| Abstract|| |
Background: Preterm low birth weight (PTLBW) is a public health issue which needs to be dealt with by educating the general female population. One of the major contributing factors is periodontal disease and treatment of the same could reduce the occurrence of PTLBW babies. Therefore, awareness of this among the female population is highly essential. Hence, this survey was planned with the aim to explore the awareness of the general female population regarding the association of periodontal disease and PTLBW.
Material and Methods: This survey consisted of nine close-ended questions answered by 1284 females.
Results: Younger individuals had higher knowledge scores as compared to the older individuals (r = −0.161) and the more educated group had a higher knowledge score as compared to the less educated groups (r = 0.322). Furthermore, married women seemed to be more aware of the relation of PTLBW to periodontal disease as compared to unmarried women.
Conclusion: Younger and educated females had better awareness of the association between periodontal diseases and PTLBW. Hence, efforts to educate the general female population on this association could contribute toward the reduction of the risk of PTLBW.
Keywords: Female population, periodontal disease, preterm low birth weight
|How to cite this article:|
Tarannum F, Shiva Prasad R K, Shobha R, Santosh Kumar B B, Ebenezer S. Awareness of the association between periodontal disease and adverse pregnancy outcome among the general female population. Indian J Dent Res 2015;26:21-5
Birth weight is considered to be an important factor in determining the chance of survival, growth and development of an infant. It has also been used as an indicator for the health of the entire population under study. Despite advances in perinatal medicine, the prevalence of preterm low birth weight (PTLBW) infants has actually increased.  PTLBW is a significant public health issue in both developed and developing countries.  Preterm birth is defined as labor or birth before 37 weeks of gestation, and low birth weight is defined as birth weight <2.5 kg. 
|How to cite this URL:|
Tarannum F, Shiva Prasad R K, Shobha R, Santosh Kumar B B, Ebenezer S. Awareness of the association between periodontal disease and adverse pregnancy outcome among the general female population. Indian J Dent Res [serial online] 2015 [cited 2020 Feb 17];26:21-5. Available from: http://www.ijdr.in/text.asp?2015/26/1/21/156791
Although about 25% PTLBW occurs without a suspected factor, studies have shown that maternal genitourinary infections during pregnancy, low maternal height, lower socioeconomic status, nutrition, stress, and absence of prenatal care traditionally are the main risk factors. , Periodontal disease accounts for about 18.2% of all PTLBW cases.  A systematic review of randomized controlled trials concludes the association between periodontal disease and PTLBW.  Prevention and treatment of periodontal disease are critical in improving the pregnancy outcomes in patients. Hence, it is necessary that the female population, as well as the attending physicians, is aware of the problem in question.
In recent years, studies have assessed the knowledge and practices of medical practitioners and obstetricians in relation to periodontal disease and PTLBW. The results indicate that obstetricians are aware of the association between periodontal disease and adverse pregnancy outcomes while general practitioners were less aware. ,, Alwaeli and Al-Jundi and Gόntsch et al. surveyed the awareness of pregnant population regarding oral and periodontal health and concluded that there was a need to educate pregnant women regarding the effects of periodontal health on pregnancy outcomes. , Thus, there is a deficiency in the knowledge of the female population on the subject of periodontal disease in relation to the adverse effects on pregnancy.
Hence, this survey was conducted on the general female population to assess their awareness regarding periodontal disease and PTLBW.
| Materials and methods|| |
This cross-sectional survey was done on general female population reporting to the Out-Patient Department of a Dental Teaching Hospital located in Bangalore, India. The study protocol was approved by the Institutional Review Board and Ethics Committee prior to commencement of the project. A total of 2000 female patients in the age range of 18-65 years reporting between 01/09/2012 and 15/12/2012 were surveyed. Subjects were requested to complete an anonymous, self-administered, structured, close-ended questionnaire with responses presented as yes/no.
