Data collection: The present study was designed as questionnaire based survey. After preliminary construction of the questionnaire, it was sent to Dr Alka Sehgal, Associate professor, Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Sector-32 to test its validity, and her suggestions regarding some modifications in the design of some of the questions were taken into account. Pilot study was conducted on 20 pregnant and 20 non pregnant women. These filled questionnaires were used to measure the reliability of the test using Cronbach’s alpha test. The coefficient of reliability was more than 0.7, indicating that the questionnaire is reliable, and meets the purpose of this study. The structured questionnaire was checked for validity by three experts from the field of Gynecology and Periodontology (annexure 1). The questionnaire was verbally explained in the local language to illiterate women and those facing any problem. Written consent was taken from all the participating women. Permission was taken from Medical Superintendants of the Government Hospitals. The ethical clearance for the study was received from Ethical Committee, Panjab University, Chandigarh.

Sample size was estimated based on the results of the pilot study. The mean difference for knowledge score between pregnant and non-pregnant group was 0.93 with a SD of 3.5. Hence sample size was estimated to bee 176 subjects per group at a power of 80 % and confidence interval of 95%. The study was conducted between September 2011 - December 2012 on 200 non-pregnant females (Group A) and 200 pregnant (Group B) females randomly selected amongst expecting mothers and the family members of the expecting mothers visiting the obstetrics and gynaecological departments of Government Medical College and Hospital, Sector-32 and Government Hospital Sector-16, Chandigarh. A computer generated randomisation was utilized for selecting them. Women not willing to participate in the study, having less than 20 teeth in their oral cavity, of <20 years or >50 years of age were excluded from the study.

Discrete categorical data were presented as n (%). For categorical data comparisons were made by Pearson Chi-square test. All statistical tests were two-sided and performed at a significance level of α=0.05. An analysis was conducted using SPSS for Windows (version 15.0; SPSS Inc., Chicago, IL, USA).

We applied factor analysis to the questionnaire. The Kaiser-Meyer- Olkin value (KMO value) was 0.737, and the questions in the questionnaire fell under 6 main subheadings, namely, questions on Socio-demographic background, Oral hygiene habits, Aetiology of dental caries, Signs and symptoms of gum disease, Assessment of awareness of both the groups regarding oral and systemic inter-relationship and Assessment of knowledge regarding correlation of oral health to adverse pregnancy outcomes in pregnant females.

Socio-demographic background: The mean range of age of women was 20-50 years. Respondents’ data has been compiled in [Table/Fig-1], and the variables which showed a statistically significant association with Education in [Table/Fig-2].

Oral hygiene habits: Majority reported quite favourable oral hygiene habits [Table/Fig-3]. The reasons for the gap between knowledge and practice of the best methods of tooth cleaning have been depicted in [Table/Fig-4].

[Table/Fig-4]:

If there is a gap between practice and knowledge, the reason for not using the best method for cleaning the teeth

Aetiology of dental caries: Out of total, 33.5% of women in Group A and 19.0% in Group B had no knowledge about cariogenic food. [Table/Fig-5] depicts the awareness of both the groups regarding signs and symptoms of periodontal/ gum diseases.

[Table/Fig-5]:

Awareness regarding signs and symptoms of gum disease

Assessment of awareness of both the groups regarding oral and systemic inter-relationship has been tabulated in [Table/Fig-6]. Majority of women of both groups (97.5% of Group A and 94% of Group B respectively, p>0.05) were of the opinion that if they were made aware about the relationship of oral and overall health they would have been more careful in maintaining a good oral health.

Assessment of knowledge regarding correlation of oral health to adverse pregnancy outcomes in pregnant females has been tabulated in [Table/Fig-7]. Among pregnant women (Group B): 25.8% had history of abortion and 14.7% reported that their previous child was born prematurely.

The majority of studied population had quite favourable tooth brushing habits (brushing at least once a day and rinsing after every meal) which are in agreement with the findings of Hullah et al., and Hashim [15,16]. One of the main finding in the present study was that the majority of pregnant women (96%) had not been educated by the gynaecologist about the impact of oral health on pregnancy outcomes. These findings coincide with that of Gunay et al., who conducted a German study and found that 71% had received no information regarding oral hygiene during pregnancy [17]. Similar results were seen in a UK study which reported that only 25% of the women had received specific advice concerning their teeth and pregnancy, mostly related to gingival and periodontal health [18].

Patil et al., in their study on 36 gynaecologists and general dental practitioners in the city of Bangalore, India, reported that 85.7% of the gynaecologists never examined the oral cavity of the patient during routine check-up. Lack of knowledge, lack of time for prenatal and health counselling, lack of demand for service and limited access to Oral health care professionals were identified as the barriers among the gynaecologists for inappropriate oral health care of the pregnant patients. A 39% of the dentists had limited knowledge on prenatal oral health care and 92% of the dentists reported need for continuing dental education programmes. They concluded that there was a need for pregnancy specific education to provide appropriate preventive and curative care to the pregnant patient [19].

