Association between post-earthquake living conditions and children’s toothbrushing habits in Hatay, Turkey: a cross-sectional study

1. Introduction

A disaster is defined as a natural or human-induced event that exceeds a community’s capacity to cope and results in extensive losses and destruction. Among different types of disasters, earthquakes have particularly profound effects on society because they occur unexpectedly and cause widespread physical, psychological, and social consequences [1].

Natural disasters may lead to the development of trauma-related somatic and psychological symptoms during childhood [2]. It has been reported that musculoskeletal problems, respiratory issues, gastrointestinal disorders, and sleep disturbances are more frequently observed in child disaster survivors [3]. In addition, displacement, socioeconomic difficulties, and developmental characteristics may influence children’s behavioral responses after disasters, and these responses may vary according to the degree of disaster exposure, age, family environment, and individual coping capacity [4].

Parental attitudes, oral hygiene practices, and the importance attached to oral health within the family play a decisive role in the development of children’s oral hygiene behaviors and oral health outcomes throughout childhood and adolescence [5, 6]. Childhood is a critical developmental period during which oral and dental health-related behaviors are established. During this period, regular toothbrushing, appropriate dietary habits, and parental support are among the main determinants of maintaining good oral hygiene [7, 8]. Indeed, inadequate toothbrushing and high sugar consumption have been reported to increase the prevalence of dental caries in children [9, 10]. Studies conducted among preschool children have shown that behavioral factors, including toothbrushing frequency, brushing duration, brushing technique, and parental involvement, are significantly associated with plaque accumulation, gingival health, and caries levels [11]. Similarly, parents’ knowledge and behaviors regarding oral health have been reported to influence their children’s toothbrushing habits and consumption of sugary foods [12, 13]. Therefore, parental knowledge, attitudes, and behaviors related to oral health may influence the oral hygiene habits that children develop and maintain throughout life [14, 15].

On 06 February 2023, two large-scale earthquakes that struck Türkiye nine hours apart caused extensive destruction across a wide geographic area [16]. As a result of the destruction caused by the earthquakes, the use of temporary shelters increased in the affected regions, leading to major public health problems such as inadequate housing, deteriorated hygiene conditions, difficulties in accessing clean water and food, and overcrowded living environments [17, 18]. These environmental and social changes may directly affect children’s daily routines and self-care habits. In the post-disaster period, factors such as limited access to water, overcrowded living conditions, and disruption of established routines may interrupt children’s hygiene practices [3]. However, despite the potential impact of post-disaster living conditions on children’s oral hygiene behaviors, studies specifically evaluating this association in Hatay Province remain limited.

Limited access to clean water in post-disaster shelter settings, together with the distribution of high-calorie and sugary foods, may contribute to a reduction in oral hygiene practices and an increase in the prevalence of dental caries among children [19]. In this context, it is important to evaluate how altered living and housing conditions after a disaster may affect children’s oral hygiene behaviors. Therefore, this study aimed to evaluate the oral hygiene behaviors of children living in Hatay Province during the post-earthquake period and to examine the effect of different housing conditions on the maintenance of oral hygiene practices. In this respect, the present study may contribute to the limited body of research conducted in Hatay Province by investigating children’s oral hygiene habits in relation to housing conditions in the aftermath of a major disaster.

2. Materials and methods

3. Results

The study included 363 children aged 2–14 years and their parents. The mean age of the children was 8.87 ± 2.52 years. Of the participating children, 208 were girls and 155 were boys, accounting for 57.30% and 42.70% of the sample, respectively. Most questionnaires were completed by mothers (n = 246, 67.77%), followed by fathers (n = 86, 23.69%) and other family members or caregivers (n = 31, 8.54%). Regarding parental education level, primary education was reported by 96 participants (26.45%), secondary education by 86 participants (23.69%), high school education by 83 participants (22.87%), university education by 82 participants (22.59%), and postgraduate education by 16 participants (4.41%). Monthly income was below 28,075 Turkish Lira (TL) in 150 participants (41.32%), between 28,075 and 56,150 TL in 124 participants (34.16%), and above 56,150 TL in 89 participants (24.52%). The number of people living in the same household ranged from 2 to 40, with a mean of 5.2 ± 2.7 and a median of 5 (Table 1).

Table 2 shows the distribution of participants’ residential location before and after the earthquake. Before the earthquake, 155 participants (42.70%) lived in the provincial center, 119 (32.78%) lived in a district, 73 (20.11%) lived in a village, and 16 (4.41%) lived in another province. After the earthquake, the proportion of participants living in the provincial center decreased to 32.23%, whereas the proportions living in villages and another province increased to 28.65% and 7.71%, respectively. Overall, 232 participants (63.91%) reported that they had not moved out of Hatay after the earthquake, while 130 (35.81%) had moved out temporarily and only one participant (0.28%) had moved out permanently.

