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Causes for non-usage of floss among students in a dental institution in North India: A questionnaire study.

ABSTRACT

Plaque accumulation on the interproximal surfaces of the teeth can initiate periodontal disease and caries. For removal of plaque from interproximal surfaces, dental floss is recommended by oral health practitioners. However, advice on flossing is usually not well received and followed by the client. Objective: This study sought to identify the most common causes for non-usage of floss among the dental student population in Kanti Devi Dental College and Hospital, Mathura, India. Methods: A total of 404 dental students were segregated into flossers and non-flossers. A questionnaire on the causes for non-usage of floss was administered to the non-flossers, who were asked to select the 2 most appropriate causes for non-usage of floss. Results: Of the 404 dental students, 287 were non-flossers and 117 were flossers. Among 287 non-flossers, 62 students (21.60/0 chose "never been introduced to the habit of flossing by my parents" and "I feel my mouth is clean after brushing" as the most common combination of causes. Conclusion: The findings of this study suggest that dental students in Mathura are using floss to a very limited extent. Hence, the inclusion of advice on flossing in the oral hygiene instructions to their clients is also limited. In order to increase the awareness of flossing in the general population, efforts have to be made to better instill the importance of complete oral hygiene, which includes flossing, in the dental student population.

RESUME

L'accumulation de la plaque sur les surfaces interproximales des dents peut provoquer la maladie parodontale et causer des caries. Les professionnels de la sante buccodentaire conseillent d'utiliser la soie dentaire pour enlever la plaque des surfaces interproximales. Cependant, ces conseils ne sant pas toujours bien accueillis ni suivis par le client. Objet : Cette etude sert a identifier les causes les plus communes de l'absence d'utilisation de la soie dentaire chez la population etudiante du programme dentaire de l'etablissement Kanti Devi Dental College and Hospital, situe a Mathura en Inde. Methodes : En tout, 404 etudiants en dentisterie furent separes en deux groupes; ceux qui utilisent la sole dentaire et ceux qui ne l'utilisent pas. Un questionnaire sur les causes de l'absence d'utilisation de la soie dentaire a ete distribue au groupe d'etudiants qui n'utilisent pas la soie dentaire. Ces etudiants devaient selectionner les 2 causes principales pour lesquelles Is n'utilisent pas la soie dentaire. Resultats : Parmi les 404 etudiants en dentisterie, 287 n'utilisaient pas la soie dentaire et 117 l'utilisaient. Parmi les 287 etudiants qui n'utilisent pas la soie dentaire, 62 etudiants (21.6 0/o) ont selectionne les combinaisons de reponses suivantes comme etant les causes les plus communes pour lesquelles utiliser la soie dentaire ne fait pas partie de leur routine d'hygiene buccodentaire : Je n'ai jamais ete introduit a l'habitude d'utiliser la soie dentaire par mes parents [much greater than] et [much less than] Je trouve que ma bouche est propre apres le brossage [much greater than]. Conclusion : Les resultats de cette etude indiquent que les etudiants du programme dentaire a Mathura utilisent tres peu la soie dentaire. Consequemment, des conseils sur l'utilisation de la soie dentaire ne sont pas ajoutes aux instructions d'hygiene buccale qu'ils donnent a leurs clients. Afin de sensibiliser l'ensemble de la population a l'importance d'utiliser la soie dentaire, des efforts doivent etre mis pour que la population etudiante puisse mieux comprendre qu'une routine d'hygiene buccodentaire complete est importante, et qu'elle doit inclure l'utilisation de la soie dentaire.

