ORIGINAL RESEARCH. Self-reported Awareness of Oral Health and Infant Oral Health among Pregnant Women in Mangalore, India- A Prenatal Survey

Dr. Varghese Chacko M.D.S (Paedodontics & Preventive Dentistry) is Associate Professor, Department of Pedodontics & Preventive Dentistry, Manipal College of Dental Sciences (Mangalore), Manipal University, Mangalore - 575001 Karnataka, India. Infant Oral Health Knowledge Among Pregnant Women ORIGINAL RESEARCH Self-reported Awareness of Oral Health and Infant Oral Health among Pregnant Women in Mangalore, India- A Prenatal Survey Varghese Chacko, Ramya Shenoy, Hridya E. Prasy, Sheetal Agarwal Background: Maternal Oral Health is known to have a significant impact on her child s oral health. Knowledge and attitude towards oral health among pregnant women can thus be a strong predictor of not only her own oral health but also her future child s oral health. Dr. Ramya Shenoy M.D.S (Public Health Dentistry) is Associate Professor, Department of Public Health Dentistry, Manipal College of Dental Sciences (Mangalore), Manipal University, Mangalore - 575001 Karnataka, India. Dr. Hridya E. Prasy is B.D.S Intern, Manipal College of Dental Sciences (Mangalore), Manipal University, Mangalore - 575001 Karnataka, India. Dr. Sheetal Agarwal B.D.S is Lecturer, Department of Conservative Dentistry, Manipal College of Dental Sciences (Mangalore), Manipal University, Mangalore - 575001 Karnataka, India. Objectives: The objectives of this cross sectional survey were to evaluate knowledge and practices of pregnant women with respect their oral health, knowledge of pregnant women on Infant Oral Health and whether these parameters were influenced by maternal education level. Materials and Methods: The research tool was a questionnaire which was completed by 175 pregnant women attending various primary health centers, private clinics and nursing homes in Mangalore. The women were divided into 2 groups namely, Group 1: included women who had an education up to high school or below & Group 2: included women who had at least a graduate qualification. Comparisons were made between group 1 & group 2. The data collected was analyzed using descriptive statistics and Chi Square test. Results: A greater percentage of women in group 2 were aware of the importance of having a dental checkup during pregnancy and benefits of Fluoride toothpaste as compared to group 1. However these differences were not statistically significant. With respect to infant oral health, women in group 2 were found to have a better knowledge with respect to the association between improper feeding practices and dental caries, and this difference was statistically significant. Women in group 2 also seemed to be more aware of the possibility of bacterial transmission from mother s oral cavity to infant s oral cavity and the association between children s caries experience and their own active caries status. However these differences were not statistically significant. Conclusion: The knowledge and practices of pregnant women with respect to oral health and infant oral health was poor and was not influenced by their level of education. Keywords: Infant Oral Health, Awareness, Pregnancy. Corresponding Author: Dr. Ramya Shenoy E-mail: dr_vinaya_ramya@sify.com www.ijhrs.com 109 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2

INTRODUCTION Good infant oral health is the basis for a lifetime free from preventable oral diseases. To achieve this goal, parental involvement is a must, and ideally this involvement should start even before birth. It has been found that during pregnancy women are amenable to disease prevention and health promotion interventions 1. Hence this period can be utilized to provide prenatal oral health counseling aimed at educating the mother about infant oral health & how her own oral health can affect the general and oral health of her future baby. The association between periodontitis during pregnancy and pregnancy outcomes is still inconclusive. While some investigators report no association between periodontal disease and pregnancy outcomes 2, others report periodontal disease as a risk factor for pre-termlow birth weight (PTLBW) deliveries 3.Children born as PTLBW pose not only a major obstetric problem but also have delayed milestones of development and are at increased risk of having tooth defects like enamel hypoplasia and Early Childhood Caries (E.C.C) 4. In addition to this, it has been shown that mothers with poor oral health may be at a greater risk of infecting their children. The vertical colonization of Streptococcus mutans, the primary micro-organism in the etiology of E.C.C is well documented 5, 6.In fact, genotypes of S. mutans in infants appear identical to those present in mothers in many cases 5. Simple measures such as maintenance of good oral hygiene, use of a fluoridated tooth paste / mouthwash, diet modification, use of xylitol chewing gums, having regular dental checkups and meeting the dental treatment needs help in decreasing the likelihood of transmission of infection from mother to child and ultimately reduces the risk of E.C.C. 7.Thus there is conclusive and growing evidence that good oral health of the mother right from the pregnancy could be the key to establishing good infant oral health. Thus this study was undertaken to evaluate knowledge and practices of pregnant women with respect to their oral health, the knowledge of pregnant mothers with respect to infant oral health and the influence of level of formal education on the above two mentioned parameters. MATERIALS AND METHODS The study was a cross sectional survey among pregnant women in Mangalore city. The sample was selected from pregnant women attending various primary health care centers, private nursing homes/ clinics in Mangalore. Inclusion criteria for the study included women who could read and write English or Kannada and who were willing to participate in the study. Those women who were not willing to participate in the study and who needed an interpreter were not included in the survey. Institutional Ethics Committee approval was obtained before proceeding with the survey. Of the 253 pregnant women approached to complete the questionnaire, 175 were included in the study. The 175 women who completed the questionnaire were then divided into 2 groups (Group 1: Women who had a high school education or below and Group 2: Women who had at least a graduate degree.) Comparisons were made between the two groups to analyze the effect of education on knowledge and practice of oral health, and knowledge of infant oral health. The research tool was a semi-structured questionnaire with 21 questions which was made in both English and the local language (Kannada). The questionnaire was developed by a group consisting of 5 Pediatric Dentists and 3 Public Health dentists, all in academia. The items for the questionnaire were identified after a comprehensive review of relevant literature and the final questionnaire contained only those items which all members of the group considered as relevant. The questionnaire was translated to Kannada by a native speaker and then translated back. The questionnaire was tested for validity and reliability. The first part of the questionnaire contained questions with respect to demographic factors of the participants and the following part contained questions related to knowledge and practice of oral health in pregnancy and questions related to knowledge of infant oral health. The questionnaire was completed by the participants in the presence of one of the investigators. The data were analyzed using descriptive statistics and chi-square test. 5% level of probability was used to indicate statistical significance. 110 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2

