table 1: Comparison of gender related to knowledge of oral hygiene Items Male (%) Female (%) There are two sets of dentition in human beings, baby teeth set, and permanent teeth set, and permanent teeth set Agree 191 (96) 292 (97) Disagree 5 (2.5) 7(2.3) Do not know 3(1.5) 2(0.7) How many permanent teeth are there in adults mouth 20 5 (2.5) 3(1.0) 28 14 (7.0) 13 (4.3) 30 2(1.0) 4(1.3) 32 178 (89.4) 281 (93.4) If there is a yellow or brownish yellow discoloration near tooth/gum, what is it Food particles 28 (14.1) 38 (12.6) Calculus/tartar 59 (29.6) 132 (43.9) Stains 66 (33.2) 63 (20.9) Do not know 46 (23.1) 68 (22.6) Do you know there are some aids to clean the spaces between teeth, which are named as interdental aids? Yes 129 (64.8) 234 (77.7) No 70 (35.2) 67 (22.3) Is bleeding gums related to our general health condition Agree 162 (81.4) 215 (71.4) Disagree 30 (15.1) 78 (25.9) Do not know 7 (3.5) 8(2.7) Items Total (%) Chi-square There are two sets of dentition in human 0.882 beings, baby teeth set, and permanent teeth set, and permanent teeth set Agree 483 (96.6) Disagree 12 (2.4) Do not know 5(1.0) How many permanent teeth are there in 3.661 adults mouth 20 8 (1.6) 28 27 (5.4) 30 6(1.2) 32 459 (91.8) If there is a yellow or brownish yellow 13.484 discoloration near tooth/gum, what is it Food particles 66 (13.2) Calculus/tartar 191 (38.2) Stains 129 (25.8) Do not know 114 (22.8) Do you know there are some aids to 11.787 clean the spaces between teeth, which are named as interdental aids? Yes 363 (72.6) No 137 (27.4) Is bleeding gums related to our general 8.430 health condition Agree 377 (75.4) Disagree 108 (21.6) Do not know 15 (3.0) Items P value There are two sets of dentition in human 0.643 beings, baby teeth set, and permanent teeth set, and permanent teeth set Agree Disagree Do not know How many permanent teeth are there in 0.300 adults mouth 20 28 30 32 If there is a yellow or brownish yellow 0.004 * discoloration near tooth/gum, what is it Food particles Calculus/tartar Stains Do not know Do you know there are some aids to 0.003 * clean the spaces between teeth, which are named as interdental aids? Yes No Is bleeding gums related to our general 0.038 * health condition Agree Disagree Do not know * P<0.05 statistically significant Table 2: Comparison of gender related to the attitude of oral hygiene Items Male (%) Female (%) Do you think, oral health is important for overall health? Yes 189 (95.0) 288 (95.7) No 10 (5.0) 13 (4.3) How often should you visit the dentist? Only in problem 112 (56.3) 172 (57.1) Once in 3 months 19 (9.5) 24 (8.0) Once in 6 months 26 (13.0) 49 (16.3) Never 42 (21.1) 56 (18.6) Reason for visiting the dentist? Extraction 2(1.0) 8(2.7) As a routine visit 53 (26.6) 95 (31.6) Filling 20 (10.1) 24 (8.0) Scaling 27 (13.6) 27 (9.0) Replacement of teeth 10 (5.0) 8(2.7) Others 87 (43.7) 139 (46.2) Reason for not having routine dental visit? Lack of time 64 (32.2) 70 (23.3) Lack of access 12 (6.0) 4(1.3) Expensive 8(4.0) 20 (6.6) Lack of knowledge and motivation 4(2.0) 25 (8.3) I never had a problem 94 (47.2) 163 (54.2) Others 17 (8.5) 19 (6.3) Which one do you prefer to clean your teeth? Toothbrush and toothpaste 191 (96.0) 293 (97.3) Toothbrush and powder 3(1.5) 7(2.3) Others 5(2.5) 1 (0.3) Items Total (%) Chi-square Do you think, oral health is 1.661 important for overall health? Yes 477 (95.4) No 23 (4.6) How often should you visit the dentist? 3.374 Only in problem 284 (56.8) Once in 3 months 43 (8.6) Once in 6 months 75 (15.0) Never 98 (19.6) Reason for visiting the dentist? 7.577 Extraction 10 (2.0) As a routine visit 148 (29.6) Filling 44 (8.8) Scaling 54 (10.8) Replacement of teeth 18 (3.6) Others 226 (45.2) Reason for not having routine dental 23.422 visit? Lack of time 134 (26.8) Lack of access 16 (3.2) Expensive 28 (5.6) Lack of knowledge and motivation 29 (5.8) I never had a problem 257 (51.4) Others 36 (7.2) Which one do you prefer to clean your 8.241 teeth? Toothbrush and toothpaste 484 (96.8) Toothbrush and powder 10 (2.0) Others 6 (1.2) Items P value Do you think, oral health is 0.436 important for overall health? Yes No How often should you visit the dentist? 0.497 Only in problem Once in 3 months Once in 6 months Never Reason for visiting the dentist? 