European Journal of Public Health, Vol. 25, Supplement 2, 2015, 20–23
ßThe Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
Trends in toothbrushing in 20 countries/regions from
1994 to 2010
, Carine Vereecken
, Birgit Niclasen
, Eino Honkala
1 Department of Developmental & Preventive Sciences, Faculty of Dentistry, Kuwait University, Kuwait City, Kuwait
2 Department of Health Sciences, Faculty of Sport and Health Sciences, University of Jyva
3 Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
4 Research Foundation- Flanders (FWO), Brussels, Belgium
5 National Institute of Public Health, Copenhagen, Denmark
Correspondence: Sisko Honkala, Faculty of Dentistry, Kuwait University, Kuwait. Tel: +965 66499048, Fax: +965 25326049,
Background: For maintaining good oral health, twice-a-day toothbrushing routine is recommended world-wide.
As an association between oral diseases and the main non-communicable diseases is confirmed, the importance of
brushing is rising. The aim of this article is to describe trends in more-than-once-a-day toothbrushing frequency in
20 countries/regions participating in five consecutive HBSC Surveys between 1994 and 2010. Methods: Eleven-, 13-,
and 15-year-old children, who replied to the questionnaire in any of the five surveys, were included (N= 474 760).
Trends were analysed by logistic regression and multilevel logistic regression modelling. Results: Prevalence of
recommended toothbrushing behaviour increased in all countries except in Scandinavia, which had already
attained a very high level in 1994. The highest increase (more than + 16%) was observed in Estonia, Russia,
Latvia, Finland and in Flemish Belgium. Girls had higher prevalence of toothbrushing than boys (OR = 2.06, 99%
CI 2.03–2.10). However, the increasing trend was stronger among boys (OR
2010 vs. 1994
for boys 1.60; for girls 1.48),
and among the younger adolescents (OR
2010 vs. 1994
for 11-year-olds 1.64; for 15-year-olds 1.45). Conclusion:
Recommended toothbrushing frequency increased in most of the studied countries/regions and differences
between the countries diminished during 2004–2010.
Toothbrushing is the main self-care method to prevent the most
prevalent non-communicable diseases, periodontal disease and
dental caries. Consequently, twice-a-day toothbrushing frequency
is a universally accepted recommendation for maintaining good
dental and periodontal health.
Poor oral hygiene has been shown to be associated with higher
levels of cardiovascular diseases, diabetes mellitus, hypertension
and metabolic syndrome.
The effectiveness of regular toothbrush-
ing in preventing oral diseases has become even more important
than before, as a strong association between oral diseases and the
four main non-communicable diseases, i.e. diabetes, cancer, cardio-
vascular diseases and respiratory diseases, has been confirmed.
Very few longitudinal studies have monitored toothbrushing
habits over time in the same population.
They confirm that a
constant toothbrushing habit is adopted quite early in the life and
will not change easily later on. In Finland, health habits have been
monitored in cross-sectional surveys of 12-, 14-, 16- and 18-year-
olds with nationally representative samples every second year since
1977, and among 11-, 13- and 15-year-olds every fourth year since
They confirmed only slow improvement over two decades
among younger age groups and boys, but a decline in prevalence
of toothbrushing among girls in older age groups.
We hypothesize that higher proportions of adolescents have
adopted a twice-a-day toothbrushing habit in 2010 compared with
1994. The aim of this article is to describe the trends in more-than-
once-a-day toothbrushing frequency in different countries/regions
participating in five consecutive Health Behaviour in School-aged
Children (HBSC) Surveys between 1994 and 2010.
The HBSC mandatory question about toothbrushing ‘How often do
you brush your teeth?’ focuses on the frequency of this habit.
Response options given are from ‘never’ to ‘more than once a
day’. More-than-once-a-day toothbrushing frequency was selected
as the cut-off point for analysis, while twice-a-day toothbrushing
is a universally accepted recommendation.