A pilot study was done to check the acceptability, validity, and reliability of the questionnaire used. Validity was examined by evaluating the questions for a relevant, comprehensive reflection of the concept intended to measure. Reliability was tested by making the subjects complete the questionnaire on two separate occasions 2 weeks apart. The two sets of responses were then compared statistically using Spearman's Rank Correlation Coefficient. The acceptability of the questionnaire was evaluated by asking the subjects the ease of answering the questionnaire and time taken to complete the questionnaire.
The final questionnaire [Table 1] was prepared with a cover letter stating the title and purpose of the survey. The first part of the questionnaire recorded demographic information (age, marital status, education, and occupation) followed by questions to assess the awareness of general female Indian population to the association between periodontal disease and PTLBW.
Questionnaires with missing or incomplete data were excluded, and data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) software (Chicago, IL, USA), version 11, SPSS Inc. The primary outcome variable was awareness of the association between periodontal diseases and PTLBW infants. Frequencies and descriptive statistics were generated for all study variables. Results on continuous measurements are presented on mean ± standard deviation (min-max) and results on categorical measurements are presented in a number (%). Student t-test was used for continuous variables and Chi-square test was utilized to detect significant associations between categorical variables. Pearson's correlation analysis was conducted to evaluate the association between age and knowledge score, as well as educational status and knowledge scores. Statistical significance was set at P < 0.05.
| Results|| |
For the survey, 2000 females in the age range of 18-65 were approached out of which only 1563 females agreed to participate. The denial to participate was due to lack of time or hesitation to express their opinions. There were 279 incompletely filled questionnaire forms and these were excluded. A total of 1284 completely filled questionnaires were included for statistical analysis.
[Table 1] shows the percentage of responses for all the questions. The statistical analysis was conducted using statistical software SPSS 11. A score of the numerical value one was given for every positive response. Total knowledge score (TKS) was calculated as the sum of all the positive responses and the significance of the difference in mean scores among different groups was calculated using ANOVA. [Table 2] shows the means of TKS for different age groups. TKS was highest for lowest age group and least for the highest age group. Tukey's HSD analysis [Table 3] shows the significant difference for individual age group. [Table 4] shows mean knowledge score among different educational status groups. It shows that the postgraduate group has highest knowledge score, and the primary group has lowest mean knowledge score. [Table 5] shows Tukey's HSD analysis for significance among each educational group. [Table 6] shows correlation analysis. There was a negative correlation between age and knowledge score and positive correlation between education and knowledge score. [Table 7] shows mean knowledge score among married and unmarried females. The mean knowledge score was higher among the married group compared to unmarried group, and the difference was statistically significant.
|Table 3: Tukey's HSD post-hoc analysis for multiple comparisons of knowledge score in different age groups |
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|Table 4: Mean knowledge score among different educational status groups |
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|Table 5: Tukey's HSD post-hoc analysis for multiple comparisons of knowledge score in different educational status groups |
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|Table 6: Correlation between age and educational status with knowledge score |
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| Discussion|| |
Preterm delivery continues to be one of the most significant unresolved problems of public health and perinatology. Preterm birth is one of the strong predictors of infant mortality and morbidity, and has shown to be significantly associated with a number of poor health outcomes which include cerebral palsy, impaired vision and hearing, poor motor skills, asthma, learning disabilities, and premature death.
Although the pathophysiology of preterm delivery remains unknown, accumulating evidence suggests that subclinical infections and chronic inflammation may account for a majority of preterm deliveries. Some investigators have indicated that infections are major causes of preterm deliveries, responsible for 30-50% of all cases. However, there is increasing evidence that suggests that other infectious processes occurring elsewhere in the body may contribute to preterm delivery. Periodontal disease may be one such infection. In humans, there have been several recent observational studies and randomized clinical trials that show a significant association between periodontal disease and adverse pregnancy outcomes. PTLBW is a condition having tremendous financial impact on health care systems, and the families affected. Disorders related to PTLBW are among the leading causes of death and disability in infants and hence is a public health problem. 
