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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 221-227

Maternal knowledge and attitude about the relationship of periodontitis and its adverse obstetric outcomes in India


1 Department of Public Health Dentistry, D.J. College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
2 Department of Public Health Dentistry, Amrita School of Dentistry, Ernakulam, Kerala, India

Date of Submission05-Dec-2019
Date of Decision09-Jul-2020
Date of Acceptance21-Sep-2020
Date of Web Publication24-Oct-2020

Correspondence Address:
Ambar Khan
Department of Public Health Dentistry, D.J. College of Dental Sciences and Research, Modinagar, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_124_19

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  Abstract 


Background: Pregnancy is not a disease, but a normal physiological process; still it is associated with certain risk to the health and survival of both the mother and the child. Oral health is an essential component of the overall health status of a pregnant woman. Aim: This study aims to assess the knowledge and attitude about the association between periodontitis and its adverse obstetric outcomes among pregnant women in Modinagar, North India. Materials and Methods: A hospital-based study was conducted, which comprised of pregnant women visiting for Antenatal checkup at a public health care (Community Health Care) system in Modinagar, a North Indian city. A self-administered validated questionnaire in local language (Hindi) was used. This 30-item closed ended questionnaire consisted of different domains of oral hygiene practices, importance of periodontitis obstetric outcomes and demographic information. A 5 – point Likert scale was used to assess the attitudes of pregnant women. Statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS) 21.0 (SPSS Inc., Chicago, IL, USA). Mean, Standard deviation, and Independent t-test were used to compare the knowledge and attitude about the association of maternal periodontitis and its adverse obstetric outcomes between the two groups of women: Prima gravida and Multi gravida. P ≤ 0.05 was considered statistically significant. Results: Two hundred pregnant women participated in the study (50% each of Prima gravida and Multi gravida). The mean age of participants was found to be 32.88 ± 0.86 years. Most of the study population had poor knowledge (33%) and attitude (18.4%) about the association between maternal periodontitis and its adverse obstetric outcomes. For knowledge, a mean difference of 0.23 (P ≤ 0.05) between the two groups, which was found to be significant regarding whether visiting a dentist during pregnancy is necessary. First time pregnant (Prima gravida) has less knowledge compared with Multi gravida women regarding poor oral health which can lead to any complications during pregnancy. Conclusions: There is a knowledge deficit about pregnancy-induced periodontitis symptoms, prevention of complications and about the impact of obstetric outcomes among the mothers. Health-care providers should implement the focused health education programs during antenatal visit.

Keywords: Attitude, knowledge, oral health, periodontitis, pregnancy


How to cite this article:
Khan A, Patthi B, Janakiram C, Singla A, Malhi R, Goel D. Maternal knowledge and attitude about the relationship of periodontitis and its adverse obstetric outcomes in India. J Indian Assoc Public Health Dent 2020;18:221-7

How to cite this URL:
Khan A, Patthi B, Janakiram C, Singla A, Malhi R, Goel D. Maternal knowledge and attitude about the relationship of periodontitis and its adverse obstetric outcomes in India. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2020 Nov 29];18:221-7. Available from: https://www.jiaphd.org/text.asp?2020/18/3/221/298995




  Introduction Top


Pregnancy is not a disease, but a normal physiological process; still it is associated with certain risk to the health and survival of both the mother and the child. Oral health is an essential component of the overall health status of a pregnant woman.

Studies have shown that the maternal oral health has significant implications for birth outcomes and infant oral health. Maternal periodontitis has been described as a two-way relationship, as it can have a great influence on an individual's general health, and the general health in turn may influence the periodontal health as well. According to the consensus report of the “Joint European Federation of Periodontology/American Academy of Periodontology 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 (LBW) babies.[1]

Pregnant women are particularly susceptible to gingival and periodontal diseases. Hormonal changes during pregnancy and neglected oral hygiene practices tend to increase the incidence of maternal periodontitis. They may not experience symptoms until advanced periodontal stage and therefore unknowingly increase the risk of adverse obstetric effects. Some of these effects seen are premature birth, LBW babies, pre-eclampsia, and pregnancy granuloma. Proper nutrition and healthy lifestyle including good oral hygiene practices play an important role in the general wellbeing of pregnant women.[1],[2]