The post-earthquake shelter conditions are presented in Table 3. During the first 6 months after the earthquake, tents were the most commonly reported shelter type. However, during the 6 months immediately preceding the survey, more than half of the participants were living in their own undamaged or slightly damaged homes. Most (n = 193, 53.2%) participants reported at least one change in living place after the earthquake.

Table 4 presents children’s toothbrush/toothpaste availability and toothbrushing habits before and after the earthquake. Although most children had access to a toothbrush and toothpaste both before and after the earthquake, toothbrushing frequency decreased after the disaster. The proportion of children brushing once daily or twice daily or more decreased, whereas rare toothbrushing became more frequent. Overall, 31.96% of parents reported a decrease in their child’s toothbrushing habits after the earthquake.

As shown in Table 5, no statistically significant association was found between the shelter type used for the longest period during the first 6 months after the earthquake and changes in children’s toothbrushing habits (p > 0.05). Although tent accommodation was common among children whose toothbrushing habits decreased, this pattern did not reach statistical significance.

A borderline association was found between the number of post-earthquake changes in living environment and changes in children’s toothbrushing habits (p = 0.048) (Table 6). To identify the cells contributing to this association, an adjusted standardized residual (ASR) analysis was performed, and the results showed that children who had not changed their living environment were more likely than expected to report no change in toothbrushing habits (ASR = 2.7), whereas decreased toothbrushing habits were less frequent than expected in this group (ASR = −2.1). In contrast, children who had changed their living environment four or more times were more likely than expected to report decreased toothbrushing habits (ASR = 2.6), and no change in toothbrushing habits was less frequent than expected in this group (ASR = −2.4). No statistically significant residuals were observed in the remaining categories (|ASR| < 1.96).

A significant association was found between the post-earthquake living environment and the main reason why the child was unable to brush their teeth (p < 0.05) (Table 7). ASR analysis showed that “the living environment was not suitable” was reported more frequently than expected among participants living in tents (ASR = 3.6), dormitories/collective shelters (ASR = 2.4), and with relatives or friends (ASR = 2.1). In contrast, this response was reported less frequently than expected among those living in their own homes (ASR = −2.9) and in containers (ASR = −2.3).

Binary logistic regression analysis showed that increasing child age and female sex were associated with higher odds of decreased toothbrushing habits after the earthquake. Compared with residence in the provincial center, post-earthquake residence in a village was associated with lower odds of decreased toothbrushing habits. In addition, partially worsened and markedly worsened post-earthquake economic status were significantly associated with an increased likelihood of decreased toothbrushing habits. Children who did not have a toothbrush or toothpaste after the earthquake were also more likely to show decreased toothbrushing habits (Table 8).

4. Discussion

Oral and dental health is an important component of children’s overall health, and disruption of regular oral hygiene practices may contribute to adverse outcomes, including dental caries, gingival problems, pain, and reduced quality of life [20]. After disasters such as earthquakes, difficulties in accessing clean water and hygiene materials, together with crowded and temporary shelter conditions, may interfere with the maintenance of routine oral care [21]. At the same time, families may understandably prioritize safety, shelter, food, and other basic needs, which may cause preventive health behaviors, including oral hygiene, to receive less attention during the post-disaster period [22]. Disrupted access to dental services may further contribute to the progression of existing oral health problems [23]. Therefore, children’s oral health after a disaster should be evaluated not only as an individual behavioral issue, but also in relation to environmental conditions, household stability, and disruption of daily life [21, 23].

The 06 February 2023, Kahramanmaraş-centered earthquakes caused extensive destruction in southeastern Türkiye, resulting in large-scale displacement and widespread use of temporary shelters [24, 25]. Consistent with these post-disaster conditions, the present study showed that children’s oral hygiene behaviors deteriorated after the earthquake, and this deterioration appeared to be particularly related to instability in living conditions.