Toothbrushing frequency has been determined by this question,
which has remained unchanged, since the first study of the HBSC
This same question has been used since 1977 in the Finnish
nation-wide research program, the Adolescents Health and Life-style
Survey. The reliability and validity of the question have been tested
several times and have been shown to be good.
Data were analysed using SPSS (version 18.0) and MLwiN (version
2.25). Studied variables included study year, country, gender and
age. All countries/regions included participated in five consecutive
cross-sectional HBSC surveys from 1994 onwards (1994, 1998, 2002,
2006 and 2010). These 20 countries/regions were: Austria, Flemish-
and French-speaking Belgium, Canada, Czech Republic, Denmark,
Estonia, Finland, France, Germany, Greenland, Hungary, Latvia,
Lithuania, Norway, Poland, Russia, Scotland, Sweden and Wales.
Prevalence (%) of more-than-once-a-day toothbrushing among
11-, 13- and 15-year-olds was presented as a total sample for each
country/region for five consecutive HBSC surveys, for the trends
between the individual surveys (4 years) and for the trends
between the 1994 survey and the 2010 survey (16 years). This
sample was weighted by age group and gender in analysis. Trends
in more-than-once-a-day toothbrushing frequency in different
countries/regions were analysed by logistic regression (SPSS), and
for all countries together by multilevel logistic regression modelling
(MLwiN) where children were clustered by country/region
(n= 474 760).
Prevalence of more-than-once-a-day toothbrushing frequency
increased between 1994 and 2010 in most of the countries and
regions from 30–62% to 50–72% (fig. 1). The highest increase (more
than +16%) was observed in Estonia, Russia, Latvia, Finland and in
A slight decrease in recommended toothbrushing frequency was
seen in countries with the highest prevalence in 1994 (75–86%), i.e.
in Sweden (5.4%), Denmark (4.5%) and in Norway (0.4%).
However, the frequency in these countries still remained at a high
level in the last follow-up year, between 75 and 81% (fig. 1).
Between 1994 and 1998, the improvement was over 10% in Russia,
Latvia, Estonia and Lithuania (fig. 1). Between 1998 and 2002, the
improvement was highest (+5.6%) in Canada and between 2002
and 2006, (over 5%) in French Belgium, Czech Republic, Flemish
Belgium, Finland and Estonia. Between 2006 and 2010, the improve-
ment was over 5% in Greenland, Finland and Flemish Belgium.
In all studied countries and regions between 1994 and 2010, girls
had higher prevalence of more-than-once-a-day toothbrushing
frequency than boys (OR = 2.06, 99% CI 2.03–2.10) (table 1).
Adoption of recommended toothbrushing habits increased with
age for girls (15-year-olds vs. 11-year-olds: OR = 1.50, 99% CI
1.46–1.55), but not for boys (0.95, 0.93–0.98).
The increasing trend from 1994 to 2010 was stronger among boys
than girls (OR
2010 vs. 1994
for boys 1.60; for girls 1.48) and among the
younger adolescents (OR
2010 vs. 1994
for 11-year-olds 1.64; for 15-
From a public health perspective, improvement of toothbrushing
habits is important in preventing the most common dental
diseases, but even more so in reducing common risk factors for
the main non-communicable diseases. Furthermore, twice-a-day
toothbrushing frequency is a good indicator of a healthy lifestyle
Another positive aspect of good toothbrushing
habits is that it has been shown to predict higher educational
achievements for adolescents in later life.
Trends found in our study were mostly positive. Relative and
absolute improvement was greater among the younger age groups
and boys, although these groups had more to improve upon in 1994,
and continue to have lower prevalence in more-than-once-a-day
toothbrushing in 2010. However, inequalities by country, gender
and age group have decreased quite consistently during this time
period, suggesting this to be a period of equalization overall.
A similar positive trend was reported previously in Scotland.