There is credible evidence to support the association with poor oral health to the incidence of preterm labor and LBW babies in literature. According to National Institute of Health, as many as 18% of the 2.5 lac premature LBW infants born in the United States each year may be attributed to infectious oral disease to the mother, such as Maternal periodontitis during pregnancy.[3] The study conducted by Kiran and Suma [3] showed that that 77% of antenatal mothers had inadequate knowledge pertaining to the level of knowledge on practice regarding oral hygiene. Similarly, studies conducted by Rajesh et al.[2] and Gaffar et al.[4] showed that study population had poor knowledge (89%) and the study participants (75%) were not aware about the importance of dental check-up during pregnancy. The study concluded that awareness and knowledge level of periodontal health among pregnant women was low. It is the need of the hour to impart this knowledge to the mothers in a way such that they are able to prevent the various adverse obstetric outcomes in their children.

Thus, the aim of the current study was to assess the knowledge and attitude about the association between maternal periodontitis and its adverse obstetric outcomes in the mothers residing in Modinagar, Ghaziabad.


  Materials and Methods Top


Study design and study setting

This is a Hospital-based, Cross sectional study conducted in the Community Health Center (CHC), Govindpuri, Modinagar, Uttar Pradesh, India, to assess the lack in knowledge about the association between maternal periodontitis and its adverse obstetric outcomes in the newborn children. The study participants were selected based on convenience sampling. The subjects who visited the CHC for antenatal care present at the day of the examination and who were willing to participate in the study were included in the study, while the subjects who were not willing to participate in the study were excluded. The study was conducted for 3 months; from March 15, to June 15, 2019.

The ethical clearance was obtained from the Institutional Review Board f the college (Ref no: DJD/IEC/2019/A164). For the collection of data, permission was taken from the Chief Medical Officer of the CHC, Modinagar. Complete details and information regarding the study being conducted, the methods and the purpose of the study was explained to him. This was also explained to all the study participants and informed consents were taken from them.


  Study Subjects Top


A pilot study was undertaken on 30 mothers to determine the sample size. These subjects were later not included in the main study. The sample size was calculated according to the following formula:



(Where z is the critical value of the Normal distribution [2], L is the margin of error [5%], P is the prevalence of the condition [14%], and N[100) is the population size).

With the prevalence rate of maternal periodontitis of 14% and 5% allowable error; the sample size was calculated to be 193, which was rounded off to 200, for the convenience of the study. A total of 200 women were included in the study, divided in 2 equal groups - Prima gravida (1st time mothers) and Multi gravida (mothers having more than 1 child). A simple random sampling technique was used to select the participants for the study.

Questionnaire

The general information of the participants including age, educational status, number of children, medical history, deleterious, and adverse oral habits was recorded. The study was conducted using a self-administered structured questionnaire which consisted of 30 close ended questions. The questionnaire consisted of: 5 questions related to basic oral hygiene practices during pregnancy, 15 questions related to knowledge and 10 questions related to attitude about the changes in oral health during pregnancy, maternal periodontitis and its outcomes on the health of the child. For the questions related to knowledge of the mothers, the answers were graded on a dichotomous scale as: No = 0 and Yes = 1. For the questions related to attitude of the mothers, the answers were classified into 5 groups and each answer took the score of 1 to 5 as: Strongly agree = 5, Agree = 4, Neither agree nor disagree = 3, Disagree = 2, and Strongly disagree = 1.

The questionnaire was prepared in the local language, i.e., Hindi. The investigator distributed the questionnaires to the study participants present at the CHC and ample time was given for filling the questionnaire. While filling the questionnaire by the participants, investigator waited there itself to collect the questionnaire on the same day. Majority of the participants were able to read Hindi, so they answered on their own. For some participant's doubts regarding the questions were clarified at the same point. After collection of the questionnaire, small health education was given to all the women regarding oral hygiene habits, maternal periodontitis and its possible obstetric outcomes on the child. The data collected were compiled and were checked for completeness.

Questionnaire validation

To pretest the validity of the questionnaire and determine the feasibility of the study, a pilot study was conducted among 30 mothers who were not included in the main study. Internal consistency measured through Cronbach's alpha (α) was found to be 0.72.

Statistical analysis

The findings obtained were coded and entered into Microsoft Excel (2010). The collected data were analyzed using Statistical Package for Social sciences (SPSS) 21.0 (SPSS Inc., Chicago, IL, USA). Mean, Standard deviation, and Independent t-test was used to compare the knowledge and attitude about the association of maternal periodontitis and its adverse obstetric outcomes between the two groups of women: Prima gravida and Multi gravida. P ≤ 0.05 was considered statistically significant.