Key words: dental health behaviour; dental students; flossing; instructions; oral hygiene

INTRODUCTION

Plaque accumulation on the interproximal surfaces of the teeth can initiate periodontal disease. (1) Brushes usually do not reach and remove plaque from interproximal surfaces. For removal of plaque from these surfaces, dental floss is recommended by oral health practitioners. (1) Flossing significantly decreases the abundance of microbial species associated with periodontal disease and dental caries. (2) In the early 1800s, Dr. Levi Spear Parmly first introduced flossing as the most efficient way to prevent periodontal disease. (3), (4) Yet, while clients are compliant with advice and instructions on toothbrushing techniques, advice on flossing is usually not well received and followed. (5)

Different populations have been shown to floss with different frequency. (5), (6) Compared to the population in India, the general public in the western and developed world is very conscious of oral health and tends to use floss as an oral hygiene aid more readily. (7) In many developing countries like India, however, flossing is not practised regularly. In a study conducted on non-medical, paramedical, and medical students in Udaipur city, India, approximately 22.7% of the students used dental floss as an additional oral hygiene aid. (7) In another study, which included first-and final-year dental students in Udaipur city, India, it was reported that only 4.9% of first-year students flossed, whereas 12.1% of the final-year students flossed. (8) Usage of dental floss and the importance of maintaining good oral hygiene is usually advocated by oral health practitioners. Causes for low usage of floss could be variable; limited data have been gathered on this subject. This gap in the literature is problematic because dental students assume the role of advisors For oral hygiene maintenance when they enter clinical practice. Consequently, the aim of this study was to determine the causes for non-usage or floss among dental students in Mathura, India.

METHODS

A total of 404 third-year, final-year, internship, and postgraduate dental students in Kanti Devi Dental College and Hospital, Mathura, India, were included in a survey. The age range of the participants was 20-26 years; the average age was 23 years. Students were segregated into dental floss users (who floss regularly or occasionally) and dental floss non-users. Of the 404 dental students, 287 were non-users of dental floss. Subsequently, a questionnaire was specifically designed to determine the causes for nonusage of floss among these 287 non-users (Figure 1). The questionnaire was pretested through a pilot survey, and 6 major causes for non-usage of floss were identified, from which respondents were asked to select the 2 most appropriate. The questionnaires were handed out between 20 August 2012 and 30 August 2012, and authors SR and RS were present individually with the students while they completed it. Response rate to the questionnaire among the non-users of dental floss was 100%. All 404 dental students were also asked if they advised their clients to use dental floss.

Table 1. Distribution of the identified causes for non-usage of floss

         Combination of causes for non-usage of     Frequency   Percent
                         floss                                   (%)

1      Never been introduced to the habit of              62     21.6
       flossing by my parents / I feel my mouth
       is clean after brushing

2      Time consuming / I feel my mouth is clean          52     18.1
       after brushing

3      Technique sensitive / I feel my mouth is           43     15.0
       clean after brushing

       Never been introduced to it by my parents
       or dentists /

4      Participant is not aware of the correct            39     13.6
       technique of using floss

5      Never been introduced to the habit of              26      9.1
       flossing by my parents / technique
       sensitive

6      Participant is not aware of the correct            26      9.1
       technique of using floss / I feel my mouth
       is clean after brushing

7      Time consuming / technique sensitive               17      5.9

8      Participant is not aware of the correct             8      2.8
       technique of using floss / technique
       sensitive

9      Never been introduced to the habit of               6      2.1
       flossing by my parents / time consuming

10     Participant is not aware of the correct             5      1.7
       technique of using floss / time consuming

11     Costly / I feel my mouth is clean after             2      0.7
       brushing

12     Never been introduced to the habit of               1      0.3
       flossing / costly

Total                                                    287      100


Data on age, gender, demography, and socioeconomic status were also collected. Socioeconomic status was classified according to Prasad's classification. (9) All aspects or the study were reviewed and approved by the Institutional Ethical Committee. The research was conducted in full accordance with the World Medical Association Declaration of Helsinki. All of the students who participated in the study gave their consent to participate.

Statistical analysis

Data gathered from the students were analysed using the Statistical Package for the Social Sciences (SPSS), software version 17.0, manufactured by IBM. Chi-square tests were used to calculate proportions at 5% level of significance.