The small decline observed in toothbrushing prevalence in the
Scandinavian countries, especially in Denmark and Sweden, might
be attributed to different causes. The major reason is probably that
the public health focus has, in most recent years and to some extent,
drifted away from emphasising dental health. For example in
Denmark, school dental clinics have closed and children have to
1994 1998 2002 2006 2010
Figure 1 Prevalences (%) and trend of more-than-once-a-day toothbrushing among 11–15-year-old schoolchildren in 20 different countries/
regions in five consecutive HBSC surveys, from the 1994 survey to the 2010 survey (16 years)
Trends in toothbrushing 21
go to private dental clinics. Although, dental care is still free for all
children, attending services is not as easy as it was when the clinics
were on school premises. This might have especially affected less
privileged groups including the immigrant population. In general,
toothbrushing frequency in the HBSC countries has been shown to
be lower among the less privileged children.
increased in Scandinavia; in 2010 almost one-fifth of the population
in Sweden and one-tenth in Denmark were immigrants or their
descendants from dozens of different countries.
frequency has been shown to be lower and oral health poorer among
the immigrant children than among the native.
Oral health and
corresponding habits of immigrants can already be poorer (and es-
tablished) when moving to a new country.
This reflects to the
situation of their native country. The difference tends to remain
even after settling into a new living environment.
Adoption of recommended toothbrushing frequency has increased
in most of the studied countries or regions, except in the
Scandinavian countries where the frequency was already high in
1994. This has resulted in an equalization of toothbrushing
HBSC is an international study carried out in collaboration with
WHO/EURO and involves a wide network of researchers from all
participating countries and regions. The international coordinator
was Prof. Candace Currie, University of St. Andrews, and the
databank manager was Prof. Oddrun Samdal, University of
Bergen. A complete list of participating countries and researchers
is available on the HBSC website (http://www.hbsc.org). The data
collection in each country or region is funded at national level. We
are grateful for the staff at the Norwegian Social Science Data
Services, Bergen, for their work in preparing the international data
file for all the surveys.
We are grateful for the financial support from the government
ministries, research foundations and other funding bodies in the
participating countries and regions. We particularly thank the
Norwegian Directorate of Health, which contributed funding to
the HBSC Data Management Centre.
Conflicts of interest: None declared.
The article describes a positive trend in the toothbrushing
frequency in a large number of countries.
Cross-nationally, the article illustrates a declining difference
in toothbrushing frequency.
The article shows greater improvement among the younger
age groups and boys, which have been target groups for oral
health education for decades. However, these groups still
lacks far behind the others and need to be continuously
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Table 1 Odds ratios (OR) and their 99% confidence intervals (99% CI) for more-than-once-a-day toothbrushing frequency among the total
sample of the HBSC surveys in 1998, 2002, 2006 and 2010 compared with 1994, according to gender and age
All Gender Age
Boys Girls 11 years 13 years 15 years
OR 99% CI OR 99% CI OR 99% CI OR 99% CI OR 99% CI OR 99% CI
Boy (ref.) 1.00 1.00 1.00 1.00
Girls 2.06 2.03–2.10 1.67 1.62–1.72 2.05 1.99–2.11 2.62 2.54–2.69
11 years (ref.) 1.00 1.00 1.00
13 years 1.04 1.02–1.06 0.94 0.92–0.97 1.16 1.13–1.19
15 years 1.18 1.16–1.20 0.95 0.93–0.98 1.50 1.46–1.55
1994 (ref.) 1.00 1.00 1.00 1.00 1.00 1.00 1.21–1.34
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2002 1.31 1.28–1.35 1.33 1.29–1.38 1.29 1.25–1.34 1.32 1.26–1.38 1.31 1.26–1.37 1.29
2006 1.46 1.42–1.50 1.51 1.45–1.56 1.41 1.36–1.47 1.45 1.39–1.52 1.49 1.42–1.55 1.44 1.37–1.51
2010 1.54 1.50–1.58 1.60 1.55–1.66 1.48 1.43–1.53 1.64 1.57–1.71 1.54 1.48–1.61 1.45 1.38–1.52
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Trends in toothbrushing 23