According to the 2022 Global Oral Health Report [1] , around 3.5 billion individuals are impacted by oral diseases. These conditions not only disrupt the normal functions of the oral cavity but also have a profound impact on overall health and quality of life. However, previous research indicates that a significant portion of the population grapples with subpar oral health, a lack of awareness regarding oral hygiene, passive attitudes toward oral care, and poor oral health behavior habits [2] [3] . Given China’s expansive and diverse geographical landscape, demographic characteristics such as age, income, education, and dietary habits vary significantly among different groups. Oral health is intricately linked to factors like socioeconomic status, social standing, age, marital status, education level, tobacco and alcohol use, and dietary habits [1] [4] - [9] . For hospitalized patients in the rehabilitation department, their disease course is usually long and their mobility is inconvenient, which brings challenges to their oral hygiene and care. Along with it, risks such as bad breath, insect teeth, toothache, and an increase in harmful oral microorganisms can lead to decreased appetite, difficulty eating, increased risk of infection, and even death [10] [11] [12] . These complications not only diminish the quality of life for hospitalized patients, leading to additional financial burdens but also escalate the workload for clinical nursing personnel.

Therefore, this study takes rehabilitation nursing patients in a tertiary hospital in this city from January 2023 to October 2023 as the research object, conducts a survey on their oral health knowledge, attitudes, and behaviors, and analyzes their influencing factors. The objective is to investigate the oral health status of rehabilitation nursing patients and their possible risk factors and provide some reference for improving and developing personalized oral health education and prevention measures in the local area and even nationwide.

From January 2023 to October 2023, 231 nursing and treatment patients from a certain tertiary hospital’s rehabilitation department in this city were randomly selected as research subjects. Among them, there were 139 male patients and 92 female patients, aged 18 to 76 years old, with an average age of 53.65 ± 12.49 years old; 142 cases had cerebrovascular diseases, while 89 cases had other types of diseases. Inclusion criteria: 1) Residents who have settled in this city for a long time; 2) Voluntary participation in questionnaire surveys; 3) Clear mind. Exclusion criteria: 1) Individuals with cognitive impairment and unclear consciousness; 2) Individuals who have received dental treatment within six months. All respondents were informed of the investigation related matters and obtained informed consent.

Based on relevant literature [13] [14] , a self-designed survey questionnaire was designedunder the guidance of professional dentists, which mainly includes four dimensions: basic information of the survey subjects, oral health knowledge, attitudes, and behaviors, with a total of 26 questions. The evaluation criteria for knowledge and attitude questionnaires refer to the methods used in HU-DBI questionnaire evaluation [15] , with 9 questions and 7 questions for knowledge and attitude dimensions, respectively. A correct answer was scored 1 point, and an incorrect answer was scored 0 points. The score range was 0 - 9 points and 0 - 7 points, respectively. The higher the score, the higher the awareness of oral health knowledge and the more positive the attitude towards oral health. Oral health behaviors are evaluated using the Likert scale’s five points scoring method, with scores ranging from 0 to 4 for each item from “none” to “always”. There are a total of 10 items, with a score range of 0 to 40 points. The higher the score, the better the oral health behavior habits.

The questionnaire was conducted following the principle of random sampling, selecting rehabilitation nursing treatment patients for the survey. For patients with writing disabilities, their family members or investigators assisted in completing the questionnaire using a one-on-one question-and-answer approach. This survey utilized paper-based questionnaires, and all participants and their families involved in the survey were informed about the survey details and obtained informed consent.

Statistical analysis was conducted using SPSS 26.0 software. Descriptive statistics were presented as percentages or mean ± standard deviation. Spearman correlation analysis was employed to examine the correlation between general patient information and scores related to oral health knowledge, attitudes, and behaviors. One-way analysis of variance (ANOVA) was utilized for intergroup comparisons, a corrected F-test was used when the variance was not uniform, and a significance level (P-value) of ≤ 0.05.

Oral disease is one of the most common human diseases. The occurrence of oral disease not only affects the normal functions of chewing and swallowing but also is closely related to the occurrence of malnutrition, diabetes, cardiovascular disease, and other systemic diseases [16] [17] [18] [19] . There are many risk factors for oral health, mainly in the following two aspects: immutable factors including age, gender, and genetic predisposition, as well as external variable factors such as socio-economic living conditions, unhealthy lifestyle habits, and limitations in oral health services [13] . Therefore, exploring the oral health status and influencing factors of various populations is both challenging and necessary. This study investigated the current status of oral health knowledge, attitudes, and behaviors among nursing patients in the rehabilitation department, to provide valuable references for clinical practice, epidemiology, and clinical research.