Table 1 Demographic Characteristics Characteristics Frequency Percentage Age (Years) <20 20 11.4% 20-30 130 74.3% >30 25 14.3% No of Pregnancies First 110 62.9% More than one 65 37.1% Education High School/below 98 56% Graduate/Post Graduate Trimester 77 44% First 45 25.7% Second 78 44.6% Third 52 29.7% RESULTS Demographic Characteristics A total of 175 pregnant women participated in the survey. Of the 175 respondents, 74.3% (130) were in the age group of 20-30. The majority of women who completed the questionnaire were in their first pregnancy (62.9%, 110). 44.7% of the participants had a graduate/post graduate degree, while of the remaining 56%, 19.4% had a high school education, 33.4 % had completed primary school while 3.4% did not receive any form of formal education (Table 1). Comparison between Group1 and Group2 Oral health Problems and Practice Oral health problems of the women in group 1 and group 2 are shown in Table 2. Decayed teeth were found to be the predominant dental problem reported by women in both groups. Very few women (13.7%) were advised by their gynecologists to have a dental checkup during pregnancy. More women in Group 2 reported that a dental checkup was important during the pregnancy period as compared to women in group 1.However the number of women who utilized dental services during this period were almost identical in both the groups, with 23.5% women in group 1 and 24.7 % women in group 2 reporting the utilization of dental services during their pregnancy. Tooth brush and dentifrice were the most popular oral hygiene aids in both the groups (Table 3). However majority of the women in both groups were not aware as to whether their dentifrice was a fluoride containing dentifrice and also most of the respondents were not aware of the benefits of fluoride. Knowledge of Infant Oral Health The knowledge on infant oral health (Table 4) was found to be poor regardless of the level of education. Women in both groups had poor understanding of the association between their oral health and infant oral health. More women in group 2 (23.4%) were aware that bacteria could be transmitted from their mouth to their child s mouth as compared to group Oral Signs & Symptoms Table 2 Oral Health Problems Group 1 Group 2 Frequency Ɏ Percentage Frequency Ɏ Percentage Decayed 16 16.3% 25 32.5 Bleeding Gums 11 11.2% 13 15.4 Ulcers 6 6.1% 3 3.9 Bad Taste 7 7.1% 4 5.2 Bad Breath 5 5.1% 5 6.5 Pain 28 28.6% 11 14.3 Ɏ Number of subjects with an affirmative response 111 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2

1(12.2%). However this difference was not statistically significant. With respect to infant oral hygiene practices majority of the women in both groups, 35% in group 1 and 49% in group 2 reported that they would clean their child s mouth once the first milk tooth had erupted. Also, majority of the women in both groups reported that they would take their child to the dentist only if their child had a problem. More women in group 2 reported to be aware that improper bottle Items Important to have a dental checkup during pregnancy Figure 1 Source of Information Table 3 Oral Health Practices/Knowledge feeding/ breast feeding could be a risk factor for dental caries as compared to group 1 and this difference was found to be statistically significant. Source of Information on Infant Oral Health More women (29.9%) in Group 2 reported to receive information on their future child s oral health than women in Group 1 (13.3%). The major source of this information (Figure 1) was non health care providers in both groups. However more women in group 2 Group 1 Group 2 Frequency Ɏ Percentage Frequency Ɏ Percentage P value # 12 12.2 18 23.4 0.154 Visited a dentist during pregnancy 23 23.5 19 24.7 0.860 2 nd trimester is the best for dental treatment 6 6.1 12 15.6 0.004 * Use brush and paste 91 92.9 72 93.5 0.254 Use Fluoride containing paste 20 20.4 23 29.9 0.339 Fluoride paste is better 22 22.4 24 31.2 0.288 Ɏ- Number of subjects with an affirmative response, # - Chi-square Test, *- Significant p< 0.05 112 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2