RESULTS

A total of 404 dental students participated in the study. Of the total survey population, 117 (29%) reported using floss as compared to 287 (71%) who did not. The pretested questionnaire was administered to the non-flossers. A chart explaining the distribution of subjects in the study is presented in Figure 2. Among the dental floss nonusers (287), 33% were third-year students and 18% were postgraduate students.

The 2 most common reasons for non-usage of floss were "never been introduced to the habit of flossing by my parents" and "I feel my mouth is clean after brushing" (21.6%). The next most common combination stated was "time consuming" and "I feel my mouth is clean after brushing" (18.1%). The third most common combination reported by non-flossing students was "technique sensitive" and "I feel my mow Ii is clean after brushing" (15%). Another substantial group (13.6%) reported "never been introduced to the habit of flossing by my parents" and "not aware of the correct technique of using floss." These combinations of causes are presented in Table 1. Approximately 68% of the dental floss non-users who live in urban areas cited "time consuming" and "I feel my mouth is clean arter brushing" as the 2 most common causes (20.5%), while 17.9% identified "never been introduced to the habit of flossing by my parents" and "I feel my mouth is clean after brushing" as the 2 most common causes. Among the third-year and final-year students, 29.2% and 27.3%, respectively, gave "never been introduced to the habit of flossing by my parents" and "I feel my mouth is clean after brushing" as the most common causes. In addition, 17.5% of the interns and 21.6% of the postgraduates reported "time consuming" and "I feel my mouth is clean after brushing" as the most appropriate causes for not flossing.

Table 2. Distribution, according to
education, of professional
recommendations to clients
regarding floss use

             Advising floss use to clients
Education                              Total
                   Yes           No
Third year       5 (2.6%)  96 (44.0%)    101
Fourth year    47 (25.2%)  54 (24.7%)    101
Interns        58 (31.1%)  43 (19.7%)    101
Postgraduates  76 (41.1%)  25 (11.6%)    101
Total          186 (100%)  218 (100%)    404

p < 0.05
Chi-square test


Among the 404 students who participated in the survey, 46% said that they advised their clients to floss, while 54% did not (Table 2). There was a linear increase in the number of students recommending flossing to their clients (third-year = 2.6%; final-year = 25.2%; internship = 31.1%; postgraduate = 41.1%) (Table 2). Ninety-three percent of floss users advised their clients to floss, whereas only 26% of dental floss non-users recommended flossing to their clients. There was a statistically significant difference between years of education and reasons for recommending flossing to clients (p < 0.05). There were also statistically significant differences between years of education and reasons for non-usage of Floss (p < 0.05) (Table 3).

DISCUSSION

Several studies have shown the usefulness of dental floss in maintaining oral health. However, flossing is not practised by many individuals, and those who do floss do not do so regularly. (6) Professional oral health practitioners play an important role in teaching clients about oral hygiene techniques and in encouraging their use. In this study, students in their third year or final year, as well as interns and postgraduates were included because, according to the teaching curricul urn of the university to which the college is attached, clinical postings and interactions with clients begin in the third year of instruction. In the questionnaire, participants were asked to select the 2 most appropriate causes for not flossing, because during are pilot survey the authors (SR and RS) realized that most of the participants had more than one reason for not flossing. The 6 causes For non-usage of Floss in the questionnaire were identified Liner a pilot survey of 100 non-flossing students.

In our initial survey, only 29% reported usage of floss compared to the 71% who reported non-usage of floss. In a study conducted in United States on health care professionals, daily flossing among periodontists was reported to be 82%, though a slightly smaller number (74%) said they recommended that their clients floss once a day. (10) In a study of 79 male dentists, daily flossing was reported to be 56.3%. Clearly, the budding dental professionals in our study were using floss far less when compared to the dental professionals in the developed world. (11)