In our study, pregnancy did little to change future attitudes to dental care. The difference between oral health knowledge, attitude and practices among pregnant and non pregnant female population was statistically non- significant. There was no gain in knowledge by the females after conceiving. The expecting mothers had not been educated regarding the role of periodontal diseases in adverse pregnancy outcomes or regarding the importance of regular dental check-ups. It is a cause of concern that many medical professionals are unfamiliar with the oral cavity and oral health research. We must reach out to the medical community to improve patient care through education & communication. It is our duty as periodontists to educate, motivate and reinforce our medical counterparts and the patients regarding the same.

Another crucial finding was that there was several myths related to dentistry still prevalent in India. A 52.5% opined that teeth should not be brushed after pregnancy, 23.4% were of the opinion that visiting a dentist during pregnancy was not safe and 17.2% were of the opinion that pregnancy is a cause of loosening teeth. A total of 40.9% believed that after delivery teeth should not be brushed, and another 41.9% thought dental treatment to be unsafe during pregnancy.

Majority of studied population feel that there is no need to visit a dentist. These findings are in agreement with the findings of the study among pregnant women in USA [20]. In UK, 39% did not visit a dentist during pregnancy even though dental care is free of charge for pregnant women; reasons for not seeing a dentist were the feeling that it was not necessary, fear or not liking the dentist [18].

In a study on 750 pregnant women visiting the maternity hospitals in United Arab Emirates, Hashim R reported that although a large proportion of the pregnant women in his study had oral health problems, more than 40% had not visited a dentist during their pregnancy, and the majority only utilized dental services when they had dental pain [16].

In a study on 95 pregnant women of Darussalem, Bamaniker and Kee reported that although 96.8% of the respondents agreed that women should have a dental check-up during pregnancy, only 55.9% actually practiced this. This raises serious concern since pregnant women may need extra oral and dental care due to susceptibility to gum diseases during pregnancy, which may contribute to low birth weight babies and premature births [21].

The results of our study are in accordance with those of Avula H et al., who conducted a KAP assessment of oral health and adverse pregnancy outcomes among 359 pregnant women visiting three maternity care centres in Hyderabad, India, 87.2% of their respondents were not aware of the importance of oral hygiene and its probable association with adverse pregnancy outcomes. None of the respondents ever used dental floss and only a few (1.4%) had heard about it. Avula H et al., identified poor knowledge regarding various parameters, brushing only once daily and infrequent visits to the dentist as the probable risk indicators for gingival bleeding during pregnancy in their study group [22].

Amit et al., in their study on 400 pregnant women attending the Antenatal clinic at the SMS Medical College, Jaipur, India, also reported important gaps in dental knowledge and practices related to oral health care amongst them. Only 22% of the women believed that pregnancy predisposes to dental or gum problems. Tooth ache was the driving factor for 27.7% of the women. A 54% cleaned their teeth only once daily. An 88.2% had not consulted a dentist in the previous 12 months, and only 7% had visited the dentist in their most recent pregnancy. A 40.5% were of the opinion that every painful tooth should be removed. And although most of the women displayed a reasonable level of oral health knowledge and positive attitude to oral health, it was not reflected in their oral hygiene practices [23].

Mothers play a crucial role in transferring and demonstrating health habits to their children (Rayner, Blinkhorn), so pregnant women should be a target group for oral health education especially in a country like India where population growth is very high [24,25]. Patient education is a priority. Acceptable oral hygiene techniques need to be taught, reinforced and monitored throughout pregnancy. Expecting mothers should be made aware that periodontal treatment during pregnancy is safe for both mother and child.

In order to promote health, it is necessary for the would-be -mothers to be aware of disease symptoms and to be encouraged to adopt appropriate health behaviour. Pregnant women are more likely to seek dental care if their gynecologist/antenatal care giver recommends. They are better than the dentists to counsel and convince the patients regarding oral health care during the prenatal and postnatal period. This should involve all health agencies, Midwives and gynecologists involved in antenatal care to influence, educate and promote well-being in mothers. We would also like to recommend that periodic dental checkups be incorporated in the antenatal health cards, and routine dental checkups be clubbed with their visits to the Gynecologist in each trimester. This is a doable exercise, which would ensure that even the most ignorant of the expecting mothers, would be visiting the dentist for a checkup, thereby giving the dentist the opportunity to further stress upon the importance of good oral hygiene on a one-to-one basis.

This being a questionnaire study has certain limitations of its own. It had a relatively small sample size, hence the results should be interpreted with caution. The relationship between the level of oral health knowledge and various maternal factors such as spacing between children, care during pregnancy, and maternal nutritional status was not evaluated.

There was no gain in knowledge by the females after conceiving. An oral health history, oral health education, dental screening, and dental referral, if needed, should be a routine part of prenatal care and annual examinations.