Items If mother has decayed teeth, child is likely to have decayed teeth Bacteria can be transmitted from mothers mouth can be transmitted to child s mouth At will breast feeding/ bottle feeding with sweetened beverages can cause dental caries Start cleaning your baby s mouth before first tooth erupts Your baby s first dental visit should be after 1 st tooth erupts Table 4 Knowledge of Infant Oral Health Group 1 Group 2 Frequency Ɏ Percentage Frequency Ɏ Percentage P value # 7 7.1 14 18.2 0.616 12 12.2 18 23.4 0.157 35 35.7 44 57.1 0.004* 14 14.3 18 23.4 0.127 16 16.3 9 11.7 0.014* Ɏ- Number of subjects with an affirmative response, # - Chi-square Test, *- Significant p< 0.05 (31.2%) received information from health care providers as compared to women in group 1 (14.4%). DISCUSSION In this survey on pregnant women, it was found that tooth brush & dentifrice were the most common aids used for oral hygiene maintenance. However most of the women surveyed were not aware as to whether they were using a Fluoride containing dentifrice & were also not aware of the benefits of fluoride. These findings are similar to the findings reported by Buerlein K J et al in a study done in Maryland, U.S.A. 8.More women in group 2 reported to be using a Fluoride containing dentifrice and also seemed to be aware of the benefits of Fluoride as compared to group 1. However this difference was not found to be statistically significant. This survey also highlights the fact that even though many women reported the presence of decayed teeth and signs of periodontal disease, only 24% of the women reported visiting a dentist during this period. This figure is comparable to figures seen in other countries like Australia, where Thomas N.J. et al reported that 30% of the women utilized dental services during pregnancy 9 and in the US, where 22.7-34% of the pregnant women accessed dental care during pregnancy 10.The Level of Education did not seem to be a factor in determining the utilization of dental services, with a similar number of women in both groups reporting the use of dental services. In this study, only 13.7% of the women surveyed reported to being advised by their gynecologist to have a dental checkup during pregnancy. This could be a reason for the low utilization of dental services during this period. It is important to maintain good oral health during pregnancy as the mother s oral health has an impact on her infant s/child s oral health. High Mutans Streptococci levels, open carious lesions & poor oral hygiene in caregivers are all recognized as risk factors in the transmission of Mutans Streptococci (MS) from caregiver to child 11. This early colonization of the infant s oral cavity by MS can cause early caries initiation. Among the women surveyed, majority had a poor understanding of the relationship between maternal oral health & infant oral health. More women in group 2 (23.4%) reported to be aware of the possibility of bacterial transmission from their mouths to their child s mouth as compared to group 1(12.1%). The lack of knowledge among the women surveyed in this study with respect to bacterial transmission from mother to child is similar to the findings of Suresh et al 12 and Sakai et al 13.Also more women in Group 2 (18.2%) reported untreated decay in their oral cavity as a 113 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2

