|Year : 2018 | Volume
| Issue : 1 | Page : 5-12
Knowledge, Attitude and Practice of Oral Health and Adverse Pregnancy Outcomes among Rural and Urban Pregnant Women of Moradabad, Uttar Pradesh, India
TR Chaitra, Snehal Wagh, Saima Sultan, Seema Chaudhary, Naveen Manuja, Ashish Amit Sinha
Department of Pedodontics And Preventive Dentistry, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India
|Date of Web Publication||5-Mar-2018|
Department of Pedodontics and Preventive Dentistry, Kothiwal Dental College and Research Centre, Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: This study aimed to compare and evaluate the knowledge, attitude, and practice of oral health and adverse pregnancy outcomes among rural and urban pregnant women of Moradabad, Uttar Pradesh, India. Methods: A cross-sectional study was conducted at health-care centers, private and government hospitals, and institutions in Moradabad city (Uttar Pradesh, India). A structured questionnaire with a set of 18 questions for a sample of 515 was designed to evaluate the knowledge, attitude, and practice of pregnant women regarding oral hygiene and its adverse pregnancy outcomes [Appendix 1]. Data obtained from this questionnaire were analyzed using the SPSS statistical package. Statistical significance was measured using Chi-square test for qualitative variables at P < 0.05. Results: A majority of respondents (82.9%) of urban area were aware of dental plaque and gum diseases and of rural area only 17.1% were aware of the same (P < 0.005). Awareness of the connection between pregnancy and oral health was also seen highest among the urban participants (94.1%) whereas only 5.9% of rural participants were aware of the same. Alarming finding in this study was that none of the rural participants were aware that the mother's poor oral health can affect the unborn baby causing low birth weight of the baby. Adequate oral health practice was found in majority of the urban participants. Levels of education of the participants were found to be strongly associated with oral health practice. Conclusion: This study revealed that the knowledge of pregnant women of rural group about association of oral health and adverse pregnancy outcome was poor. The level of education and socioeconomic status was significantly associated with oral health attitude and practice. Dental health education in pregnancy can lead to improved oral health and hence improved pregnancy outcomes.
Keywords: Attitude, knowledge, oral health in pregnancy, practice
|How to cite this article:|
Chaitra T R, Wagh S, Sultan S, Chaudhary S, Manuja N, Sinha AA. Knowledge, Attitude and Practice of Oral Health and Adverse Pregnancy Outcomes among Rural and Urban Pregnant Women of Moradabad, Uttar Pradesh, India. J Interdiscip Dentistry 2018;8:5-12
|How to cite this URL:|
Chaitra T R, Wagh S, Sultan S, Chaudhary S, Manuja N, Sinha AA. Knowledge, Attitude and Practice of Oral Health and Adverse Pregnancy Outcomes among Rural and Urban Pregnant Women of Moradabad, Uttar Pradesh, India. J Interdiscip Dentistry [serial online] 2018 [cited 2022 Nov 28];8:5-12. Available from: https://www.jidonline.com/text.asp?2018/8/1/5/226639
| Clinical Relevance to Interdisciplinary Dentistry|| |
Pregnant women should be educated and motivated regarding the importance of oral health. Various health promotion interventions should be carried out for educating them. Providing affordable dental health care is fundamental in reducing dental diseases among pregnant women.
| Introduction|| |
The journey of pregnancy for a woman, designated as a unique state, is conjoined with an untold of physiological, emotional, and physical changes that increase a woman's susceptibility to oral conditions. These conditions are mainly gingivitis, periodontitis, which have been reported to range between 36% to 100% and other being benign gingival lesions, tooth mobility, tooth erosion and dental caries.
Numerous studies have shown that the maternal oral health has significant implications for birth outcomes and infant oral health.,
Maternal oral flora is transmitted to the newborn infant, and the increase in cariogenic flora in the mother predisposes the infant to the development of caries.
Periodontitis and various systemic conditions such as osteoporosis, diabetes mellitus, respiratory diseases, preeclampsia, cardiovascular diseases, infections, and preterm low birth weight, in humans and animal models, have been described as a two-way relationship as periodontitis can have a great influence on an individual's general health and general health may influence periodontal health as well.
According to the consensus report of the joint EFP/AAP workshop on periodontitis and systemic diseases, periodontal diseases provide a portal for hematogenous dissemination of oral microorganisms and their products which reach the fetal–placental unit. These microorganisms and their products could be an independent risk factor for preterm birth and low birth weight babies.
Maternal periodontitis may interact synergically with other maternal risk factors to induce preterm birth.
Proper nutrition and healthy lifestyle including good oral hygiene practices play an important role in the general well-being of pregnant women.