  Results Top


Demographic factors

The present study consisted of 200 women divided into two equal groups - Prima gravida and Multi gravida. The study participants were between the ages of 18 and 50 years. The results of demographic data revealed that the 37% (74) of the subjects were in the age group of 31–40 years (Mean age = 32.88 ± 0.86) Most of the study participants (67.5%) had received education at the Intermediate level or more. 36.5% (73) study participants resided in the rural area while 63.5% (127) were residents in the urban region. Among the study participants, 52% (104) had no existing comorbidities. 12% (24) had a tobacco-related adverse habit and 2% (4) suffered from alcoholism [Table 1].
Table 1: Demographic factors of the study participants

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Oral hygiene practices

The oral hygiene practices of the study population were assessed for cleaning aids used, methods of tooth brushing, their frequency and duration, frequency of changing tooth brush, and use of any additional cleaning aids. Among the study participants, 73.5% (147) subjects cleaned their teeth with a toothbrush and toothpaste, while 13% of the study participants do not use a toothbrush for cleaning their teeth. Out of those who used a toothbrush, 71% (142) used to brush once a day and 29% (58) brush twice daily. The various methods of tooth-brushing employed by the participants were- horizontal 18.5% (37), vertical 20 (10%), circular 24.5% (49), and both horizontal and vertical 40.5% (81). Of all the participants, only 31% (62) used any kind of additional oral hygiene aid for the maintenance of a proper oral hygiene. The various additional oral hygiene aids used by the participants were mouthwash 48.4% (30) followed by toothpick 24.2% (15), tongue cleaner 21% (13), interdental brush 3.2% (2), and dental floss 3.2% (2) [Table 2].
Table 2: Oral hygiene practices of the studied population

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In this study, it was observed that irrespective of their number of children, majority of the study population had poor knowledge and attitude about the association between maternal periodontitis and its adverse obstetric effects. Only a few participants had good knowledge (33%) and attitude (18.4%) regarding maternal periodontitis and its various ill effects during child birth as well as the overall health of the child. When the comparison was brought about using the Independent t test between the two groups – Prima gravida and Multi gravida, the knowledge (31%) and attitude (5%) was found to be more in Multi gravida than that of Prima gravida.

Knowledge

Knowledge of the study participants about maternal periodontitis and its adverse obstetric effects are described in [Table 3] and [Table 4]. Regarding whether the subjects visited a dentist during pregnancy, a mean of 0.25 ± 0.435 was seen in Prima gravida and 0.16 ± 0.368 in Multi gravida (P ≤ 0.05). A mean of 0.67 ± 0.473 in Prima gravida and 0.44 ± 0.499 in Multi gravida was seen regarding whether it is necessary to visit a dentist during pregnancy (P ≤ 0.05). In the case of receiving any dental counseling regarding oral health during pregnancy, a mean of 0.21 ± 0.409 and 0.08 ± 0.273 was found among Prima gravida and Multi gravida respectively (P ≤ 0.05). Regarding if they faced any complications during pregnancy, a mean of 0.23 ± 0.423 and 0.29 ± 0.456 was found among primagravida and multigravida, respectively (P ≤ 0.05). About the experience of any premature labor or Pre-eclampsia or LBW infant, a mean of 0.23 ± 0.423 and 0.29 ± 0.456 was found among primagravida and multigravida, respectively (P ≤ 0.05) [Figure 1].
Table 3: Knowledge about the association of maternal periodontitis and its adverse obstetric outcomes

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Table 4: Mean knowledge scores about the association of maternal periodontitis and its adverse obstetric outcomes

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Figure 1: Mean knowledge scores of the studied subjects about maternal periodontitis and its adverse obstetric effects

