ORIGINAL Pentapati MANUSCRIPT et al
Knowledge of Dental Decay and Associated Factors Among Pregnant Women: A Study from Rural India Kalyana Chakravarthy Pentapatia/Shashidhar Acharyab/Meghashyam Bhatc/ SreeVidya Krishna Raoa/Sweta Singhd Purpose: To assess the knowledge of dental decay among pregnant women and its relationship with sociodemographic characteristics and caries experience in rural India. Materials and Methods: A cross-sectional study was conducted among 381 pregnant women in southern India. Variables and knowledge of dental decay were recorded using a structured self-administered questionnaire. Dental caries was recorded by a calibrated examiner as per WHO guidelines. Results: The majority of the respondents were under 30 years of age (91.6%), utilised a public health-care delivery system (57.2%), were primigravid (63%), had a pre-universtiy diploma (64.8%) and were in the 3rd trimester (63%). Overall, poor knowledge was expressed by 12% to 37% of the women. The mean (±SD) DT (decayed teeth), MT (missing teeth), FT (filled teeth) and DMFT (decayed, missing and filled teeth) were 3.08 (±2.6), 0.93 (±2.23), 0.39 (±1.14) and 4.4 (±3.56), respectively. There were no significant differences in the responses to the knowledge of caries with respect to age and trimester. Educational status, health-care delivery system and number of pregnancies had a significant association with knowledge of caries. Conclusion: This study highlighted the limited knowledge of dental decay among pregnant, rural, southern Indian women. Preventive programmes for pregnant women should be designed based upon a thorough interview including an informative session on the specific risks during this period, in order to motivate the patient towards oral health and implement the needed prophylactic measures. Key words: dental caries, India, knowledge, pregnancy Oral Health Prev Dent 2013;11:161-168 doi: 10.3290/j.ohpd.a29734
P
regnancy constitutes a physiological state characterised by a series of temporary adaptive changes in body structure, as the result of an increased production of oestrogens and progesterone (Guzmán and Suárez, 2004). Oral changes due to these complex physiological alterations will lead to an increase in oral vascular permeability and a decrease in host immune response, making the a
Assistant Professor, Department of Community Dentistry, Manipal College of Dental Sciences, Manipal University, India.
b
Professor and Head, Department of Community Dentistry, Manipal College of Dental Sciences, Manipal University, India.
c
Associate Professor, Department of Community Dentistry, Manipal College of Dental Sciences, Manipal University, India.
d
Senior Lecturer, Department of Public Health Dentistry, Babu Banarasi Das College of Dental Sciences, Lucknow, India.
Correspondence: Dr. P. Kalyana Chakravarthy, Department of Community Dentistry, Manipal College of Dental Sciences, Manipal University, Manipal, India 576104. Tel: +91-991-603-6303. Email:
[email protected]
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Submitted for publication: 08.07.11; accepted for publication: 08.06.12
oral cavity more susceptible to infections (Barak et al, 2003). Oral conditions seen in pregnancy include pregnancy gingivitis and periodontal infection, pregnancy epulis, caries, erosion, increased tooth mobility and increased tooth loss with parity (Amar and Chung, 1996; Scannapieco, 2004). Many epidemiological studies exist in the literature on gingival and periodontal health during pregnancy (Löe and Silness, 1963; Arafat, 1974; Samant, 1976; Chaikin, 1977; Rakchanok et al, 2010), but only a few studies have reported on caries (Radnai, 2005; Rakchanok et al, 2010; Esa et al, 2010). However, no studies have explored whether the combination of oral changes thought to occur during pregnancy, such as increased consumption of carbohydrates, increased acid in the mouth from vomiting and reduced salivary production and/or increased acidity of saliva raise the risk of caries in pregnant women.