Hence, women should routinely be kept posted about the maintenance of good oral health care during whole of their lives as well as during pregnancy. This will minimize the risk of transmission of disease from mother to the baby.
Literatures witness scanty articles regarding knowledge, attitude, or practice of oral health in pregnant women.,, Hence, the chief objective of the present study was to compare and evaluate the knowledge, attitude, and practices of oral health and adverse pregnancy outcomes among pregnant women of Moradabad city, Uttar Pradesh, India.
| Methods|| |
The present cross-sectional study was conducted in health-care centers, private and government hospitals, and institutions in Moradabad city (Uttar Pradesh, India) for 5 months among pregnant women. All the above-mentioned health organizations catered lower- and middle-class urban and rural population. Permission to conduct the study was obtained from the directors of the health centers and the study was approved by the Institutional Ethics and Review Board of Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India.
Inclusion criteria for the study included women who were willing to participate in the study and then written consent was taken from them. A structured questionnaire with a set of 18 questions was designed to evaluate the knowledge, attitude, and practice of pregnant women regarding oral hygiene and its adverse pregnancy outcomes. The questionnaire was pretested among ten pregnant women to confirm its validity and reliability and to avoid ambiguity. Following the pretest, some modifications in the order of questions and terminologies were made in the final questionnaire. A sample size of 515 was calculated and questionnaire was designed in such a way that the procedure should not take more than 10 min per sample. The final questionnaire included general and demographic information, present and past pregnancy details [Table 1], 5 questions for assessing respondent's oral health and hygiene practices [Table 2], 3 questions for evaluating participant's knowledge regarding oral health and hygiene and adverse pregnancy outcomes [Table 3], and 2 questions for assessing respondent's attitude [Table 4]. Being an interviewer-administered questionnaire, two interviewers were trained and made familiar with all the questions. The relevant data acquired from the questionnaire were recorded and maintained.
Data obtained from this questionnaire were analyzed using statistical package for social sciences of software version 16.0 (SPSS Inc., Chicago, IL, USA).
Descriptive analysis was used for frequency distribution of responses to various questions and Chi-square test was used for comparisons based on location of the participants (Urban/Rural). Statistical significance was set at P ≤ 0.05. A statistical significant difference was found for the responses to all questions when compared based on urban/rural location.
| Results|| |
The results of demographic data [Table 1] revealed that 97% of urban population had a mean age of 27.54 and 100% of rural population had a mean age of 26.60 that were surveyed. A minority of illiterate participants were found in urban area (2.6%) whereas majority was in the rural area (24.8%). As much as 3% of urban and 1.6% of rural participants had a salary <Rs 50,000. The pregnancy characteristics of the patients indicate that most of the participants of urban area were in the 1st trimester of pregnancy (60.8%) and 50.8% in the 2nd trimester of pregnancy in rural area. 57.7% of urban participants were primiparous and 53.2% of the rural population had 2nd order of birth.
The oral hygiene practices of the sample [Table 2] were assessed for their frequency, mode of tooth brushing, use of dental floss, frequency of changing tooth brush, and use of mouth fresheners. 34% participants of the urban and 53.2% participants of the rural population brushed their teeth once daily whereas 51.3% of urban and 43.6% participants of rural brushed twice daily. The observed difference was statistically significant (P< 0.005).
52.6% of the urban and 47.4% of rural population used tooth brush and tooth paste and 44% of urban and 56% of rural population used tooth brush and tooth powder. It was found that none of the participants from the urban area used finger and tooth powder as an aid for tooth cleaning whereas this type of cleaning was used by 7 participants of rural area. The observed difference was statistically significant (P< 0.005). Respondents who did not use dental floss in urban area counted 36.5% and 63.5% in rural population. And, among the participants who used dental floss counted 89.65% in urban and 10.34% in rural area. The observed difference was statistically significant (P< 0.005). Participants who changed their tooth brush after 6 months were 50.6% in urban and 44.4% in rural, whereas 30.6% of the urban population and 36.4% of rural population changed their tooth brush after 1 year. The observed difference was statistically significant (P< 0.005). Participants who used paan to mask bad breath counted 43.8%, chewing gum 100%, mouth fresheners 59.76%, and others 33.34% in urban area. Whereas, in rural area, participants using paan, chewing gum, mouth fresheners, and others to mask bad breath were 52.6%, 0%, 40.24%, and 66.6%, respectively (P< 0.005).