Among the combination of causes chosen by the students, "never been introduced to the habit of flossing by my parents" and "I feel my mouth is clean after brushing" emerged as a commonly cited combination of reasons. "Never been introduced to the habit of flossing by my parents" seems to be a reasonable choice because, if the parents are themselves unaware of the technique of flossing, it would be unlikely that they would encourage or teach their children to floss. If a habit is not introduced by a parent or dentist at home or in the clinic, it would be unreasonable to expect it from the individual when he or she grows old. (12-14) In addition, there is no clarity on when to initiate flossing in children. In contrast, there is adequate guidance given to parents on when to initiate toothbrushing in their children. This inconsistency or lack of clear recommendations for childhood oral hygiene practices from professional and paediatric organizations may be a contributing factor for low rates of dental flossing. (15)

The next most common reason cited by participants was that they felt their mouth was clean after brushing. Because toothbrushing is usually performed first during daily oral care, the need for additional oral hygiene measures may not seem as important, particularly if participants feel that brushing removes substantial amounts of plaque from the surfaces of the teeth. As a result, when instructing clients on flossing, care should be given to recommend that flossing be performed first, followed by toothbrushing. (16) This protocol also facilitates better absorption of fluoride from toothpaste on all tooth surfaces, especially interproximal, after the removal of the biofilm. (16)

Table 3. Distribution of reasons for non-usage of floss according
to education

                                            Combination of causes*

Education        1      2      3     4      5     6     7        8

Third year       17     0      4     28     0     2     12       2
              17.7%  0.0%   4.2%  29.25  0.0%  2.1%  12.5%    2.1%

Final year        6     3      8     21     3     0      8       3
               7.8%  3.9%  10.4%  27.3%  3.9%  0.0%  10.4%    3.9%

Interns          11     3      7      6     2     1      2       9
              17.5%  4.8%  11.1%   9.5%  3.2%  1.6%   3.2%   14.3%

Postgraduate      5     0      7      7     0     5      4       3
               9.8%  0.0%  13.7%  13.7%  0.0%  9.8%   7.8%    5.9%

Total            39     6     26     62     5     8     26      17
              13.6%  2.1%   9.1%  21.6%  1.7%  2.8%   9.1%    5.9%

Education       9     10     11       12    Total

Third year       15     0     16       0      96
              15.6%  0.0%  16.7%    0.0%  100.0%

Final year       15     0     10       0      77
              19.5%  0.0%  13.0%    0.0%  100.0%

Interns          11     0     10       1      63
              17.5%  0.0%  15.9%    1.6%  100.0%

Postgraduate     11     2      7       0      51
              21.6%  3.9%  13.7%    0.0%  100.0%

Total            52     2     43       1     287
              18.1%  0.7%  15.0%    0.3%  100.0%

* refer to Table 1 for details on each combination
p = 0.016
Chi-square test


Many participants mentioned that flossing is a time-consuming procedure. Indeed, one of the main barriers to flossing is the time constraint. Students in professional colleges often have a very busy schedule and may have very low levels of patience. They would much rather use an automated tool or some other device to remove debris from the teeth quickly without the effort of flossing. Furthermore, it can be difficult to manipulate the floss in between every tooth. Because the oral cavity is a small space compared to the size of an average hand, trying to work the floss into each space between the teeth can be a challenge. (17) In a study of dental clients in Australia, which focussed on their dental care experiences and particularly on the relationship between clients and dentists during the provision of preventive care and advice, researchers found that many clients considered flossing to be time consuming. (18) The clients also stated that preventive care might not be of much use and would be a waste of money. (18)

"Technique sensitive" was another reason cited by our study participants for not using floss. This finding is consistent with those of a study conducted on Japanese dentists, wherein subjects were categorized into very easy, easy, moderate, and difficult groups according to their perceptions of the ease of flossing. In that study, 13.7% and 36.4% found flossing to be very difficult and difficult, respectively, whereas 30.2% and 16.8 % found flossing to be moderately easy and easy/very easy, respectively. (19)