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Recently, the dental community has focused on potential ways in which oral health may contribute to general health outcomes. A systematic review by Xiong et al (2006) emphasises the relationship between maternal oral health and adverse birth outcomes. Studies by Irigoyen et al (2009) and Wan et al (2001) also suggest that there is a causal association between the mother’s and the child’s oral disease. Pregnant women with caries might facilitate the establishment of an oral environment that places the newborn at risk of developing caries (Irigoyen et al, 2009). Recent data reported by Wan et al (2001) suggest that initial acquisition of bacteria (mutans streptococci and Lactobacillus acidophilus) can be found as early as three months of age. Irigoyen et al (2009) have shown that mothers with high levels of salivary mutans streptococci tend to have children who are infected with the bacteria at a younger age and are likely to develop a large number of carious lesions in the primary dentition. Since caries is preventable, promoting early positive behaviours in pregnancy toward oral health care could also reduce the incidence of caries. Prevention of dental caries begins even before birth, with pregnant women’s behaviour and knowledge of infant oral health care. It is essential to understand that the pregnant women’s knowledge of caries is fundamental to developing strategies in the dental community that educate pregnant women and positively and change their attitudes and knowledge in the long term. The State of the World’s Mothers (SOWM) 2011, published online by the international non-governmental organisation Save the Children (www.asianage.com/columnists/mother-s-day-sop-004) reports that the countries where mothers are most at risk are also the countries which fare poorly in many other areas — women’s health, education, economic and political status and children’s well-being. On women’s status, SOWM 2011 ranks India 76th out of 80 countries compared. The major underlying difference is in the status of women. Where women enjoy a high status, mothers are safe and fare well. Where women are neglected, mothers fare poorly. In millions of homes across the country, girls are fed less and educated less because they are not seen as assets. Considering the poor general health status of the mothers, it is plausible that oral health might also be compromised. In view of the paucity of data, it is worthwhile to assess pregnant women’s knowledge about dental caries and its associated factors. The current study aimed to evaluate knowledge of dental decay
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among pregnant women and its relationship with characteristics and caries experience in rural India. This study will provide a baseline to develop preventive and educational programmes for this high-risk group.
MATERIALS AND METHODS A cross-sectional survey was conducted for a period of 3 months among pregnant women attending their regular monthly pre-natal check-ups in two major health care centers in the field practice area of Manipal University, Manipal, India. These health centers cater to a predominantly lower- and middleclass rural population. A total of 400 pregnant women were invited to participate, out of which 386 women consented. Inclusion criteria were those willing to participate and aged 18–40 years. Exclusion criteria were those having any systemic disease contraindicating the examination and those under antibiotic prophylaxis in the last 3 months. The study was approved by the University Ethics Committee, Manipal University. A written informed consent was obtained from all the participating women prior to the study. A structured self-administered questionnaire was designed in the Kannada language, which is the regional language in the study area. The questionnaire had information on demographic data and 6 questions on the perceptions of dental decay. Demographic data consisted of age, type of health delivery system, previous history of pregnancy, education and trimester. The items on dental decay were ‘Decayed teeth can make people look bad’, ‘Decayed teeth can cause serious problems’, ‘Decayed teeth will affect people’s work or other aspects of their everyday life’, ‘Decayed teeth can cause other health problems’, ‘Brushing teeth with fluoridated toothpaste helps prevent tooth decay’ and ‘Eating sweets causes tooth decay’. Possible responses were ‘Yes’, ‘No’ and ‘Don’t know’. These questions were adapted and modified from an 18-item oral health belief questionnaire out of which items related to caries and of particular interest to the study area were selected (Nakazono et al, 1997). All the items in the questionnaire were initially prepared in English followed by translation into the local language as described by Acquadro et al (2008). In the first step, the questions were independently translated into Kannada by two qualified English-to-Kannada translators. After a group discussion with the translators and one author, the
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first consensus Kannada questionnaire was backtranslated into English. The back translation was compared with the original questionnaire and the first consensus Kannada questionnaire. After finalising the questionnaire, 25 pregnant women filled it out during the pilot study and these completed questionnaires were used to measure the reliability using Cronbach’s alpha (= 0.89).
Statistical analysis The knowledge of caries with respect to demographic data was compared using the chi-square test, while caries was compared among the groups of mothers with responses ‘yes’, ‘no’ and ‘don’t know’ using ANOVA followed by Tukey’s post-hoc test. All statistical analysis was done using SPSS version 17 (SPSS; Chicago, IL, USA). A P-value of 0.05 was considered to be statistically significant.
Clinical examination The clinical examination was done on a dental chair with artificial lighting using mouth mirrors and CPI probes. Caries was recorded by the principal investigator (PKC) according to WHO (1997) guidelines. Decayed, missing and filled teeth were assessed and summarised to yield the DMFT (decayed, missing and filled teeth) index. Intra-examiner reliability was shown to be 0.98 for caries.
RESULTS A total of 381 pregnant women constituted the final sample. Five women were excluded due to various systemic diseases. The mean age of the study population was 25.69 ± 3.68 years, with an age range from 18–37 years. The majority of the respondents were younger than 30 years (91.6%), utilised a public health-care delivery system (57.2%), were primi-
Table 1 Pregnant women’s knowledge of dental caries in relation to the age groups Age groups in years
Q1.