A majority of respondents (82.9%) of urban area were aware of dental plaque and gum diseases and of rural area only 17.1% were aware of the same (P< 0.005) [Table 3]. Awareness of the connection between pregnancy and oral health was also seen highest among the urban respondents (94.1%) whereas only 5.9% of rural respondents were aware of the same. Respondents unaware of the same made a count of 40.9% in urban and 59.1% in rural area (P< 0.005). Alarming finding in this study was that none of the rural participants (0%) were aware that the mother's poor oral health can affect the unborn baby causing low birth weight of the baby, whereas 100% of urban respondents had knowledge about this connection (P< 0.005).
On enquiring about visit to dentist during pregnancy, 81.7% of urban pregnant women gave a history of dental visits whereas only 18.3% of rural group had to do so only when they felt toothache.
It was also found that 51.5% of urban and only 48.5% of rural pregnant women were fully interested to gain knowledge about how to keep oral cavity healthy during pregnancy and to know the connection between mother's oral health and well-being of their babies (P< 0.005).
| Discussion|| |
Obstetric complications are not only a noteworthy health-care expense but also affect the well-being of the affected infants throughout the life.
Periodontal disease, which is a Gram-negative anaerobic infection of the mouth, is a more severe and destructive irreversible form of the disease and has been demonstrated higher in pregnant women.,
According to the WHO (1976), low birth weight is defined as a birth weight <2500 g. Births before the 32nd gestational weeks are called as preterm birth.
The rate of preterm birth is increasing globally and is a known predictor of infancy morbidity and mortality.
The results of a study by Offenbacher et al. in 1996 was the first to report that maternal periodontal disease was associated with a 7-fold increased risk of delivery of a preterm low birth weight infant and hence is a significant risk factor.
Later, the results of various studies confirmed this finding by showing that women with healthy periodontal status had a lower risk of having adverse pregnancy outcomes.,,
Although many studies have shown an association, an equally large number of studies found no such relation.,,
Other risk factors for preterm birth includes smoking, alcohol consumption, low maternal weight, older and younger maternal age, low socioeconomic status, education, and poor maternal nutrition.
In the present study, a majority of the pregnant women in both urban and rural were in the age group of 26–27 years. Education status revealed that 2.6% of urban and 24.8% of rural women were illiterate. These findings have clearly shown that the knowledge of pregnant women of rural group about association of oral health and adverse pregnancy outcome was poor. Studies have shown that the dental knowledge of the patients increases with their level of education.,
The majority of the participants of urban area were in the 1st trimester of pregnancy (60.8%) and majority of rural participants (50.8%) were in the 2nd trimester of pregnancy. The proportion of Gram-negative anaerobic bacteria in dental plaque has been found to increase during the 2nd trimester of pregnancy, compared to aerobic bacteria. These bacteria can produce a variety of bioactive molecules that may directly affect the host.
The rate of preterm low birth weight among women treated periodontally during 2nd trimester has been reported less than those who have not received such a treatment.,,
A microbial component, lipopolysaccharide, can activate macrophages and secrete a wide range of molecules including cytokines interleukin 1 beta (IL-1 β), tumor necrosis factor-α, IL-6, and prostaglandin E2 and matrix metalloproteinases. These components can cross placental barrier through bloodstream, inducing preterm birth.
Fusobacterium nucleatum and other subspecies coming from the oral flora have been found in the amniotic fluid of women with preterm births.
The most common oral disease during pregnancy is preventable by the institution of simple measures such as regular tooth brushing and flossing. However, such positive behavior would be influenced by the individual's oral health knowledge and attitudes.
Our survey showed that the most common aids used for oral hygiene practices by the urban pregnant women were tooth brush and tooth paste (52.6%) and 89.65% used dental floss. The frequency of brushing was also found to be more in them. On the contrary, 47.4% rural pregnant women used tooth brush and tooth paste and only 10.34% used dental floss. This is in accordance with the study by Avula et al., in which none of the participants used dental floss. The authors related this varying degree of dental knowledge, to factors such as respondent's socioeconomic status, affordability, and access to oral care services. Similar results were reported by Bamanikar and Kee and Thomas et al. According to these studies, socioeconomic status and ethnic background have an impact on the knowledge and practices that positively influence the dental-seeking behavior.
Adequate awareness in urban population disclosed in the current study could probably be the result of higher educational status in them, in which majority of them (55.1%) were found to be graduates.
The American Dental Association recommends to replace tooth brush approximately every 3–4 months or sooner if the bristles are frayed. Majority of the urban pregnant women changed their tooth brush within 6 months and used chewing gum and mouth fresheners to mask bad breath. The results obtained from the questionnaire showed that the respondents of the urban category exhibited a good dental knowledge. However, important gaps in dental knowledge and practices among rural pregnant women were found. This could be due to lower educational achievements and low economic resources.