Many students chose "not aware of the correct technique" as one of the causes for non-usage of floss. This cause was more prevalent among third- and final-year students as compared to interns and postgraduates. In a survey of floss frequency, habit, and technique conducted in a hospital dental clinic and private periodontal practice, it was noted that 40% of the participants were not using proper flossing technique. (20) This finding highlights the need for faculty to give equal importance to flossing and brushing techniques. Cases have been reported in periodontal literature wherein improper flossing techniques have lead to gingival trauma and periodontal bone loss. (21-23)

Very few people chose cost as a reason for non-usage of dental floss. Most of the participants in the study were either from high socioeconomic groups or from the upper middle class. Because of their socioeconomic status, most study participants correctly felt that they could easily afford dental floss. In addition, since study participants were either students attending dental clinics or interns and postgraduates, they had access to dental floss in the form of samples from various floss manufacturing companies. Consequently, neither the availability nor the cost of floss was a cause for non-usage of dental floss among our study participants. In a study carried out on 291 Japanese dentists, however, 187 felt floss was moderately expensive, 59 felt it was slightly expensive, and 29 felt the price of floss was cheap. (19) In our study most of the participants felt cost was not a major factor for non-usage of floss.

In our study, there was a linear increase in the number of students who floss as well as recommend flossing to their clients over the course of their dental college program. This increase is primarily due to increased exposure of these students to the benefits of flossing (reducing caries, gingivitis, and periodontal disease). Our findings are in agreement with studies conducted on Iranian dental and non-dental students. (24) Studies of first- and final-year dental students revealed that knowledge and attitudes towards better oral health improved among final-year students. (25-27)

At Kanti Devi Dental College, oral health prevention lectures begin in year 3, i.e., at the beginning of clinical years. Details about floss and flossing instructions are included in the 2-hour on-campus lectures on mechanical plaque control. In the Department of Periodontology, each student group is given a briefing about the oral hygiene instruction protocol during the clinical introductory sessions in year 3. Students are instructed to demonstrate the correct brushing technique using toothbrush and dental models after every client appointment. Dentists whose teachers at dental school had demonstrated dental flossing tended to recommend flossing to their clients 2.2 times (1.0-4.6: 95% CI) more frequently than those who did not see demonstrations of flossing at dental school. (19) The demonstration of the use of dental floss by teachers gave dentists a good impression and a positive opinion of dental flossing. This was closely associated with recommendations to their clients to use dental floss. (19) Thus, time spent by dental school educators on flossing instructions and methods should improve the attitude of the student towards flossing, which in turn may result in more flossing by the student and may also have a positive impact on their advice to clients regarding flossing.

Limitations of the study

This study included students who were primarily from urban areas and belonged to the upper or upper-middle socioeconomic strata. In addition, girls outnumbered the boys, so the suitable associations of non-usage of floss with both gender and socioeconomic strata could not be drawn.

CONCLUSIONS

The findings of this study suggest that dental students in Mathura are using floss to a very limited extent. Hence, the inclusion of advice on flossing in oral hygiene instructions to their clients is also limited. To increase the awareness of flossing in the general population, efforts have to be made to better instill the importance of complete oral hygiene, which includes flossing, in the dental student population. A more aware dental community will be better equipped to impart the importance of flossing to the masses.

Figure 2. Distribution of study participants based on responses to the survey

404 dental students

287 non flossers

Combination of causes for nonusage of floss

117 flosses

218 Non-inclusion of flossing advice in oral hygiene instructions to their patients

186 Inclusion of flossing advice in oral hygiene instructions to their patients

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Sulugodu Ramachandra Srinivas*, MDS; Reetika Singha[section], MDS; Navpreet Kaur[double dagger], MDS

* Faculty of Dentistry, SEGi University, Selangor, Malaysia

[section] Department of Periodontology, Kanti Devi Dental College, Mathura, India

[double dagger] Department of Preventive Dentistry, Kanti Devi Dental College, Mathura, India

Correspondence to: Sulugodu Ramachandra Srinivas; periosrinivasagmail.com

Submitted 2 May 2014; revised 10 July 2014; accepted 17 July 2014
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