Knowledge of Women About Children’s Orodental Health in Their First Pregnancy: a Cross Sectional Study

Oral health is one of the most important factors affecting the general health of the community and families; in this regard, parents, especially mothers, can play an effective role in the oral and dental health of children. This study aimed to evaluate the knowledge of pregnant women on children oral and dental health in the rst pregnancy. Methods This cross-sectional and descriptive-analytical study was conducted on 200 pregnant women in the second and third trimesters of pregnancy referred to Obstetrics and Gynecology clinics and private oces in Isfahan-Iran from. To assess the knowledge of mothers about oral and dental health, a researcher-made questionnaire including 24 questions was used which was evaluated and veried in terms of validity and reliability. Collected data was analyzed by SPSS software version 22 using Pearson correlation coecient and Spearman tests. The signicance level was considered to be less than 0.05. The results of this study showed that the knowledge of mothers on the oral health of the child was 8.66 ± 4.53, so that their knowledge was moderate in 82 (41%) and 109 (54.5%) in poor level And 9 (4.5%) were high. In addition, the relationship between mother’s age (r = 0.288), maternal education (r = 0.497) and family’s economic status (r = 0.182) with the mother’s knowledge of oral health were signicant (P <0.05).


Introduction
Since dental caries during the early years of childhood is a source of concern and an index for the unavailability of disease prevention measures in all the countries, children must observe orodental health measures [1]. Orodental health affects the quality of life, especially in young children, because it can affect growth, weight, self-con dence, socialization, and the ability to learn in children, overshadowing children's and parents' daily routines [2]. Since children's behaviors in the early years of life shape their lifestyle and attitudes during adulthood and considering the importance of deciduous teeth in children's general health, increasing breastfed children's mothers' knowledge has a pivotal role in decreasing caries rate in the community. Therefore, parents, especially mothers, have a signi cant role in maintaining their children's orodental health, and their knowledge can establish correct health behaviors in children [3]. The rst steps to preserve a child's oral health and teeth by parents (a pregnant mother) begin during pregnancy [4], and the mother's oral health not only can affect her health and esthetic appearance during and after pregnancy, but also it can affect the general and dental health of the newborn baby [5]. Most studies have shown that pregnancy can increase the susceptibility to periodontal diseases and dental caries. Besides, severe gingivitis in pregnant women might be associated with adverse effects, such as increased risks of low birth weight, premature birth, and preeclampsia [6]. Hormonal changes during this period might also lead to the gingiva's sensitivity and in ammation; therefore, pregnant women brush their teeth and use dental oss less frequently, nally leading to microbial plaque formation on the teeth [2]. According to previous studies, there is a strong correlation between Streptococcus mutans counts in pregnant women and caries experience in their children. In other words, active dental caries in association with a high S. mutans counts might be transmitted from the mother to the infant, leading to carious lesions during early life. It is necessary to control a pregnant mother's oral plaque and decrease her oral S. mutans counts to decrease oral contamination risk in the child and prevent dental caries [7]. George et al. [8] evaluated the views of healthcare providers for pregnant women about the orodental health during pregnancy in Australia and concluded that pregnant mothers' knowledge about their oral health and the importance of their oral health during pregnancy was inadequate. Nagarajapa et al. [9] evaluated the orodental health in newborns and their mothers' knowledge, attributes, and behavior in Udaipur, India, and reported that mothers with low educational levels had poor knowledge and attitudes toward their children's orodental health. However, mothers with high educational levels exhibited positive attitudes towards orodental health and better performance concerning their children's dental care.
Mani et al. [10] evaluated the parents' attitudes towards the prevention of orodental diseases in children in Malaysia in 120 parents with children <2 years of age, concluding that 60.8% of parents had positive attitudes towards proper nutrition and 1.96% had positive attitudes towards routine examinations by dentists as a means of preventing dental caries in children.
Chu [11] evaluated 600 mothers with preschool children in Hong Kong and reported that 10% of the mothers had poor knowledge, 51% had moderate knowledge, and 39% had proper knowledge about children's orodental health.
Since no study is available on pregnant women's knowledge about their children's orodental health, the present study aimed to evaluate pregnant women's knowledge about their children's orodental heath in their rst pregnancy. The null hypothesis stated that pregnant women have a high level of knowledge about their children's orodental health in their rst pregnancy.

Materials And Methods
The present cross-sectional/analytical study evaluated pregnant women referring to private obstetrics o ces and clinics in Isfahan. Based on the inclusion criteria, pregnant women in their rst pregnancy, who were in their second and third trimesters, and interested in taking part in the study, were included. Questionnaires in which <20% of the questions had been replied were excluded.
