WITHDRAWN: Oral Health Knowledge and Attitude among Nursing Students and Staff in Mahasamund City, India

DOI: https://doi.org/10.21203/rs.3.rs-2342033/v1

Abstract

Introduction

The study was conducted to assess the oral health knowledge and attitude among nursing students and staff of Mahasamund city, India.

Materials and Methods

A total of 281 nursing students and staff from nursing colleges were included and requested to complete 25 questions close ended questionnaire.

Results

53% were of the view that tooth paste and brush is ideal material for brushing. Almost 66.4% reported that brushing should be done twice daily. Majority of them (65%) had sufficient knowledge for detection of Dental Caries. Most of them (70%) were interested in doing work in Public Health Dentistry.

Conclusion

Overall oral health knowledge and attitude of nursing students and staff was insufficient. Only half of the study participants were aware of various aspects of oral health. Nurses should have basic knowledge about oral health and disease.

Introduction

Oral health is a human right, an integral part of general health and essential for overall wellbeing and quality of life.1 The World Health Organization (WHO) defines oral health as “a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking and psychosocial wellbeing”.2,3 It includes dental caries, periodontal disease, tooth loss, oral cancer, oro-dental trauma, noma and birth defects such as cleft lip and palate. The Global Burden of Disease Study 2019 estimated that oral diseases affect nearly 3.5 billion people around the world. International Agency for Research on Cancer reported that Cancers of lip and oral cavity are among the top 20 most common cancers globally with close to 180 000 deaths each year.4.5

Majority of oral diseases share modifiable risk factors with the leading noncommunicable diseases (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes). These risk factors include tobacco use, alcohol consumption and high sugar diets, all of which are increasing at worldwide. Many Evidence has proved that there is a proven relationship between oral and general health.4,6,7,8 It is reported, for example, that diabetes is linked with the development and progression of periodontitis.9 Moreover, there is a causal link between high consumption of sugars and diabetes10, obesity and dental caries11.

Proper oral health care reduces premature mortality. A detail oral examination can detect signs of nutritional deficiencies as well as a number of general diseases like microbial infections, immune disorders, injuries and oral cancer. For example, the salivary glands are a model of the exocrine glands, and an analysis of saliva can provide important clues to general health or diseases.12,13,14,15

Dental caries and periodontal diseases have been considered to be the most important global oral health burdens. With the combination of community, professional and individual actions, both can be effectively prevented and controlled. In current scenario, distribution and severity of oral diseases vary in different parts of the world and within the same country. A large number of epidemiological surveys show that there are significant role of socio-behavioral and environmental factors in oral health.

Dental caries is a major oral health problem in most industrialized countries at present. About 60–90% of schoolchildren and majority of adults are affected by Dental Caries. Prevalence of Dental Caries is very high among oral disease in several Asian and Latin American countries and it appears to be less common and less severe in most African countries. The signs of gingivitis are prevalent among children and adolescents, while the adults suffer with the initial stages of periodontal diseases worldwide. In 35–44 years age group, 5–20% population suffer with severe periodontitis and Nearly 2% of youth are affected by Juvenile Periodontitis during puberty.16

India is a developing country located in South East Asia, which has the second largest population in the World.17 Prevalence of Dental Caries is increasing in India due to changes in life styles and dietary habits.18 According to oral health survey done by Ministry of Health -WHO India at 2007-08, the prevalence of dental caries among the 12-year- old’s ranged between 23.0–71.5% and adults aged 35–45 years was between 48.1–86.4%. 65–74 years age group had dental caries in the range of 51.6–95.1%. Similarly, periodontal diseases among adults & elderly were in the range of 15.32–77.9% & 19.9–96.1%.19

Oral health care is an essential component of medical care for hospitalized patients, which is mainly provided by nurses and medical care professionals; thus, knowledge and awareness of oral health measures for admitted patients are essential and mandatory. Nursing is one such profession within the health care sector that focuses on the care of individuals, families and communities, so they may attain, maintain or recover optimal health and quality of life. Hospitals worldwide differ in terms of the importance and priority they give to providing oral health measures for their hospitalized patients.

