Socio Demographic Factors affecting the Oral Health Status and Behaviour of Pregnant Women: A South Indian Context

: Aim: To assess Social and demographic factors affecting the oral health status and behaviour of pregnant women in Kerala. Methodology: The present cross-sectional study was conducted in a group of expecting mothers at 2 private hospitals in Trichur district, Kerala, India. A questionnaire was used to assess the social and demographic factors affecting the oral health status and behaviour of pregnant women. Results: Study subjects having a professional education status did not having any periodontal pocket (CPI score 3 and 4). 85.7 % of the Study subjects having professional education status brushed twice daily whereas only 7.7 % of the study subjects having intermediate education or diploma brushed twice daily. There was a statistically significant difference between BPL status and frequency of brushing, as well as financial independence and number of teeth missing. CPI & LOA score was associated with sociodemographic factors. Conclusion: Social factors like SES etc act as a strong hindrance which lead to less use of dental health care services. Dental health education has to be given to overcome this.


Introduction:
Social determinants of health include both specific characteristics of and pathways by which societal (including cultural) conditions impact health.Examples include income, education, social capital, occupation, community structure, social support, availability of health services etc 1 .Persons can be categorized into subcategories by the method of social stratification.They are classified on the basis of variables which are regarded as significant by the society like income, gender, education etc.Individuals with better parameters are categorized in the higher social status 1 .
Health disparities denote a less proportionate burden or risk of death, disease etc.Studies have reported that females visit a dentist more often than males.But very less females get oral care during gestational period which is a crucial period in their life 1 .
Gestation is a natural process during which changes in hormonal status occurs.These variations enhance the risk of dental infections like gingivitis during gestation 2 .
Periodontal diseases are related to health problems like heart disease, diabetes, preterm birth etc.Some cultural beliefs negatively affect proper nutrition and the ability of females during gestational period to attain better 1. Ph.D. Scholar, Faculty of Dental Sciences, M.S. Ramaiah University of Applied Sciences, Bangalore.

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dental health 2 .Additionally some research indicates that being pregnant increases the risk of dental caries 3 .
During different stages of life social and demographic characteristics affect heath status and even lead to subcategories of riskier groups, during which prenatal care is important.Females during the period of gestation is a target group for giving educational strategies which identifies gestational period as a better stage for establishing healthier practices.Expecting mothers are psychologically more accepting of new information which helps them to advocate good life style habits which can also help the remaining members in the family 4 .
Adoption of better life style practices by females during the gestational period depends on socioeconomic variables like literacy, number of kids & age 4 .Dental health behaviour during the gestational period like visit to a dental surgeon, dental hygiene, eating sweets, have a vital impact on their dental health and on their kid's future dental health.Females during their gestational period are advised to brush regularly and floss, and to avoid having high levels of sugar intake.
Females during the gestational period do not know about the impacts of dental health on the foetus and its effects on pregnancy.Researches indicate that females during the gestational period had poor attitude towards dental health care during gestation 5 .Hence, the present study was undertaken to assess Social and demographic factors affecting the oral health status and behaviour of pregnant women in Kerala.

Methodology:
The  There was a significant difference between financial independence and total missing teeth where, 74.1 % of study subjects who reported having financial independence did not have any missing teeth compared to 20.8% of the study subjects who had no financial independence.(p value<0.001).
There was a significant difference between whether there were BPL card holder and frequency of tooth brushing, only 7.9 % of the study subjects who were BPL card holders had a habit of brushing twice daily compared to 66.2% of study subjects having no BPL Card.( p value=0.000).In the present study, 61.7 percent reported that they had no miscarriage which is comparable to the study done by Barbieri W et al 4 on pregnant women attending the primary health care unit in Sao Paulo Brazil, 77.9 percent reported that they had no miscarriages.

