Maintaining optimal oral hygiene is essential for the prevention of dental diseases such as gingivitis, dental caries, and periodontitis, which remain prevalent across diverse population groups [1]. Flossing, a crucial adjunct to tooth brushing, plays a vital role in the removal of interdental plaque and food particles that are inaccessible to conventional brushing [2]. Despite its documented benefits, the practice of flossing remains inadequately adopted in many populations, particularly in low-resource and rural settings [3].

Evidence suggests that improper or infrequent interdental cleaning significantly contributes to periodontal breakdown and dental decay, especially in individuals with poor oral hygiene awareness [4]. Urban populations typically have better access to dental health services, oral hygiene products, and educational resources, which may enhance their knowledge and practice of flossing [5]. In contrast, rural communities often face barriers such as lower socioeconomic status, limited availability of dental professionals, and lower health literacy, which hinder the adoption of effective oral hygiene techniques [6].

Flossing techniques, including the correct method, frequency, and choice of floss type (waxed, unwaxed, dental tape), are often poorly understood even among those who report using floss regularly [7]. Misconceptions such as flossing being painful or unnecessary if brushing is done properly further reduce compliance, particularly in rural populations [8]. Additionally, oral health promotion in rural areas is frequently limited to basic brushing education, with little emphasis on interdental cleaning [9].

Comparative studies exploring the knowledge gap between urban and rural populations regarding flossing are limited in the Indian context. Understanding these disparities is crucial for designing community-specific preventive programs aimed at reducing oral disease burden [10]. This study aims to evaluate and compare the knowledge of flossing techniques among urban and rural populations, highlighting the influence of education, access, and awareness on oral hygiene behavior.

Study Design and Setting

This was a cross-sectional, questionnaire-based comparative study conducted over a period of three months in both urban and rural regions. Ethical clearance was obtained from the institutional review board prior to data collection.

Study Population and Sampling

The study included individuals aged 18 years and above from both urban and rural areas. A total of 400 participants were enrolled, with 200 respondents from urban areas and 200 from rural areas selected through stratified random sampling. Individuals with cognitive impairment or those unwilling to participate were excluded.

Questionnaire Development

A structured, pre-validated questionnaire was used to assess the participants’ knowledge of dental flossing techniques. The questionnaire was prepared in English and translated into the local vernacular language, followed by back-translation to ensure consistency. It comprised 20 items covering aspects such as:

• Awareness of dental floss
• Knowledge of proper flossing technique
• Frequency and practice of flossing
• Source of information (dentist, media, school, etc.)
• Barriers to flossing

Content validity was confirmed by a panel of five dental public health experts, and a pilot test on 40 subjects (20 urban, 20 rural) was conducted to assess reliability (Cronbach’s alpha = 0.84).

Data Collection Procedure

Participants were approached at community health centers, dental clinics, and through door-to-door surveys. Informed written consent was obtained. Investigators administered the questionnaire in a face-to-face interview format to minimize literacy-related bias.

Scoring System

Each correct response was assigned one point. A cumulative knowledge score out of 20 was calculated for each participant. Scores were categorized as:

• Good knowledge (≥15)
• Moderate knowledge (10–14)
• Poor knowledge (<10)

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 25.0. Descriptive statistics (mean, standard deviation, and percentages) were calculated. The Chi-square test was applied to compare categorical variables between groups. Independent t-test was used to compare mean knowledge scores. A p-value <0.05 was considered statistically significant.

A total of 400 participants were included in the study, with 200 each from urban and rural settings. The demographic and knowledge-related responses are summarized below.

Table 1: Demographic Profile of Participants

• The mean age of urban participants was 32.4 ± 10.2 years, slightly younger than the rural group (34.1 ± 11.5 years), though not statistically significant (p = 0.07).
• Females made up a higher proportion in both groups: 56% in urban and 53% in rural (p = 0.49).
• A significantly higher number of urban participants had education up to or beyond high school (87%) compared to rural participants (46%) (p < 0.001).
• Monthly income over ₹20,000 was reported by 64% of urban respondents versus only 19% of rural respondents (p < 0.001), indicating socioeconomic disparity.