Periodontitis is the most prevalent infection of the oral cavity, and there is ample evidence to suggest that periodontal disease is a risk factor for preterm deliveries. Estimates suggest that about 18.2% of all PTLBW cases may be attributable to periodontal disease.  Periodontal infections are preventable and treatable; hence, periodontitis can be viewed as a modifiable risk factor in relation to preterm births. There is a need to expand preventive measures for pregnant women and to educate the female population on the adverse pregnancy outcomes caused due to periodontal disease. Since PTLBW is a public health problem, any contribution to reduce its occurrence would make a great difference to the economy. Before forming education schemes, there is a need to evaluate the knowledge and awareness of the association between pregnancy and periodontal disease among the general female population. In the light of the above facts, the present survey was conducted to evaluate the awareness of the association between periodontal disease and PTLBW.
The results of this survey showed that 96.8% of the general female population was aware that oral health is related to systemic health and oral hygiene measures are necessary for good systemic health. It was observed that the younger population had higher knowledge scores as compared to the older age groups. Level of education had a significant impact on the knowledge score. There was a positive correlation between educational status and knowledge score. The younger generation as well as the educated population has better exposure to multimedia and hence may be more aware of the new advances in the field of health care services. This survey also showed that married females had higher level of awareness as compared to unmarried females. There is no literature published addressing the awareness of the general female population on the association between periodontal disease and pregnancy. Since this survey appears to be the first of its kind the results cannot be discussed in comparison.
About 97% of the population has agreed that good oral hygiene is necessary for good systemic health, and also 70% of the population under survey agrees that additional oral hygiene is required during pregnancy. This indicates that the population is aware that adverse oral health can have adverse effects during pregnancy. This probably can be attributed to the increasing awareness of this association among general medical practitioners and gynecologists as shown in some of the previously conducted surveys. , A previous survey shows that about 60% of the gynecologists and medical practitioners were aware of the association between disease and PTLBW.  Perhaps gynecologists and medical practitioners are attempting to educate and inform patients about this association. This survey was conducted among the female population in Bangalore, a metropolitan city which has seen immense medical advancement. The gynecologists in the city have very good access to knowledge about latest developments in the field of medicine through continuing education programs. The city has umpteen numbers of well-equipped hospitals and also there is excellent accessibility to dental health services.
However, when questioned about the association of pregnancy to signs of periodontal disease and periodontal disease to birth outcomes, the awareness was low. Gingival inflammation and gingival enlargements during pregnancy are associated with hormonal changes during gestation. The results of this survey suggest that the general female population is not aware of the gingival changes during pregnancy. This survey attempted to evaluate the awareness about the gingival changes during pregnancy, in an attempt to link the awareness to the association between periodontal diseases and PTLBW. Negative opinion of the participants might either indicate a lack of awareness of the association or their disagreement with the association.
In view of the effects of periodontal disease on pregnancy outcomes, American Academy of Periodontology has recommended that pregnant women or women planning pregnancy undergo periodontal examination and receive appropriate treatment if indicated.  To our dismay, half the population in this survey did not agree that dental treatment can be carried out during pregnancy. Before projecting the importance of periodontal treatment during pregnancy, it is important to improve their knowledge through elaborate educative programs. This can be possible through a joined effort from the health care sector which includes government policy-makers, general medical practitioners, gynecologists, and general dental practitioners. This may turn out to be a small contribution toward reducing the occurrence of the PTLBW, which is a significant public health problem. 
Preterm born infants are at increased risk for poor health outcomes posing a huge economic burden on the country and psychological burden for the family. The health challenges faced by premature infants often necessitate that they spend the first few weeks or months in neonatal intensive care units. Ventilators are required to facilitate the infants' breathing, incubators to maintain body temperature, and nasogastric tubes are required for feedings. There is clearly a need to reduce the rates of preterm birth since the complications of preterm birth are not limited simply to mother and child; rather, it is a matter that concerns all: Parents, health care providers, policy-makers, and communities at large.