Although periodontal disease profile differs from one population to another, studies have reported that African and Asian populations suffered more severe periodontal disease than other population., The awareness regarding dental plaque and gum diseases and its relation on infant's oral health was found to be inadequate among rural group. A women's lack of receiving routine dental care when not pregnant is the most significant predictor of lack of receiving care during pregnancy as was found in our survey. In our study, less percentage of rural population visited the dentist during their pregnancy than the urban. When enquired about not visiting the dentist, they responded that they visit a dentist only during toothache, which they never had. Relatively poor attendance among rural group can be attributed to fear, misconception associated with dental treatment, lack of knowledge, and nonavailability of dental service. Besides neglecting medical care during pregnancy, most expectant females of all ages do not seek dental care even though half of them have a dental disease.
According to postpartum survey data from the Pregnancy Risk Assessment Monitoring System in 10 states, 59% of women did not receive any counseling about oral health during pregnancy. In our study, most of the respondents of both rural and urban group showed positive response toward receiving and gathering information regarding oral health care and to know about the relationship between mother's oral health and well-being of their babies. Hence, it is the responsibility of the dentist and the profession to inform the patients about the biological plausibility that negligence about the oral health increases not only the risk of unfavorable pregnancy outcomes but also of developing conditions that may affect the well-being of the newborn.
López et al.found that the incidence of preterm birth in women decreased whose teeth were treated with scaling or root planning during pregnancy. We being dentists, very important part of the society therefore, should make both the urban and the rural pregnant women aware of the relationship of mother–infant oral health and advise them to have a periodic dental examination along with treatment for any dental or periodontal disease.
One of the limitations of the study was that clinical assessment of oral health status of patients was not done, being a questionnaire study. Hence, large-scale longitudinal epidemiological and interventional studies are necessary to authenticate the contributory relationship of periodontal diseases to adverse pregnancy outcomes.
| Conclusion|| |
Knowledge is power and information is liberating. Education is the premise of progress in every society, in every family. Counseling for the pregnant women includes general and oral changes that may occur during pregnancy and infant oral health care. This study revealed that the level of education and socioeconomic status was significantly associated with oral health attitude and practice. In the context of oral health during pregnancy, an add-on to the awareness about health care and associated preventive measures, better positive attitudes can always be achieved at every step. Education on effective tooth brushing to prevent periodontal diseases and its impact on their newborns is needed in the current population, especially in rural areas. Apart from the benefit to the health of the women, mothers play a crucial role in transferring and demonstrating health habits to their children; therefore, pregnant women should be a target group for oral health education. The effect of dental diseases on their pregnancy outcomes and the oral health of their offspring should also be highlighted. The potential of poor oral hygiene during pregnancy should be understood so as to protect the oral health of the mother as well as of the unborn, with the purpose of being an effective supervisor of the child's oral health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abiola A, Olayinka A, Mathilda B, Ogunbiyi O, Modupe S, Olubunmi O, et al.
Asurvey of the oral health knowledge and practices of pregnant women in a Nigerian teaching hospital. Afr J Reprod Health 2011;15:14-9.
Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60:257-64.
Bayanku AK, Rwakatema DS. Oral health of pregnant women. Prof Med J 2013;20:365-73.
Clothier B, Stringer M, Jeffcoat MK. Periodontal disease and pregnancy outcomes: Exposure, risk and intervention. Best Pract Res Clin Obstet Gynaecol 2007;21:451-66.
Brambilla E, Felloni A, Gagliani M, Malerba A, García-Godoy F, Strohmenger L, et al.
Caries prevention during pregnancy: Results of a 30-month study. J Am Dent Assoc 1998;129:871-7.
Offenbacher S. Periodontal diseases: Pathogenesis. Ann Periodontol 1996;1:821-78.
Sanz M, Kornman K; Working Group 3 of the Joint EFP/AAP Workshop. Periodontitis and adverse pregnancy outcomes: Consensus report of the joint EFP/AAP workshop on periodontitis and systemic diseases. J Periodontol 2013;84:S164-9.
Agueda A, Echeverría A, Manau C. Association between periodontitis in pregnancy and preterm or low birth weight: Review of the literature. Med Oral Patol Oral Cir Bucal 2008;13:E609-15.
López NJ, Da Silva I, Ipinza J, Gutiérrez J. Periodontal therapy reduces the rate of preterm low birth weight in women with pregnancy-associated gingivitis. J Periodontol 2005;76:2144-53.
Avula H, Mishra A, Arora N, Avula J. KAP assessment of oral health and adverse pregnancy outcomes among pregnant women in Hyderabad, India. Oral Health Prev Dent 2013;11:261-70.