In the present study, the proportion of participants living in the city center decreased from 43% before the earthquake to 32% after the earthquake, whereas the proportion living in villages increased from 20% to 29%, and the proportion living in another province increased from 4% to 8%. Although 64% of the participants did not move out of Hatay after the earthquake, this does not necessarily indicate that their daily living conditions remained stable, as many families experienced changes in shelter type, household environment, and daily routines within the province. Therefore, the effects of the disaster should not be interpreted only in terms of relocation outside Hatay, but also in relation to the broader disruption of children’s living environments and self-care routines [20, 21, 23]. The findings on oral hygiene behaviors support this interpretation. Before the earthquake, 32% of the children brushed their teeth twice daily or more and 41% brushed once daily; after the earthquake, these rates decreased to 30% and 37%, respectively, while the rate of rare toothbrushing increased from 24% to 31%. Although the absolute decrease in regular toothbrushing may appear modest, the increase in rare toothbrushing and the finding that approximately one-third of parents reported a decrease in their child’s toothbrushing habits indicate a meaningful deterioration in oral hygiene behaviors after the disaster. In contrast, the proportion of children who had a toothbrush and toothpaste decreased only slightly, from 96% to 94%, suggesting that the deterioration in toothbrushing habits cannot be explained solely by a lack of hygiene materials. Rather, it may also reflect disruption of daily routines, changes in housing conditions, and instability in the living environment. This finding is consistent with the Malatya study [26], which reported a decrease in children’s toothbrushing habits after the earthquake, and with previous evidence showing that oral hygiene routines may be markedly disrupted in temporary shelter settings [23].

No significant association was found between the living environment during the early post-earthquake period and changes in children’s toothbrushing habits (p = 0.301). Although tent accommodation was common among children whose toothbrushing habits decreased, this pattern was also observed in children whose habits did not change or were already low, suggesting that deterioration in toothbrushing habits cannot be explained by shelter type alone. This finding indicates that, in the post-disaster context, the effect of living conditions on oral hygiene behaviors may be related not only to the type of shelter, such as a tent, container, or collective shelter, but also to broader factors including disruption of daily routines, lack of a suitable environment for hygiene practices, and interruptions in access to oral healthcare [21, 23]. In this regard, the present findings suggest that children’s oral hygiene behaviors after disasters should be evaluated not only according to shelter type, but also in relation to the stability and adequacy of the living environment [26, 27]. Similar findings have been reported in international post-disaster oral health studies. Studies from Japan have shown that temporary housing and disrupted living conditions after major earthquakes may negatively affect oral hygiene and increase oral health complaints among disaster survivors [27, 28]. In addition, a study conducted after the 2015 Nepal earthquake reported that oral hygiene practices and nutritional habits were adversely affected in earthquake-affected areas [29]. These findings are consistent with the present study and suggest that disruption of oral hygiene after disasters may represent a broader public health problem related to shelter instability, limited access to hygiene resources, and disruption of daily routines, rather than a problem attributable to one specific shelter type alone.

In contrast, an association was observed between the number of post-earthquake changes in living environment and changes in children’s toothbrushing habits. This finding suggests that instability and repeated relocation after the earthquake may have contributed to disruption of children’s oral hygiene routines. In particular, children who had not changed their living environment were more likely to maintain their toothbrushing habits, whereas those who had changed their living environment four or more times were more likely to show decreased toothbrushing habits. This pattern indicates that the continuity and stability of the living environment may be more relevant to the maintenance of oral hygiene behaviors than the shelter type alone. Previous studies have also reported that uncertainty in living conditions, temporary shelter processes, and disruption of daily routines after disasters may negatively influence oral health behaviors and daily self-care practices [23, 26, 27, 28]. In this context, the present findings suggest that providing shelter alone may not be sufficient to protect children’s oral health, and that stable, predictable, and continuous living conditions may also be important for preserving regular toothbrushing habits [20, 21]. The regression analysis further showed that worsening post-earthquake economic conditions and the absence of a toothbrush or toothpaste were associated with a higher likelihood of decreased toothbrushing habits. These findings indicate that post-disaster oral hygiene behaviors may be influenced not only by instability in the living environment, but also by socioeconomic difficulties and limited access to basic hygiene materials [20, 21, 23]. The regression analysis also demonstrated that older age and female sex were independently associated with a higher likelihood of decreased toothbrushing habits after the earthquake. One possible explanation for the age-related finding is that older children may have experienced greater disruption of daily routines and psychosocial well-being during the post-disaster period. Previous studies have reported that displaced children often face psychological distress, uncertainty, overcrowded living conditions, and disruption of self-care behaviors, all of which may adversely affect oral hygiene practices [30]. The association observed among girls may reflect gender-related differences in how post-disaster living conditions influence hygiene-related behaviors. In emergency and temporary shelter settings, female children and adolescents may encounter additional challenges related to privacy, safety, and access to appropriate sanitation and hygiene facilities [31]. Such barriers may interfere with the maintenance of regular personal hygiene routines, including toothbrushing. Although the underlying mechanisms cannot be fully explained within the scope of the present study, these findings suggest that older children and girls may represent particularly vulnerable groups with regard to maintaining oral hygiene after disasters. Future post-disaster oral health programs should therefore consider age- and gender-specific needs when designing preventive interventions and support strategies.