The samples consisted of 200 pregnant women who were selected using a two-stage random clustered sampling technique. To select the private o ces and clinics, of 15 urban districts in Isfahan, seven districts were selected using the cluster sampling method, and then one clinic and two o ces were randomly selected from each cluster (the selected district) by numbering them. The pregnant women in each o ce or clinic were selected using a convenient non-random technique, and the questionnaires were distributed among them and collected immediately after they were completed.
The questions were prepared in the form of a questionnaire to evaluate pregnant women's knowledge about their children's orodental health. The questions were extracted from similar studies and translated. In designing the questionnaire questions, an attempt was made to observe the principles for designing questionnaires used to determine awareness and knowledge. For example, the questions were written in a manner not to induce the correct response. The questionnaire was submitted to ve professors in the Pediatric Department to ensure its face and content validity. Each professor was asked to score each question as follows for rating each question in terms of its necessity: Necessary: 1, Useful but unnecessary: 2, Unnecessary: 3.
Besides, the professors were asked to make suggestions about each question if they wanted to. After evaluating the professors' views, questions with a score of 2 or 3 were eliminated or revised based on the professors' views. Then the questions' content validity ratio (CVR) was calculated, and questions with a CVR of <0.42 were eliminated [12]. Finally, the professors' opinions were asked about the face validity of the questionnaire.
To evaluate the questionnaire's reliability, it was submitted to 30 pregnant women in a pilot study, and Cronbach's alpha was calculated. Questions with a Cronbach's alpha of <0.7 were eliminated; the overall Cronbach's alpha was then calculated, which was >0.7. Therefore, its reliability was con rmed, too [13].
The nal approved questionnaire consisted of three questions on demographic data, including age, educational level, and economic status, and 24 questions on the awareness about oral health and prevention of dental caries (four multiple-choice questions with four choices, and 20 questions with replies running as correct/incorrect/I do not know).
Concerning the mothers' economic status, their personal views and appraisal of their economic status were accepted, and their opinions about the family's economic status were categorized into four levels of low, moderate, good, and excellent.
After con rming the questionnaire's validity and reliability, the questionnaire was distributed among the pregnant women in private o ces and clinics and collected after they were completed. Informed consent was obtained from all subjects.
The data on the questionnaire's main questions were coded and scored, with zero (I do not know, incorrect) or 1 (correct). Finally, the score range for knowledge questions was 0-24. The scores were categorized as follows: 0-8: poor knowledge, 9-16: moderate knowledge, 17-24: high knowledge.
The data were analyzed with SPSS 22. Means, standard deviations, frequencies, and frequency percentages were used to report descriptive statistics. Pearson's and Spearman's correlation coe cients were used for inferential statistics. Statistical signi cance was set at P<0.05 in all the analyses.

Results
The present study aimed to evaluate pregnant women's knowledge about their children's orodental heath during their rst pregnancy. The subjects were selected from those referring to private prenatal o ces and clinics in Isfahan.
According to Table 1, the mean age of the present study subjects was 25.28±4.79 years, with a range of 17-42 years. The majority of the subjects were in the 20-25 and 26-30 years age groups, with 34.5% and 32%, respectively.  Table 2 presents the frequency distributions of pregnant women's educational levels in the present study. The majority of the subjects were high school graduates (69, 34.5%), and only one was illiterate.  Table 3 presents the frequency distributions of the economic status of the families. Based on the mothers' self-reports, 48.5% of the families had good economic status, and only 2.5% had low economic status.   was the highest with a mean score of 0.7±0.46. In the domain 'awareness of children's dental caries', the mothers' awareness of 'a decrease in dental caries rate due to giving water to the child after giving it milk' was the highest with a mean score of 0.63±0.48. Also, 'awareness of prevention and dental treatments' in terms of the 'use of uoride' was the highest with a mean score of 0.44±0.50. Finally, 'awareness of the proper time to visit a dentist' at 'the proper time for children's non-emergency dental procedures' was the highest with a mean score of 0.19±0.39. In general, the highest and lowest knowledge was related to the children's orodental health and the proper time to refer to a dentist, with mean scores of 0.442±0.301 and 0.157±0.255, respectively.
An attempt was then made to calculate the overall score instead of matching the study domains and evaluating each domain's overall mean score. Table 5 presents the results of this evaluation, providing the minimum and maximum scores, means, and standard deviations of mothers' knowledge in general and in each domain. Finally, since it is possible for epidemiologic factors, including age, educational levels, and the family's economic status, to affect mothers' knowledge, in this section, the relationship between these factors and the overall knowledge scores of the mothers about children's orodental health was evaluated. The results are presented in Table 6, according to which there were signi cant and direct relationships between mothers' age (P<0.001 r=0.288) and educational level (P<0.001, r=0.497) and the family's economic status (P=0.10 r=0.182) and the mothers' knowledge about their children's orodental health.