possible risk factor for caries in their future child compared to group1 (7.1%).Once again, these differences were not found to be statistically significant. The women s knowledge on infant oral health was also found to be inadequate. Even though the ideal recommendation is to clean the gum pads of the infant after every feed, most women in this survey reported they would start cleaning their child s oral cavity once the first tooth erupts. This is in contrast to a study done on mothers of toddlers in Moradabad, India by Suresh et al, in which most of the mothers reported that they would start brushing their child s teeth only once all the primary teeth erupted 14.More women in group 2 (23.4%) rightly reported that they would start cleaning their future child s teeth even before the first tooth erupts as compared to group 1(14.3%). However this difference was not found to be statistically significant. Awareness regarding the timing of the first dental visit was also poor with most women reporting that they would only take their child to a dentist if the child had any problem. A statistically significant difference was found between women with a graduate degree (group 2) & those without (group 1), with respect to their knowledge of at will breast feeding/ bottle feeding with a sweetened drink as a risk factor for caries. More women in group 2 reported to be aware that the above mentioned feeding habits could lead to dental caries. One of the reasons for the poor knowledge of women in this study can be attributed to a lack of exposure to the right information. Majority of the women reported to receiving information on infant oral health either from the media or non- health care providers. However more women in group 2 were found to receive advice on infant oral health as compared to women in group 1. Also more women in group 2 were found to receive their information from health care professionals. This could be because with higher education, mothers are more likely to be able to choose the right source for the information they are seeking & also understand the information better 15. This was a self reported survey & therefore has its inherent weaknesses & biases. However the findings of this survey give us an insight into the knowledge of pregnant women on oral health and infant oral health in this region. We find that even though women with a higher education level seemed to be better informed with respect to oral health and infant oral health. The difference in awareness between the groups was not significant. At present there is enough science based literature to suggest that good oral health during the period of pregnancy can not only improve the quality of life of the pregnant mother, 15 but also possibly reduce complications during pregnancy & the risk of early child hood caries in the future infant. Also there is enough evidence which suggests that the benefits of providing dental care during pregnancy outweigh the potential risks. However for this literature to have an impact & be useful it must reach pregnant women at the appropriate time & must be communicated to them in a form that they easily understand. CONCLUSION Based on the results of the present survey, the following conclusions can be made. The women surveyed had a poor knowledge on oral health. Most of the women surveyed did not consider it important to have a dental checkup during the antenatal period. Their knowledge on the benefits of fluoride was also found to be inadequate. The knowledge of pregnant women on infant oral health was poor. Even though women with a higher level of education were found to have a better knowledge on many of the parameters tested the difference between the groups was not significant. As seen in the present survey, one of the reasons for the poor knowledge among pregnant women can be attributed to the lack of advice from antenatal health care providers on oral health. Considering the fact that women are amenable to disease prevention and health promotion interventions during pregnancy, this period needs to be utilized to motivate and educate expectant mothers on the importance of good oral health during pregnancy and on infant oral health. Whether re-educating gynecologists and other antenatal health care providers on the importance of good oral health during pregnancy and infant oral health will help in this needs further investigation. Also the influence of factors such as socio-economic status and ethnicity on knowledge and practices of oral 114 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2

health and infant oral health needs to be studied further. CONFLICTS OF INTEREST None declared REFERENCES 1. Gaffield ML, Gilbert BJC, Malvitz DM, Romaguera R. Oral health during pregnancy. An analysis of informationcollected by the PregnancyRisk Assessment MonitoringSystem. JADA. 2001; 132: 1009-1016. 2. Davenport ES, Williams CECS, Sterne JAC, Murad S, Sivapathasundram V, Curtis MA. Maternal Periodontal Disease & Preterm Low Birthweight: Case-Control Study. J Dent Res. 2002; 81 (5): 313-318. 3. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G. Periodontal infection as a possible risk factor for Pre-Term Low Birth Weight. J Periodontol. 1996; 67: 1103-13. 4. Wan AKL, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. A longitudinal Study of Streptococcus mutans colonization in infants after tooth eruption. J Dent Res. 2003; 82 (7): 504-508. 5. Douglass JM, Li Y, Tinanoff N. Association of Mutans Streptococci between caregivers & their children. Pediatr Dent. 2008; 30 (5): 375-387 6. Caufield PW. The Fidelity of initial acquisition of Mutans Streptococci by infants from mothers. J Dent Res. 1995; 74, 681-5 7. AAPD Guidelines on Infant Oral Health: Reference Manual 2008; Vol 30 (7):90-93 8. Buerlein KJ, Horowitz A, Child L.Perspectives of Maryland women regarding oral health during pregnancy and early childhood. Journal of Public Health Dentistry. Early view (Online version of the Record published before inclusion in any issue) 9. Thomas NJ, Middleton PF, Crowther CA. Oral & Dental Health Practices in Pregnant Women in Australia: a postnatal survey. BMC Pregnancy & Childbirth 2008; 8:13 10. 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 (7): 1009-16. 11. Douglass JM, Li Y, Tinanoff N. Association of MutansStreptotococci between Caregivers & Their Children. Pediatr Dent.2008; 30 (5): 375-387. 12. Suresh BS, Ravishankar TL, Chaitra TR, Mohapatra AK, Gupta V. Mothers Knowledge about pre-school child s oral health. J Indian Soc Pedo Prev Dent. 2010; 28 (4): 282-287. 13. Sakai VT, Oliveira TM, Silva TC, Moretti AB, Geller-Palti D, Biella VA et al. Knowledge and attitude of parents and caregivers regarding transmissibility of caries disease. J Appl Oral Sci.2008;16:150-4. 14. Williams NJ, Whittle JG, Gatrell AC. The relationship between socio-demographic characteristics and dental health knowledge & attitudes of parents with young children. Br Dent J. 2002; 193 (11): 651-654. 15. California Dental Association Foundation, American College of Obstetricians and Gynecologists. District IX. Oral Health during pregnancy & early childhood: Evidence based guidelines for health Professionals. J Calif Dent Assoc 2010; 38 (6): 391-440. For More Information Log on to www.ijhrs.com 115 April 2013 International Journal of Health and Rehabilitation Sciences Volume 2 Issue 2