Academic programs in nursing have gaps in the knowledge they provide their students on oral healthcare procedures for hospitalized patients. However, some healthcare providers conduct regular educational programs about oral health care for their staff. The main reason behind such programs is to increase oral health knowledge and awareness among healthcare workers. Other healthcare providers have clear guidelines for oral health care for hospitalized patients and residents that vary according to their length of stay and medical conditions.

It is important to ensure that full oral care is provided for long-term patients and those who are physically restricted owing to their medical condition. Deterioration of oral health can adversely affect the medical situation of the patient. When there is inadequate oral care for hospitalized patients, oral health problems such as dental caries, periodontal inflammation, oral abscess can appear. These problems may appear as a result of the patient’s medical condition, medication side effects, and previous inadequate oral hygiene. Therefore, it is necessary to educate Nurses who deliver bedside care regarding any pathological changes in the oral cavity that can be caused by a patient’s medical condition or medication side effects, so as to prevent any deterioration that may lead to other health problems.

Public health nurses can educate people about health subjects. They can improve public health including oral health and increase access to care. In country like India, where lack of health facilities, patients have to wait a lot when they come to hospital with an illness, public health nurses go into communities to try and help people for improvement in their health. 70% Indians live in villages where less access to health care, public health nurses may provide health services including preventive care, screening services and health education.20

Nurses can easily reach the public as comparison to dentist Therefore, Nurses can play an important role in oral health promotion among common citizen of India. There is a greater dearth of auxiliary personnel in India as only dental surgeons and dental hygienist are functioning here. A nurse is an essential member in dental hospitals and multispecialty hospitals.21 Nurses act as a link between admitted patients and doctors in the hospital.22

A low priority is given to the dental education among nurses, especially among those with lesser education.23 Evidence based study suggested that oral care is important but neglected area of nursing. Most of the nurses have insufficient knowledge about oral care. At present, oral care education program for nurses is very much required in India.24 By collecting information about the existing oral health knowledge and attitude among nursing students, we can assess their efficiency in promoting awareness about oral health among common Indian people. Keeping this objective in mind, this study was undertaken among nursing students and staff of Mahasamund city.

Material And Methods

This study was conducted on 4 January, 2022 to 8 January, 2022 in five nursing colleges in Mahasamund city, India. The ethical clearance for this study was obtained from the ethical committee of Rungta College of Dental Sciences and Research, Bhilai and permission for conducting the study among nursing students was obtained from their respective head of institutions of the nursing colleges. A written informed consent was taken from all the nurses before the study.

The total number of nursing students and staff enrolled in these colleges were 281. The students and staff who were present on the day of the survey and those who gave consent for participation were included in the study and a pretested questionnaire was administered to them. The questionnaire consisted of 25 close-ended questions which were adapted from an earlier study.21 Questionnaires comprised of four sections related to demography, knowledge of oral health and diseases, oral hygiene practices, dentistry and other related knowledge.

The data collected was analyzed by using SPSS software package version 16.0 and descriptive statistics such as frequencies were calculated for each item in the questionnaire.

Results

The total number of nursing students and staff were 281, out of which 258 (92%) present on the day of the survey were approached to participate in the study. Out of those participants, who gave consent and responded to all the 25 items in the questionnaire formed the final sample. Response rate was 89%. The mean age of the participants were 23.7 years (SD 5.8) and most of participants were females (Fig. 1).

Basic Oral Health Knowledge: (Table 1, Fig. 2)

 
Table 1

Frequency Distribution of Participants regarding Oral Health Knowledge

Question

Number

Questions

Options

Frequency

Percentages

1

How many deciduous teeth are there in the human oral cavity?

20

16

32

12

150

58

12

31

60%

23.2%

4.8%

12%

2

How many permanent teeth are there in human oral cavity?