Sociodemographic factors affecting the frequency of
percent had upto higher educational level regarding education.
In the present study, 22.4% of study subjects having miscarriage had a CPI score of 4 compared to 10 % of study subjects having no miscarriage.This is in comparison to the study done by Barbieri W et al 4 which reported that miscarriage and abortion are factors impacting the oral health of pregnant women.
In the present study socioeconomic condition/status and educational status negatively influence the CPI & LOA score and DMFT status .This is similar to the study done by Nota A et al 20 where the level of education is a vital component of socioeconomic condition and educational level of mothers was an important factor on the kid's general and oral health.
In the current study lack of adequate access to transportation, the greater the distance from dental clinic to house/residence was negatively associated with CPI, LOA score and DMFT status.Also, many of them were not sure whether their health insurance covered dental treatment needs.This was similar to the study done by Patrick DL et al 6 , where in Patients with limited socioeconomic resources assess the amount of time & money taken to visiting dental clinic once, in visiting the dentist .The eligibility for Medicaid insurance does not necessarily result in patients' enrollment, and enrollment does not ensure the availability, accessibility, and obtainment of needed dental care.
In the present study, none of the pregnant women visited the dentist during pregnancy.This is in comparison to the study done by Saddki N et al 22 where poor socio-economic conditions denoted by low education level, lack of a and small household income, were significant factors correlated with decreased probability of not going for a dental visit during the gestational period.In the present study, only 7 percent of the study subjects were caries free.This is in comparison to the study done by El-Mahdi Ibrahim HM et al 2 in Sudan where in only 24.5 % of the study subjects were free from dental caries.This is in comparison to the study done by El-Mahdi Ibrahim HM et al 2 where,10.7 percent were illiterate, 36.9 percent had educational level of primary school, 30.2 percent upto high school, 22.2

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In the study done by El-Mahdi Ibrahim HM et al 2 , 22.6 percent reported that their present dental health was poor.El-Mahdi Ibrahim HM et al 2 , reported only 9.5 percent used other dental hygiene methods like dental floss.
In the present study, 41.4 percent of the study subjects reported that they had no health insurance covering dental needs, whereas, 35.9 percent of the study subjects reported that there might be dental insurance, but they were not sure.22.7 percent of the subjects reported that they did not know whether they had health insurance covering dental needs.In the studies done by Al Habashneh R, Guthmiller JM et al 23 ,Vergnes JN, Pastor-Harper D et al 24 , Amin M, ElSalhy M et al 25 health insurance coverage was positively correlated with visits to dental surgeon during gestation.
Only 9.4 percent of the study subjects in the present study reported that they frequently visited a dentist.There was no significant association between income and visits to the dentist.This is in contrast to the study done by Sun et al 26 2014, where low income women who were pregnant had a regular oral care.This is also in contrast to the studies done by Boggess KA et al 27 and Amin and Elsalhy et al 25 where income was associated with seeking oral health care during pregnancy .The finding of this study is similar to studies done by Al Habashneh R et al 23 , Saddki et al 22 which showed no association between income and dental care use during gestation period.

Recommendations:
Further researches have to be carried out in a longitudinal fashion to assess the effect of socio demographic factors identified from this study in detail.

Conclusion:
Sociodemographic factors like SES, job status, financial independence, BPL status, enrolment in government programs, preference regarding availing oral health care services during pregnancy, choice of free / paid treatment, access to transportation, family encouragement in obtaining regular oral health care etc. acts as a strong barrier resulting in less use of dental health care services, which has to be effectively overcome by proper dental health education.

Table 1 : Distribution of study subjects according to Education and CPI score
The content of the questionnaire was validated by a total of 6 experts including 2 gynaecologists and 4 public health dentists.All the questions got a CVR value of 0.66 or above, hence all questions were retained.The questionnaire was translated and back translated by a Malayalam expert.After which, suitable modifications were made.Oral health status was assessed using DMFT index and CPI Index, Oral mucosal lesions scoring and coding adopted from WHO oral health assessment proforma 1997.Statistical analysis was done using SPSS version 21 .Chi square test and fischer's exact test was performed to test association between categorical variables.Fischer's exact test was done in case where value is less than 5 for more than 20 percent of the expected frequencies.Results:The Mean age of the study subjects is25.79.The mean CPI score is 2.72.The mean LOA score is 0.141.Mean DMFT is 4.586.Mean number of decayed teeth is 1.953. .Study subjects who reported having a professional education did not have CPI score 3 and 4, which codes for shallow and deep periodontal pocket.The percentage of study subjects having shallow and deep pockets ie, CPI score of 3 and 4 increased with decrease in level of education with a highly significant difference among various educational levels.This difference was statistically significant.85.7 % of the Study subjects having professional education status brushes twice daily, while only 7.7 % of the study subjects having intermediate education or diploma brushed twice daily .Percentage of study subjects who brushes twice daily decreased with decreasing educational level which was statistically significant (p value =0.000).