Discussion
The overall awareness of pregnant women about children's orodental health was low in their rst pregnancy. Therefore, the null hypothesis of the study was rejected.
Since children's behaviors during the early days of life form their lifestyle and attitudes in adulthood and considering the role of deciduous teeth in children's general health, increasing the knowledge of breastfeeding mothers has a critical role in decreasing dental caries rate in the community. Therefore, parents, especially mothers, have a pivotal role in their children's orodental health, and their awareness can establish healthy behaviors in their children [3]. In the present study, pregnant women's awareness was evaluated in ve domains, including awareness of children's orodental health, awareness of children's orodental problems, awareness of children's dental caries, awareness of prevention and dental treatments, and awareness of the proper time to refer to a dentist. The highest awareness was recorded in the domain on children's orodental health, and the lowest was recorded in awareness about the proper time to refer to a dentist.
Determining the mean awareness score of mothers during their rst pregnancy about children's orodental health showed that the mean score on 'children's orodental health' was 0.442±0.301; i.e., >50% of the mothers had proper knowledge in this domain or had no knowledge, with the least frequency of misinformation. Consistent with the present study, studies by Chu et al. [11] and Lloyd et al. [14] showed a moderate level of mothers' awareness about children's orodental health, which might be explained because studies in this eld have shown that cultural factors and the geographic location do not affect the results, and mothers exhibited a moderate level of awareness about children's orodental health.
The mean score of the mothers' awareness about 'children's orodental problems' was 0.936±0.238. Besides, the mothers' awareness about the adverse effects of alcohol use and cigarette smoking during pregnancy and the use of paci ers or thumb sucking on children's orodental problems was higher than other elds, and the lowest awareness related to the effect of mothers' viral diseases during pregnancy on children's dental problems. Also, concerning tooth eruption, the mothers exhibited the highest misinformation. Consistent with the present study, a study by Retnakumari et al. [15] showed a signi cant relationship between sleeping with a paci er and the incidence of dental problems in children, with the mothers participating in the study being aware of the problem. Therefore, the mothers in both these studies were aware of children's orodental problems and the etiologic factors involved and were able to help improve their children's orodental health by decreasing the factors responsible for these problems. Therefore, it might be concluded that mothers can help prevent and solve their children's orodental problems by gaining knowledge about these problems and taking the necessary precautions.
The mothers' mean awareness score for 'children's dental caries' was 0.375±0.205. Evaluation of the questions in this domain showed that the mothers were aware that breastfeeding and use of a milk bottle nightlong led to dental caries in children and giving water to the child after feeding him/her with milk and attention to the restoration and preservation of deciduous teeth can decrease dental caries in children. In this context, Togoo et al. [16] showed that almost half of the mothers fully agreed that giving milk to the child immediately before sleep causes dental caries. In contrast, the participants had low awareness and wrong beliefs about sharing a spoon between the mother and infant and the adverse effects of iron drops on children's dental caries. Mazaheri et al. [17] reported that mothers in Shiraz believed that iron drops were the primary etiologic agent for dental caries. In addition, they provided correct responses about the deciduous teeth' lack of need for restoration because they shed spontaneously, which is different from a study by Sultan et al. [18] The mothers' mean awareness score about 'prevention and dental treatments' was 0.315±0.347. On the other hand, the frequency distribution of the responses to the questions in this domain showed that mothers had moderate awareness about uoride therapy at 18-24 months of age; however, they had misinformation and insu cient knowledge about preventive measures for dental caries and the effect of using xylitol chewing gums during pregnancy. Consistent with the present study, two studies by Thakare et al. [19] and Mounissamy et al. [20] showed that mothers were unaware of the bene ts of oral hygiene habits and preventive measures and dental treatments. Besides, a study by Mani et al. [10] in Malaysia showed that only 1.96% of parents had positive attitudes towards routine examinations by dentists to prevent children's dental caries. However, the study by Mazaheri et al. [17] showed that more than half of the mothers of 1 to 3-year-old children in Shiraz had proper knowledge about the therapeutic use of uoride, such as uoride varnishes in children, which is different from the present study. Such a discrepancy might be attributed to the statuses of the mothers evaluated, the city they resided in, etc. because in the present study, only pregnant women in their rst pregnancy were evaluated. Mothers with several pregnancies and raising their children might have exhibited different knowledge levels because their experience would increase to help them gain adequate information in raising their children. Mothers in their rst pregnancy might not have adequate knowledge in this eld. Therefore, it is necessary to train these women during pregnancy and provide them with information in this eld. Educating children in dental and oral care and observing oral hygiene by young children is considered an investment in children's health with long-term bene ts. Therefore, mothers must pay adequate attention to these subjects and issues and gain adequate knowledge because parents, especially mothers, have a crucial role in improving their children's oral hygiene habits. Previous studies have also provided ever-increasing evidence about bacteria's role, especially Streptococci, in inducing dental caries. Streptococcus mutans can produce large amounts of acid, is highly durable in acidic environments, and is mainly responsible for dental caries in human beings. This bacterial species is more prevalent in pregnant women, which is very important because pregnant women can transmit infections to the fetus, causing unfavorable complications.