Agbelusi G, Sofa O, Jeboda S. Oral health knowledge, attitude and practices of pregnant women in the Lagos University Teaching Hospital. Niger Q J Hosp Med 1999;9:116-20.
Rakchanok N, Amporn D, Yoshida Y, Harun-Or-Rashid M, Sakamoto J. Dental caries and gingivitis among pregnant and non-pregnant women in Chiang Mai, Thailand. Nagoya J Med Sci 2010;72:43-50.
Akila G, Navin I, Preena C, Chandrasekhara R. A survey on dental knowledge and gingival health of pregnant women attending government maternity hospital in Chennai. JOHCD 2011;5:24-30.
Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc 2006;137 Suppl 10:7S-13S.
Offenbacher S, Lin D, Strauss R, McKaig R, Irving J, Barros SP, et al.
Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: A pilot study. J Periodontol 2006;77:2011-24.
Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, et al.
Periodontal disease and preterm birth: Results of a pilot intervention study. J Periodontol 2003;74:1214-8.
World Health Organization. The incidence of low birth weight: an update. Weekly Epidemiol Rec 1984;59:205-11.
Cruz SS, Costa Mda C, Gomes Filho IS, Vianna MI, Santos CT. Maternal periodontal disease as a factor associated with low birth weight. Rev Saude Publica 2005;39:782-7.
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al.
Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103-13.
López NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized controlled trial. J Periodontol 2002;73:911-24.
Sant'Ana AC, Campos MR, Passanezi SC, Rezende ML, Greghi SL, Passanezi E, et al.
Periodontal treatment during pregnancy decreases the rate of adverse pregnancy outcome: A controlled clinical trial. J Appl Oral Sci 2011;19:130-6.
Dasanayake AP. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol 1998;3:206-12.
Mumghamba EG, Manji KP. Maternal oral health status and preterm low birth weight at muhimbili national hospital, Tanzania: A case-control study. BMC Oral Health 2007;7:8.
Macones GA, Parry S, Nelson DB, Strauss JF, Ludmir J, Cohen AW, et al.
Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: Results from the periodontal infections and prematurity study (PIPS). Am J Obstet Gynecol 2010;202:147.e1-8.
Bobetsis Y, Barros S, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc 2006;137:75-125.
Mårtensson C, Söderfeldt B, Andersson P, Halling A, Renvert S. Factors behind change in knowledge after a mass media campaign targeting periodontitis. Int J Dent Hyg 2006;4:8-14.
Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases caused by oral infection. Clin Microbiol Rev 2000;13:547-58.
Sadatmansouri S, Sedighpoor N, Aghaloo M. Effects of periodontal treatment phase I on birth term and birth weight. J Indian Soc Pedod Prev Dent 2006;24:23-6.
] [Full text]
Offenbacher S, Beck JD, Lieff S, Slade G. Role of periodontitis in systemic health: Spontaneous preterm birth. J Dent Educ 1998;62:852-8.
Offenbacher S, Jared HL, O'Reilly PG, Wells SR, Salvi GE, Lawrence HP, et al.
Potential pathogenic mechanisms of periodontitis associated pregnancy complications. Ann Periodontol 1998;3:233-50.
Thomas NJ, Middleton PF, Crowther CA. Oral and dental health care practices in pregnant women in Australia: A postnatal survey. BMC Pregnancy Childbirth 2008;8:13.
Bamanikar S, Kee LK. Knowledge, attitude and practice of oral and dental healthcare in pregnant women. Oman Med J 2013;28:288-91.
Glaze PM, Wade AB. Toothbrush age and wear as it relates to plaque control. J Clin Periodontol 1986;13:52-6.
Bassani DG, Olinto MT, Kreiger N. Periodontal disease and perinatal outcomes: A case-control study. J Clin Periodontol 2007;34:31-9.
Miyazaki H, Pilot T, Leclercq MH, Barmes DE. Profiles of periodontal conditions in adults measured by CPITN. Int Dent J 1991;41:74-80.
Boggess KA, Urlaub DM, Massey KE, Moos MK, Matheson MB, Lorenz C, et al.
Oral hygiene practices and dental service utilization among pregnant women. J Am Dent Assoc 2010;141:553-61.
Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc 2001;132:1009-16.
Hwang SS, Smith VC, McCormick MC, Barfield WD. Racial/ethnic disparities in maternal oral health experiences in 10 states, pregnancy risk assessment monitoring system, 2004-2006. Matern Child Health J 2011;15:722-9.
[Table 1], [Table 2], [Table 3], [Table 4]
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