Preterm births represent one of the greatest health challenges of the 21 st century. Health policy-makers in many low-and middle-income countries have not prioritized preterm birth as a health problem due to the lack of data showing the toll of prematurity and associated disabilities. It was not until 2009 that the first global and regional rates of preterm birth were published by the World Health Organization.  India has the highest numbers of children under-five dying from preterm birth complications each year followed by Nigeria. Over 3.6 lakh children under age five die from preterm birth complications each year in India, according to a new study which found premature birth kills more under-fives globally than anything else.  The care and prevention of preterm births will require entirely different medical and public health approaches. Although most of the females are aware of the need of additional oral health care during pregnancy not all of them agree that adverse pregnancy outcomes could be due to poor oral health. Measures should be taken to increase the awareness about this association thereby attempting to prevent the occurrence of adverse pregnancy outcomes.
| Acknowledgment|| |
The authors thank Dr. Nancy Srivastava and Dr. Preena Bajaj, Post Graduate Students, Department of Periodontics, MR Ambedkar Dental College and Hospital, Bangalore, Karnataka for their support in data collection for the survey.
| References|| |
Galson SK. Preterm birth as a public health initiative. Public Health Rep 2008;123:548-50.
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.
Davenport ES, Williams CE, Sterne JA, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birth weight: Case-control study. J Dent Res 2002;81:313-8.
Crowther CA, Thomas N, Middleton P, Chua MC, Esposito M. Treating periodontal disease for preventing preterm birth in pregnant women. Cochrane Database Syst Rev 2005;2:CD005297.
Kim AJ, Lo AJ, Pullin DA, Thornton-Johnson DS, Karimbux NY. Scaling and root planing treatment for periodontitis to reduce preterm birth and low birth weight: A systematic review and meta-analysis of randomized controlled trials. J Periodontol 2012;83:1508-19.
Wilder R, Robinson C, Jared HL, Lieff S, Boggess K. Obstetricians' knowledge and practice behaviors concerning periodontal health and preterm delivery and low birth weight. J Dent Hyg 2007;81:81.
Robinson CB, Lieff S, Wilder R, Boggess K, Benedict S. Obstetricians' knowledge of and practice behaviors concerning periodontal disease and preterm low birth weight. J Dent Hyg 2005;79:12-25.
Al-Habashneh R, Aljundi SH, Alwaeli HA. Survey of medical doctors' attitudes and knowledge of the association between oral health and pregnancy outcomes. Int J Dent Hyg 2008;6:214-20.
Alwaeli HA, Al-Jundi SH. Periodontal disease awareness among pregnant women and its relationship with socio-demographic variables. Int J Dent Hyg 2005;3:74-82.
Güntsch A, Schüler I, Kneist S, Heinrich-Weltzien R, Sigusch BW. Oral health of pregnant women and their awareness of oral hygiene. Gesundheitswesen 2013;75:e69-73.
Shenoy RP, Nayak DG, Sequeira PS. Periodontal disease as a risk factor in pre-term low birth weight - an assessment of gynecologists' knowledge: A pilot study. Indian J Dent Res 2009;20:13-6.
Tarannum F, Prasad S, Muzammil, Vivekananda L, Jayanthi D, Faizuddin M. Awareness of the association between periodontal disease and pre-term births among general dentists, general medical practitioners and gynecologists. Indian J Public Health 2013;57:92-5.
Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology. American Academy of Periodontology statement regarding periodontal management of the pregnant patient. J Periodontol 2004;75:495.
Beck S, Wojdyla D, Say L, Betran AP, Merialdi M, Requejo JH, et al.
The worldwide incidence of preterm birth: A systematic review of maternal mortality and morbidity. Bull World Health Organ 2010;88:31-8.
Robert Black. The Lancet: Latest estimates show that preterm birth complications and pneumonia are the leading causes of death in children under 5 years. Public Release Date. Available from: http://www.eurekalert.org/pub_releases/2014-09/tl-tll092914.php. [Last Released on 2014 Sep 30].
M. R. Ambedkar Dental College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]