This survey found that rehabilitation nursing patients have moderate knowledge of oral health and weak awareness of oral health. This is similar to the results obtained by Júlia Moldvai et al. [10] , which found that stroke patients exhibited poorer oral health conditions. But contrary to the research results of Rui Jiang et al. [20] on the population in Guangzhou, China. This suggests that the oral health status may be related to the population, region, and disease situation of the surveyed individuals; and it indirectly proves the importance of conducting oral health surveys on different populations. The vast majority of patients agree that sweets and long-term use of toothpicks for tooth removal are harmful to oral health, but the awareness of carbon water drinks causing tooth decay is relatively low. It is now clear that the intake of sugar in food and beverages is the most important risk factor for dental caries and shows a clear dose-response relationship. The World Health Organization’s sugar guidelines also recommend reducing the daily total energy intake of free sugar to less than 10% and further reducing it to 5% of total energy [21] [22] . The awareness rate of oral disease hazards such as gum bleeding during brushing and the effectiveness of dental floss in oral cleaning among respondents is not ideal. Previous studies have shown that gum bleeding during brushing is a precursor to gingivitis [23] [24] , and the use of water floss can help reduce plaque. According to data from the American Dental Association, dental floss can remove up to 80% of interdental plaque [25] , and compared to regular dental floss, water floss shows stronger effectiveness in reducing plaque in adjacent areas of teeth [26] . This suggests that it is necessary to educate patients to reduce their intake of carbonated beverages and take relevant preventive measures while strengthening oral health education and knowledge dissemination among the population. A survey on oral health attitudes found that the majority of rehabilitation care patients are aware of the importance of oral health and acquired oral care. However, those who hold a positive attitude towards their own oral health (37.23%), are not afraid of seeing their teeth (53.68%), and are aware that smoking and drinking are harmful to oral health (57.14%) are in the minority. Dental anxiety and fear are common phenomena in the dental environment, and dental fear can have a negative impact on dental care patterns, clinical and subjective oral health conditions [27] . There is literature indicating that smoking and alcohol can increase the risk of periodontal disease and affect oral health [28] [29] . The reason for this is that currently, the public’s knowledge of oral health is not yet complete, and there is a lack of supporting oral health services, which to some extent affects the establishment of a positive attitude towards oral health.

This survey found that the overall qualification rate of oral health care behaviors among rehabilitation nursing patients is not high. A survey on oral health behavior shows that there are not many people who maintain brushing their teeth at least twice a day, and seek medical attention promptly when there is gum swelling, bleeding, and tartar. There are even fewer people who change their toothbrush every three months and use the correct brushing method to brush their teeth. The frequency of brushing teeth is related to the severity of periodontitis [30] , and dental calculus can cause gingival bleeding and expand the radius of periodontal damage caused by dental plaque [31] . The above results all indicate that it is necessary to strengthen the education of oral health behaviors among patients. That is, cultivating good oral health habits, regular dental examinations, and mastering the correct brushing methods are of great significance for early detection and prevention of oral health problems. In addition, in subsequent follow-up visits, it was learned that the majority of patients believe that the inconvenience of movement caused by illness is the main reason affecting their implementation of oral health behaviors.

This survey found that individuals with higher levels of education possess richer oral health knowledge, more positive attitudes, and higher compliance rates with oral health behaviors. Smoking status influences oral health behaviors. Higher education levels are often associated with a greater wealth of oral health knowledge and more oral health care needs, thereby reducing the risk of poor oral hygiene habits [13] [15] . The results of this survey also indicate that as age increases, the scores of oral health knowledge, attitude, and behavior show a decreasing trend, and there are significant differences in the scores of oral health knowledge and attitude among patients of different age groups (P < 0.001 or P < 0.05), but there is no significant difference in the scores of oral health behavior (P > 0.05). As the level of education increases, the scores of oral health knowledge and behavior show an upward trend, and there is a statistical difference in the scores of oral health knowledge and behavior among patients with different levels of education (P < 0.001). The oral health knowledge scores of patients with cerebrovascular disease were lower than those of non-cerebrovascular disease patients, and the difference was statistically significant (P < 0.05). Oral health is related to the deterioration of cognitive function and physical condition. Elderly patients with cognitive fragility pay less attention to oral health [32] , which may be related to the lack of public health policies in this age group [33] . The older the age, the worse the oral condition, and the corresponding increase in adverse health consequences and medical and dental expenses [34] , which will inevitably bring economic pressure to the patient's family. In addition, Mary Lyons et al. [11] proposed that oral care after a stroke is important, but it is often overlooked due to the high work pressure of nursing staff, weak oral health care guidelines, and a lack of information on how to better provide oral care. Therefore, it is of great significance to introduce professional dental physician training and oral health care procedures in the inpatient treatment ward of the rehabilitation department.

In addition, it was found in this survey that only one out of 231 patients had participated in oral health education activities, and it was an accidental experience during a dental visit many years ago. This indicates that the oral health education and publicity efforts in the local area are insufficient and need to be further strengthened.

It should be noted that due to time and resource limitations, and since this survey only involves one hospital in the city, the research results cannot be extrapolated to the entire province or even the whole country. We suggest conducting a nationwide study with multiple centers in different provinces to comprehensively understand the oral health knowledge, attitudes, and behaviors of rehabilitation nursing patients.

The oral health status of rehabilitation nursing patients is not optimistic, with a moderate level of oral health knowledge, weak awareness of oral health, and a low qualification rate of oral health behaviors. Older patients, self-funded medical expenses, low education levels, and poor oral health are associated with cerebrovascular disease. In this survey, there was almost no oral health education and training for rehabilitation nursing patients, indicating that it is urgent to strengthen the promotion and education of oral health public health; It is of great significance to simultaneously carry out oral health education and popularization for patients, and introduce oral health care procedures in rehabilitation wards.

This study was funded by The Science and Technology Research Project of Jiangxi Provincial Department of Education (GJJ218113), and The School-level Science and Technology Project of Fuzhou Medical University (fykj202212).

*Corresponding Author.