Table 2: Awareness and Practice of Flossing

• Awareness of dental floss was much higher in the urban group (72.5%) than in the rural group (36%) (p < 0.001).
• Knowledge of the correct flossing technique was reported by 52% of urban and only 19.5% of rural participants (p < 0.001).
• Daily flossing was practiced by 28.5% of urban participants and just 10.5% of rural participants (p < 0.001).
• A significant portion of rural participants (69%) had never used floss, compared to 32.5% in urban areas (p < 0.001).

Table 3: Mean Knowledge Scores by Region

• The average knowledge score was substantially higher among urban participants (13.8 ± 3.2) compared to rural (8.1 ± 3.9).
• The difference in knowledge scores was statistically significant (p < 0.001), indicating a clear gap in flossing awareness and understanding between the two populations.

Table 4: Source of Information on Flossing

• Urban participants primarily received information from dentists (51%), while only 14.5% of rural respondents reported the same (p < 0.001).
• Social media and internet served as secondary sources for urban participants (22%) compared to 9% in rural areas (p = 0.002).
• Friends and family were the most common source among rural participants (43.5%), suggesting reliance on informal knowledge (p < 0.001).
• A significant portion of rural respondents (33%) reported health camps and schools as sources, whereas this was only 8% in the urban group (p < 0.001).

Table 1: Demographic Profile of Participants

Table 2: Awareness and Practice of Flossing

Table 3: Mean Knowledge Scores by Region

Table 4: Source of Information on Flossing

This study highlights significant differences in the knowledge and practice of dental flossing between urban and rural populations. The results demonstrate that urban participants not only had higher awareness levels but also superior understanding and implementation of correct flossing techniques. These findings are in line with broader trends in oral health literacy, where urban populations benefit from greater exposure to healthcare services, oral hygiene education, and access to dental products [11,12].

The urban group’s higher mean knowledge score reflects their better educational background and more frequent interactions with dental professionals. Studies have previously shown that regular dental visits are associated with improved oral health behaviors, including interdental cleaning practices like flossing [13]. Conversely, rural participants in this study exhibited lower knowledge levels, which may be attributed to factors such as limited dental service availability, lower income, and minimal oral health promotion in rural settings [14]. The disparity in educational attainment, as evident in this study, further explains the gap in oral hygiene understanding.

The low percentage of daily flossing in both groups, particularly in rural participants (only 10.5%), underscores the broader issue of poor compliance with interdental cleaning, even among those aware of flossing. This suggests that knowledge alone does not always translate into behavior change. Barriers such as perceived difficulty, lack of motivation, and misconceptions about the necessity of flossing have been cited as contributing factors in other studies [15,16]. In rural regions, these challenges are compounded by the dominance of informal sources such as friends or family for health-related information, which may perpetuate myths and incorrect practices [17].

Interestingly, only a small fraction of rural participants cited dentists as their source of information, indicating a gap in professional outreach. Community-based interventions, such as school dental programs, health camps, and mobile dental clinics, have shown promise in improving awareness in underserved areas [18]. Incorporating culturally relevant education and demonstrations of flossing during such initiatives could be an effective way to bridge the knowledge gap.

Technological innovations, including mobile apps, social media campaigns, and instructional videos, could serve as additional tools to promote flossing, especially among tech-savvy younger populations [19]. However, for rural populations with limited internet access, traditional community engagement and visual aids remain essential.

Overall, this study emphasizes the need for targeted oral health education strategies tailored to the socioeconomic and cultural realities of both urban and rural populations. Empowering individuals through structured awareness programs and improved accessibility to dental care could significantly enhance interdental hygiene practices and ultimately reduce the burden of periodontal disease [20].

This comparative study revealed a significant urban–rural divide in knowledge and practice of flossing techniques. Urban populations demonstrated higher awareness and better adherence to proper flossing, while rural participants lagged due to limited access to dental information and services. Strengthening oral health education, particularly in rural settings, through community-based programs and professional involvement, is crucial for improving nationwide oral hygiene standards.

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