0.181 Extraction As a routine visit Filling Scaling Replacement of teeth Others Reason for not having routine dental 0.001 * visit? Lack of time Lack of access Expensive Lack of knowledge and motivation I never had a problem Others Which one do you prefer to clean your 0.083 teeth? Toothbrush and toothpaste Toothbrush and powder Others * P<0.05 statistically significant Table 3: comparison of gender related to oral hygiene practices Items Male (%) Female (%) How often do you brush your teeth? Once a day 133 (66.8) 214 (71.1) Twice a day 57 (28.6) 85 (28.2) More than twice a day 2(1.0) 1 (0.3) Occasionally 7(3.5) 1 (0.3) What type of motion do you use while brushing? Vertical 17 (8.5) 21 (7.0) Horizontal 17 (8.5) 30 (10.0) Combined 124 (62.3) 196 (65.1) Circular 41 (20.6) 54 (17.9) What type of brush do you use? Hard 11 (5.5) 11 (3.7) Medium 106 (53.3) 138 (45.8) Soft 65 (32.7) 121 (40.2) Never noticed 17 (8.5) 31 (10.3) How often you change your toothbrush? Monthly 63 (31.7) 91 (30.2) 2-3 months 105 (52.8) 140 (46.5) 4-5 months 14 (7.0) 55 (18.3) When bristles flare 17 (8.5) 15 (5.0) Do you clean your tongue? Yes 179 (89.9) 282 (93.7) No 20 (10.1) 19 (6.3) Do you rinse your mouth after eating? Yes 165 (82.9) 239 (79.4) No 34 (17.1) 62 (20.6) Do you use a mouthwash? Yes 78 (39.2) 91 (30.2) No 121 (60.8) 210 (69.8) Have you ever noticed smell from your mouth? Yes 90 (45.2) 106 (35.2) No 109 (54.8) 195 (64.8) Apart from brushing, what other methods do you use to clean your teeth? Dental floss 25 (12.6) 40 (13.3) Interdental brushes 10 (5.0) 16 (5.3) Tooth pricks 74 (37.2) 86 (28.6) None 90 (45.2) 159 (52.8) Have you ever noticed bleeding in your gums? Yes 56 (28.1) 82 (27.2) No 143 (71.9) 219 (72.75) If yes, what method you prefer to control bleeding Visit a medical practitioner 9(14.5) 15 (16.9) Visit a dentist 17 (27.4) 31 (34.8) Use some home remedies 19 (30.6) 26 (29.2) Wait for bleeding to reoccur 13 (21.0) 16 (18.0) Others 4 (6.5) 1 (1.1) Items Total (%) Chi-square How often do you brush your teeth? 8.821 Once a day 347 (69.4) Twice a day 142 (28.4) More than twice a day 3 (0.6) Occasionally 8 (1.6) What type of motion do you use while 1.239 brushing? Vertical 38 (7.6) Horizontal 47 (9.4) Combined 320 (64.0) Circular 95 (19.0) What type of brush do you use? 4.520 Hard 22 (4.4) Medium 244 (48.8) Soft 186 (37.2) Never noticed 48 (9.6) How often you change your toothbrush? 14.368 Monthly 154 (30.8) 2-3 months 245 (49.0) 4-5 months 69 (13.8) When bristles flare 32 (6.4) Do you clean your tongue? 2.328 Yes 461 (92.2) No 39 (7.8) Do you rinse your mouth after eating? 0.953 Yes 404 (80.8) No 96 (19.2) Do you use a mouthwash? 6.101 Yes 169 (33.8) No 331 (66.2) Have you ever noticed smell from 3.991 your mouth? Yes 196 (39.2) No 304 (60.8) Apart from brushing, what other methods 4.235 do you use to clean your teeth? Dental floss 65 (13.0) Interdental brushes 26 (5.2) Tooth pricks 160 (32.0) None 249 (49.8) Have you ever noticed bleeding in 5.710 your gums? Yes 138 (27.6) No 362 (72.4) If yes, what method you prefer to 4.085 control bleeding Visit a medical practitioner 24 (15.9) Visit a dentist 48 (31.8) Use some home remedies 45 (29.8) Wait for bleeding to reoccur 29 (19.2) Others 5 (3.3) Items P value How often do you brush your teeth? 0.032 * Once a day Twice a day More than twice a day Occasionally What type of motion do you use while 0.744 brushing? Vertical Horizontal Combined Circular What type of brush do you use? 0.210 Hard Medium Soft Never noticed How often you change your toothbrush? 0.002 * Monthly 2-3 months 4-5 months When bristles flare Do you clean your tongue? 0.127 Yes No Do you rinse your mouth after eating? 0.329 Yes No Do you use a mouthwash? 0.047 * Yes No Have you ever noticed smell from 0.262 your mouth? Yes No Apart from brushing, what other methods 0.237 do you use to clean your teeth? Dental floss Interdental brushes Tooth pricks None Have you ever noticed bleeding in 0.127 your gums? Yes No If yes, what method you prefer to 0.395 control bleeding Visit a medical practitioner Visit a dentist Use some home remedies Wait for bleeding to reoccur Others * P<0.05 statistically significant Graph 2: Gender distribution of participants female 60% male 40% Note: Table made from pie chart.
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Reddy, G. Jagadish; Suchithra, K.; Abhinav, A.; Ravikiran, V.|
|Publication:||Indian Journal of Dental Advancements|
|Date:||Jan 1, 2018|
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