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Attitude

Attitude of the study participants about maternal periodontitis and its adverse obstetric effects has been described in [Table 5] and [Table 6]. A mean of 0.23 ± 0.423 in Prima gravida and 0.29 ± 0.456 in Multi gravida was seen, regarding whether the mother's poor oral health can lead to any complications during pregnancy (P ≤ 0.05). Regarding whether a mother's poor oral health during pregnancy can lead to: a premature delivery, a mean of 0.23 ± 0.456 and 0.29 ± 0.456 was seen; for a LBW baby infant, a mean of 0.94 ± 0.239 and 0.91 ± 0.288 was seen and for Pre-eclampsia, a mean of 0.45 ± 0.500 and 0.32 ± 0.469 was seen among Prima gravida and Multi gravida respectively (P ≤ 0.05). A mean of 0.03 ± 0.171 and 0.10 ± 0.302 was seen in Prima gravida and Multi gravida respectively regarding whether is it important for the mother to know about their oral hygiene during pregnancy and its impact on the infant's health (P ≤ 0.05) [Figure 2].
Table 5: Attitude about maternal periodontitis and its adverse obstetric outcomes

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Table 6: Mean attitude scores about the association of maternal periodontitis and its adverse obstetric outcomes

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Figure 2: Mean attitude scores of the studied subjects about maternal periodontitis and its adverse obstetric effects

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Most of the participant's responses regarding the knowledge and attitude about the association between maternal periodontitis and its adverse obstetric outcomes were found to be statistically significant (P ≤ 0.05). This shows that mothers with more number of children have a better knowledge and attitude towards maternal periodontitis and its adverse obstetric effects. An alarming finding in this study was that only a few participants (3.1%) were aware of the fact that the mother's poor oral health can affect the unborn child leading to adverse obstetric effects, such as pre-mature labor, pre-eclampsia and LBW infant.


  Discussion Top


Obstetric complications are not only a noteworthy health-care expense but also affect the well-being of an infant throughout his entire life. Periodontitis is a more severe and irreversibly destructible form of oral infection which has been demonstrated higher in pregnant women.[5],[6] In the last decade, there was an increase of reports in which periodontal infections have been associated with different conditions affecting child morbidity and mortality. The various adverse obstetric outcomes associated with maternal periodontitis are: Preterm birth, LBW infant and Pre-eclampsia. The rate of preterm birth is increasing globally and is a known predictor of infancy morbidity and mortality.[1] Preterm birth is defined as childbirth occurring at <37 completed weeks or 259 days of gestation. According to the WHO (1976), LBW is defined as weight at birth of <2500 g with an adequate gestational age. Pre-eclampsia is defined as an onset of a new episode of hypertension during pregnancy, characterized by: persistent hypertension (diastolic blood pressure ≥90 mm Hg) and substantial proteinuria (>0.3 g/24 h). These three conditions are considered as public health problems as well as health inequality indicators in different social groups.[7]

The study conducted by Offenbacher et al. in 1996, was the first to report that maternal periodontitis was associated with a 7fold increased risk of delivery of a preterm LBW infant and hence is a significant risk factor.[8] Later, the results of various studies confirmed this finding by showing that maternal periodontitis was associated with pre-eclampsia, preterm labor and LBW infant, and, women with healthy periodontal status had a lower risk of having adverse pregnancy.[9],[10],[11],[12] In the present study, a majority of the mothers were in the age group of 18–30 years. Education status revealed that 16.5% of the mothers were illiterate. These findings have clearly shown that the knowledge and attitude of the mothers about the association of maternal periodontitis and its adverse oral outcomes is relatively poor in illiterate group of women. Studies have shown that the dental knowledge of the patients increases with their level of education.[1],[3],[13],[14],[15] When a comparison was brought about among the two groups – Prima gravida and Multi gravida, the knowledge and attitude was seen to be more in Multi gravida than that of Prima gravida. These findings were supported by Kabali and Mumghamba, as they reported that post natal mothers had more general knowledge of periodontal diseases as compared to pregnant women and women not having any children.[16] Thus, it is the primary need to impart knowledge to the mothers in a way such they are able to prevent the various adverse obstetric outcomes in their children. 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.[1]

In the current study, the awareness regarding dental plaque and gum diseases and its relation on infant's oral health was found to be more among the mothers of Multi gravida group. It was also found that a women's practice of not receiving routine dental care when not pregnant is the most significant predictor of lack of receiving any care during pregnancy. In our study, a meager percentage of the study population visited the dentist during their pregnancy. When enquired about not visiting the dentist, they responded that they visit a dentist only during any major problem such as toothache, which they did not experience during their pregnancy. This can also be attributed to the fear of dentist, misconception associated with dental treatment, lack of knowledge, and non-availability of dental service. Besides neglecting dental care during pregnancy, most females irrespective of their age do not seek dental care even though half of them have a dental disease.[1]

In this study, most of the study respondents 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 wellbeing of the newborn. López et al., found that the incidence of preterm birth in women decreased who were treated with scaling or root planning during pregnancy.[9] Thus, being a dentist, we play a major role to make the mothers aware about the relationship of mother-infant oral health and in advising them to have a periodic dental examination along with treatment for any dental or periodontal disease.