Response
≤25
26-30
31-35
Yes
169 (88.5%)
133 (84.2%)
25 (86.2%)
2 (66.7%)
>35
Decayed teeth can make people look bad
No
19 (9.9%)
18 (11.4%)
2 (6.9%)
1 (33.3%)
Don’t know
3 (1.6%)
7 (4.4%)
2 (6.9%)
0 (0%)
Q2.
Yes
162 (84.8%)
137 (86.7%)
26 (89.7%)
No
27 (14.1%)
16 (10.1%)
3 (10.3%)
0 (0%)
0 (0%)
0 (0%)
Don’t know
2 (1%)
5 (3.2%)
Q3.
Yes
164 (85.9%)
141 (89.2%)
27 (93.1%)
Decayed teeth will affect people’s work or other aspects of their everyday life
No
24 (12.6%)
16 (10.1%)
2 (6.9%)
0 (0%)
Don’t know
3 (1.6%)
1 (0.6%)
0 (0%)
0 (0%)
Q4.
Yes
159 (83.2%)
131 (82.9%)
25 (86.2%) 3 (10.3%)
0 (0%)
1 (3.4%)
0 (0%)
0.608
3 (100%) 0.85
3 (100%)
Decayed teeth can cause other health problems
No
27 (14.1%)
26 (16.5%)
Don’t know
5 (2.6%)
1 (0.6%)
Q5.
Yes
116 (60.7%)
107 (67.7%)
18 (62.1%)
1 (33.3%)
Brushing teeth with fluoridated toothpaste helps prevent tooth decay
No
65 (34%)
48 (30.4%)
9 (31%)
2 (66.7%)
Don’t know
10 (5.2%)
3 (1.9%)
2 (6.9%)
0 (0%)
Q6.
Yes
158 (82.7%)
129 (81.6%)
22 (75.9%)
No
29 (15.2%)
23 (14.6%)
5 (17.2%)
0 (0%)
Don’t know
4 (2.1%)
6 (3.8%)
2 (6.9%)
0 (0%)
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0.416
3 (100%)
Decayed teeth can cause serious problems
Eating sweets causes tooth decay
P-value
0.722
0.445
3 (100%) 0.795
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gravid (63%), had a pre-university diploma (64.8%) and were in the 3rd trimester (63%). There were no significant differences in the responses to the knowledge of caries with respect to age groups (Table 1). Table 2 shows significant differences in responses to questions with respect to health-care delivery system (Q1 and Q5) and number of pregnancies (Q1). Respondents who used a private health-care system were more likely to have better knowledge of caries (Q1 and Q5; P = 0.008 and P = 0.035, respectively). Primigravid women had significantly better knowledge of caries than did multigravid women (Q1; P = 0.024). Table 3 showed significant differences in responses to the questions with respect to education. Women having a Bachelor’s degree or a preuniverstiy diploma were more likely to have better
knowledge of caries than others (Q1, Q2, Q5 and Q6; P < 0.001, P < 0.001, P < 0.001 and P < 0.001, respectively). There were no significant differences in responses to Q3 and Q4 with respect to educational qualification. When trimesters were considered, no significant differences were observed in the knowledge of caries for any of the questions. The mean (± SD) DT, MT, FT and DMFT were 3.08 (± 2.6), 0.93 (± 2.23), 0.39 (± 1.14) and 4.4 (± 3.56), respectively, for the whole sample. The only significant differences were seen for Q6 and clinical caries experience (Table 5). Women who responded with ‘don’t know’ had a significantly higher mean number of missing teeth and DMFT than those who said ‘yes and no’ (P = 0.006 and P = 0.004, respectively).
Table 2 Pregnant women’s knowledge of dental caries with respect to health-care delivery system and number of pregnancies Health-care delivery system
Q1.
Response
Public
Private
Yes
179 (82.11%)
150 (92.02%)
P-value
Primigravid 216 (90%)
28 (12.84%)
Don’t know
11 (5.05%)
1 (0.61%)
6 (2.5%)
6 (4.3%)
Q2.
Yes
180 (82.57%)
148 (90.80%)
209 (87.1%)
119 (84.4%)
Decayed teeth can cause serious problems
No
32 (14.68%)
27 (11.3%)
19 (13.5%)
Don’t know
6 (2.75%)
1 (0.61%)
4 (1.7%)
3 (2.1%)
Q3.
Yes
192 (88.07%)
143 (87.73%)
213 (88.8%)
122 (86.5%)
Decayed teeth will affect people’s work or other aspects of their everyday life
No
23 (10.55%)
19 (11.66%)
Don’t know
3 (1.38%)
1 (0.61%)
4 (1.7%)
0 (0%)
Q4.