Therefore, preventive measures should be adopted in pregnant women.
The mothers' score on awareness about 'the correct time to refer to a dentists' was 0.157±0.295, with many mothers having misinformation or inadequate knowledge in this respect.
The mothers in this study had the least awareness about the correct time to take their children to a dentist.
Mazaheri et al. [17] reported that only 8.9% of mothers were aware that a dentist should examine their infants before one year of age, and most mothers were not aware of this, consistent with studies by Thakare et al. [19] and Mounissamy et al. [20].
Besides, the mothers participating in the present study were unaware of the proper pregnancy trimester during which non-emergency dental procedures could be carried out, consistent with studies by Kandan et al. [21] and Gonik et al. [22]. Considering these two studies and since pregnancy might increase susceptibility to gingival diseases and dental caries and by considering the misinformation, many pregnant women believe that routine dental treatments are dangerous to the fetus, and it is necessary to provide them with the necessary information and ask them to refer to a dentist at the correct time by the care providers. This can decrease the complications of gingival diseases, including increased risk of low birth weight.
The mother's mean score on their 'overall awareness of children's orodental health' was 8.66±4.33. Consistent with the present study, Mohebbi et al. [5] reported mothers' low awareness despite using various data sources about children's oral health. Besides, studies by George et al. [8] and Pothnie et al. [23] are consistent with the present study.
Torabi et al. [24] evaluated the awareness and performance of mothers concerning children's orodental health. A total of 400 mothers were included in the study in Kerman. The results showed that mothers' awareness about children's orodental health was favorable, which is different from the present study results. Such a discrepancy might be attributed to differences in sample sizes between the two studies and inattention to the number of pregnancies.
Finally, evaluating the relationship between demographic factors, such as age, educational level, and family's economic status with mothers' scores of overall knowledge about children's orodental health, showed a direct and signi cant relationship between mothers' age and their knowledge about children's orodental health. However, Nazari et al. [25] showed no signi cant relationship between mothers' age and their knowledge and attitude scores about children's orodental health. Although the results of the studies above are different from the present study concerning the results of the present study, it might be pointed out that since younger mothers have inadequate knowledge about children's orodental health and the relevant care due to their inadequate experience, mother's aging has resulted in increased awareness about their children's orodental health. Furthermore, mothers' educational level exhibited a direct and signi cant relationship with their knowledge about children's orodental health. Nagarajapa et al. [9] reported from India that mothers with low educational level had poor knowledge and attitudes towards children's orodental health; in contrast, mothers with higher educational levels exhibited positive attitudes towards children's orodental health and had good performance concerning the care of their children's teeth, with a signi cant relationship between knowledge and mothers' educational level. To explain this nding, education is one of the most critical socio-economic parameters that affect knowledge, attitudes, and the necessary skills to adopt proper health-related behaviors. Therefore, educated parents are more sensitive about their children's health, resulting in more regular visits to evaluate health status. The family's economic status was signi cantly related to the mothers' overall knowledge about their children's orodental health. Consistent with the present study, Kallestal et al. [26] reported a direct correlation between the economic status, gender, residential area, ethnicity, social status, and parents' occupation with the parents' performance concerning their children's orodental health. To explain this nding, there was a signi cant relationship between the economic status and the overall awareness of mothers about children's orodental health. Besides, according to previous studies, a better economic status of mothers and their employment results in their higher rate of communication with other community members and their access to data sources and better education, increasing their awareness and improving their performance concerning their children's orodental health.
The present study evaluated only pregnant women referring to the private obstetrics o ces and clinics in Isfahan, which is considered one of the present study's limitations. Since the data collection tool in the present study was a questionnaire, some participants might not have provided accurate responses to the same questions. It is suggested that similar studies be carried out in different cities of the country with larger sample sizes to evaluate whether these ndings are valid in other parts of the country or not. Since many children <6 years of age are looked after in kindergartens, it is suggested that a similar study be carried out to evaluate the kindergarten nurses' awareness of children's orodental health.

Conclusion
According to the present study results, the mothers had a low knowledge level about children's orodental health. Besides, there were direct and signi cant relationships between the mothers' age and educational level and the family's economic status, and mothers' awareness about children's orodental health. Therefore, it is necessary to hold educational workshops and provide useful data for mothers before pregnancy or during pregnancy.