One of the limitations of this study was that clinical assessment of oral health status of patients was not done since it was a questionnaire study. Another limitation is the smaller sample size due to which the study cannot be generalized. Hence, large-scale longitudinal epidemiological and interventional studies are necessary to authenticate the contributory relationship of periodontal diseases to adverse pregnancy outcomes.


  Conclusions Top


The present study concluded that the overall knowledge and attitude of the mothers about the association between maternal periodontitis and its adverse obstetric outcomes in the selected population is very low. 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. Knowledge is power and information is liberating. Education is the premise of progress in every society, in every family. Dental counseling for the pregnant women includes general and oral changes that may occur during pregnancy and infant oral health care. Thus, women need to be educated and motivated regarding the importance of their 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 the women.

Recommendations

Education on effective tooth brushing to prevent periodontal diseases and its impact on their newborns is needed in the current population. 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, mothers 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 made 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. A system of a mandatory dental health education during pregnancy for the women can lead to their better oral health and hence improved obstetric outcomes in the infants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chaitra TR, 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 Interdisciplinary Dent 2018;8:5-12.  Back to cited text no. 1
    
2.
Rajesh KS, Ashif A, Hedge S, Kumar A. Assessment of knowledge and awareness level about periodontal health in pregnant women: A questionnaire study. Int J Appl Dent Sci 2018;4:138-42.  Back to cited text no. 2
    
3.
Kiran U, Suma LP. Level of knowledge and knowledge on practices regarding periodontal disease among antenatal mother attending Mch centre, Chittoor, A.P. Narayana Nurs J 2018;1:45-6.  Back to cited text no. 3
    
4.
Gaffar BO, El Tantawi M, Al-Ansari A, AlAgl AS. Association between oral health knowledge and practices of Saudi pregnant women in Dammam, Saudi Arabia. East Mediterr Health J 2016;22:411-6.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
    
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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.  Back to cited text no. 6
    
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Vivares-Builes AM, Rangel-Rincón LJ, Botero JE, Agudelo-Suárez AA. Gaps in knowledge about the association between maternal periodontitis and adverse obstetric outcomes: An Umbrella Review. J Evid Based Dent Pract 2018;18:1-27.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    
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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.  Back to cited text no. 9
    
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Sant'Ana AC, Campos MR, Passanezi SC, Rezende ML, Greghi SL, Passanezi E. Periodontal treatment during pregnancy decreases the rate of adverse pregnancy outcome: A controlled clinical trial. J Appl Oral Sci 2011;19:130-6.  Back to cited text no. 10
    
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Dasanayake AP. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol 1998;3:206-12.  Back to cited text no. 11
    
12.
Priyanka S, Sowmya K, Anitha S. Prevalence of maternal periodontitis and its association with preterm and low birth weight infants: A hospital-based study. Int J Reprod Contracept Obstet Gynecol 2019;8:1767-74.  Back to cited text no. 12
    
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Catão CD, Gomes TD, Rodrigues RQ, Soares RD. Evaluation of the knowledge of pregnant women about the relationship between oral diseases and pregnancy complications. Rev Odontol UNESP 2015;44:59-65.  Back to cited text no. 13
    
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Jindal A, Namdev R, Aggarwal G, Singhal P, Asija S, Thukral H. Attitude and awareness of expectant and lactating mothers toward infant oral health care in North Indian subpopulation: A cross-sectional study. Saudi J Oral Sci 2018;5:28-34.  Back to cited text no. 14
  [Full text]  
15.
Sedky NA. Assessment of knowledge, perception, attitude, and practices of expectant and lactating mothers regarding their own as well as their infants' Oral Health in Qassim Province, Kingdom of Saudi Arabia. J Contemp Dent 2016;6:24-37.  Back to cited text no. 15
    
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Kabali TM, Mumghamba EG. Knowledge of periodontal diseases, oral hygiene practices, and self-reported periodontal problems among pregnant women and postnatal mothers attending reproductive and child health clinics in Rural Zambia. Int J Dent 2018;2018:9782092.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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