Yes
179 (82.11%)
139 (85.28%)
203 (84.6%)
115 (81.6%)
Decayed teeth can cause other health problems
No
33 (15.14%)
23 (14.11%)
33 (13.8%)
23 (16.3%)
Don’t know
6 (2.75%)
1 (0.61%)
4 (1.7%)
3 (2.1%)
Q5.
Yes
133 (61.01%)
109 (66.87%)
150 (62.5%)
92 (65.2%)
Brushing teeth with fluoridated toothpaste helps prevent tooth decay
No
80 (36.70%)
44 (26.99%)
78 (32.5%)
46 (32.6%)
Don’t know
5 (2.29%)
10 (6.13%)
Yes
180 (82.57%)
132 (80.98%)
No
33 (15.14%)
24 (14.72%)
Don’t know
5 (2.93%)
7 (4.29%)
Eating sweets causes tooth decay
164
0.052
0.733
0.286
0.035
18 (7.5%)
23 (9.6%)
12 (5%)
0.54
P-value
113 (80.1%)
No
14 (8.59%)
0.008
Multigravid
Decayed teeth can make people look bad
Q6.
12 (7.36%)
Number of pregnancies
22 (15.6%)
19 (13.5%)
0.024
0.763
0.164
0.742
0.374
3 (2.1%)
199 (82.9%)
113 (80.1%)
35 (14.6%)
22 (15.6%)
6 (2.5%)
6 (4.3%)
0.602
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DISCUSSION Many studies have evaluated the periodontal disease awareness and dental service utilisation among pregnant women (Alwaeli and Jundi, 2005; Habashneh, 2005; Honkala, 2005). Data on caries and its awareness are scant in this target group. This study highlighted the limited knowledge of dental decay among pregnant, rural southern Indian women. The mean caries experience of the present population was similar to the previous studies reported in this area by Acharya et al (2009), but was much lower than the other studies done in developed countries (Jago et al, 1984; Radnai et al, 2005; Vasiliauskiene et al, 2007). The mean number of decayed teeth in pregnant women was higher than in the previous studies done by Jago et al
(1984) and Agbelusi et al (2000). The mean number of missing teeth and filled teeth among pregnant women was lower than that reported by Jago et al (1984). These differences could be due to the numerous non-disease factors which are involved in tooth mortality. In addition, prevailing treatment philosophies, attitudes, costs, availability and accessibility of dental health care play a major role for the decision to extract teeth or to have teeth extracted. The present study reported that women who used a private health-care system had better awareness regarding the appearance of decayed teeth and use of fluoridated toothpaste. This could be due to the fact that the women who can afford private health care were likely to have a better social status and knowledge about dental health. Primi-
Table 3 Pregnant women’s knowledge of dental caries with respect to educational qualification Education
Q1.
Response
Primary school or less
Secondary School
Pre-universtiy diploma
Bachelor’s degree and above
Yes
10 (50%)
46 (79.3%)
222 (89.9%)
51 (91.1%)
Decayed teeth can make people look bad
No
8 (40%)
9 (15.5
19 (7.7%)
4 (7.1%)
Don’t know
2 (10%)
3 (5.2%)
6 (2.4%)
1 (1.8%)
Q2.
Yes
8 (40%)
43 (74.1%)
226 (91.5%)
51 (91.1%) 5 (8.9%)
Decayed teeth can cause serious problems
No
12 (60%)
12 (20.7%)
17 (6.9%)
Don’t know
0 (0%)
3 (5.2%)
4 (1.6%)
Q3.
Yes
18 (90%)
50 (86.2%)
216 (87.4%)
51 (91.1%)
Decayed teeth will affect people’s work or other aspects of their everyday life
No
2 (10%)
8 (13.8%)
27 (10.9%)
5 (8.9%)
Don’t know
0 (0%)
0 (0%)
Q4.
Yes
14 (70%)
48 (82.8%)
211 (85.4%)
45 (80.4%)
32 (13%)
10 (17.9%)
4 (1.6%)
6 (30%)
8 (13.8%)
Don’t know
0 (0%)
2 (3.4%)
4 (1.6%)
1 (1.8%)
Q5.
Yes
3 (15%)
26 (44.8%)
174 (70.4%)
39 (69.6%)
Brushing teeth with fluoridated toothpaste helps prevent tooth decay
No
15 (75%)
68 (27.5%)
12 (21.4%)
Don’t know
2 (10%)
3 (5.2%)
5 (2%)
5 (8.9%)
Q6.
Yes
8 (40%)
42 (72.4%)
213 (86.2%)
49 (87.5%)
No
12 (60%)
13 (22.4%)
26 (10.5%)
6 (10.7%)
Don’t know
0 (0%)
3 (5.2%)
8 (3.2%)
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