The post-earthquake shelter environment may have influenced not only whether children’s toothbrushing habits were disrupted, but also the reasons underlying this disruption. Adjusted standardized residual analysis showed that the response “the living environment was not suitable” was reported more frequently than expected among children living in tents, dormitories/collective shelters, and with relatives or friends, whereas it was reported less frequently than expected among those living in their own homes and in containers. This finding suggests that unstable or temporary living arrangements may create practical environmental barriers that interfere with the maintenance of regular oral hygiene routines. Therefore, disruption of toothbrushing after the earthquake should not be interpreted solely as a matter of individual unwillingness or lack of motivation, but also as a consequence of structural difficulties encountered in the post-disaster living environment. These difficulties may include lack of privacy, crowded living conditions, limited access to water, and the absence of an appropriate space for daily hygiene practices. Previous studies on oral health after disasters have similarly emphasized that temporary and inadequate shelter conditions may make routine oral care more difficult [21, 23, 27]. Accordingly, interventions aimed at protecting children’s oral health after disasters should include not only the provision of toothbrushes, toothpaste, and hygiene education, but also efforts to create suitable physical environments in which children can maintain daily oral care [20, 22].

Overall, the findings of this study indicate that children’s oral hygiene behaviors after the earthquake were affected by multiple interrelated factors, particularly shelter inadequacy, instability in living conditions, disruption of daily routines, socioeconomic difficulties, and limited access to basic hygiene materials. These findings suggest that children’s oral health in the post-disaster period should not be addressed only as an individual behavioral issue, but should also be considered within the broader context of environmental and structural conditions [21]. Therefore, preventive oral health programs for disaster-affected children should emphasize the provision of hygiene materials, the availability of appropriate living environments, the re-establishment of daily care routines, and improved access to basic oral health services [20, 23]. Such integrated approaches may help children maintain regular oral hygiene during the post-disaster period and may reduce the risk of subsequent oral health problems.

5. Conclusions

This study showed that toothbrushing habits were adversely affected among children living in Hatay after the 06 February 2023 earthquakes. The decrease in toothbrushing habits in approximately one-third of the children indicates that the sustainability of oral hygiene behaviors weakened in the post-disaster period. The findings suggest that this deterioration was associated not only with a lack of hygiene materials, but also with changes in shelter conditions, instability in the living environment, and the absence of a suitable physical environment for toothbrushing. In particular, the increased likelihood of decreased toothbrushing habits among children who experienced repeated changes in living environment highlights the importance of stable living conditions for children’s oral health after a disaster. Therefore, oral and dental health services for children after a disaster should not be limited to hygiene material support and individual education, but should also include preventive approaches aimed at ensuring appropriate shelter conditions and re-establishing daily self-care routines. These findings indicate that children’s oral health should not be neglected in disaster management and should be regarded as a public health priority. Therefore, oral and dental health services planned for the post-disaster period should not be limited to individual education and hygiene material support, but also include multidimensional interventions that support the stability of living conditions and ensure the sustainability of daily self-care routines.

6. Limitations

This study has several limitations. Since the research was conducted with the parents of children who presented to a pediatric dentistry clinic, the generalizability of the findings to the entire population of children affected by the earthquake is limited. In addition, because the survey was conducted nearly three years after the 06 February 2023, earthquakes, retrospective evaluation of changes in children’s oral hygiene behaviors may have been subject to recall bias. Furthermore, because children’s oral hygiene behaviors were reported by parents rather than directly observed, proxy reporting bias may have occurred, particularly in cases where children spent substantial time away from the responding parent. Another potential limitation is the lack of information regarding parental influence on children’s toothbrushing habits, since parents’ own oral hygiene practices and motivational behaviors were not specifically evaluated. In addition, the 21-item questionnaire was adapted from previous literature and did not undergo formal validity or reliability testing prior to data collection. Nevertheless, the study’s strengths include providing field data from the post-disaster period and addressing children’s oral health through environmental and structural factors. Future studies involving longitudinal follow-up and community-based sampling may provide a more comprehensive understanding of the long-term effects of disasters on children’s oral hygiene behaviors and access to oral healthcare services.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

BT—designed the study, performed the data collection and analysis, and wrote the manuscript. AMÇ—contributed to the organization of the study and provided support during the data collection process; critically reviewed the manuscript and contributed to editorial revisions. Both authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Hatay Mustafa Kemal University Non-Interventional Clinical Research Ethics Committee (Decision No: 2026/40). Written informed consent was obtained from the parents of all participating children prior to inclusion in the study.

Acknowledgment

The authors would like to thank all participants and their families for their contribution to this study.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.