20

28

32

30

1

36

202

11

0.4%

14.4%

80.8%

4.4%

3

What age do you advise children to start brushing?

6 Months

From birth

1 years

2 years

7

38

112

93

2.8%

15.2%

44.8%

37.2%

60% of respondents answered correctly about number of deciduous teeth in oral cavity of children. Almost 81% of the respondents answered that there are 32 permanent teeth in a healthy adult. 44% reported that brushing should be started from 1st year after birth, while 37.2% said that brushing should be started from 2nd year after birth and only 2.8% replied six months from birth.

Oral Hygiene Practices: (Table 2, Fig. 3)

 
Table 2

Frequency Distribution of Participants regarding Oral Hygiene

Question

Number

Questions

Options

Frequency

Percentage

4

What are the ideal materials for brushing?

Tooth Paste and Brush

Tooth Powder and Brush

Charcoal and Finger

Tooth Powder and Finger

133

82

23

12

53.2%

32.8%

9.2%

4.8%

5

How many times should a person brush his teeth every day?

1 times

More than 2 times

2 times

After every meal

25

43

166

18

10%

17.2%

66.4%

6.4%

6

What kind of tooth paste should a person use?

Non- fluoridate

Fluoridated

Both a and b

None of the Above

64

146

28

12

25.6%

58.4%

11.2%

4.8%

7

What kind of brush should a person use?

Soft

Medium

Hard

None of the Above

144

93

11

2

57.6%

37.2%

4.4%

0.8%

8

What is the proper brushing method?

Horizontal

Circular

Vertical

Both b and c

11

32

62

145

4.4%

12.8%

24.8%

58%

9

How often should a person change his toothbrush?

1 month

3 month

6 month

When its bristles get fractured

41

115

74

20

16.4%

46%

29.6%

8%

10

Do you advise a person to clean his tongue?

It depends on the person

Yes

No

Don’t know

18

213

16

3

7.2%

85.2%

6.4%

1.2%

53% of the participants were of the view that tooth paste and tooth brush are ideal material for brushing. Charcoal with finger and tooth powder with finger were the ideal materials as per 9.2% and 4.8% respondents, respectively. Most of the respondents (66.4%) reported that brushing should be done twice daily. 58% knew that fluoridated tooth paste should be used. Same number of participants answered that brushing should be done in both circular and vertical methods and soft bristle tooth brush should be used. 46% respondents reported that brush should be changed after every 3 months. Majority of the respondents (85.2%) said that they will advise the public to clean his tongue.

Knowledge Of Oral Diseases: (Table 3, Fig. 4)

 
Table 3

Frequency Distribution of Participants regarding Oral Diseases

Question

Number

Questions

Options

Frequency

Percentage

11

If there is yellow or greenish yellow color deposit near the gums, what is it?

Food deposits

Calculus and Plaque

Don’t know

Saliva

84

133

22

11

33.6%

53.2%

8.8%

2.8%

12

If there is bleeding from the gums, what is it?

Gums are healthy

Ulcerated

Gums are infected

Don’t know

21

38

183

7

8.4%

15.2%

73.2%

3.2%

13

How do you identify tooth decay?

Black spot and cavity

Bleeding

Pain

Don’t know

162

41

39

8

64.8%

16.4%

15.6%

3.2%

14

Which is the ideal diet, to maintain healthy teeth?

Sticky foods

Fibrous foods

Liquid foods

All of the above

19

140

43

48

7.6%

56%

17.2%

20.2%

15

How often should a person visit a Dentist?

Once in a year

Once in 2 years

Once in 6 months

When there is a pain

47

37

145

21

18.8%

14.8%

58%

8.4%

16

What will you advice a mother of a child, when she is breastfeeding or bottle feeding her child?

Don’t know

No need to advice anything

Give some water after feeding and before going to bed

Clean the gum pads and teeth with plain water

7

29

74

140

2.8%

10.4%

29.6%

57.2%

17

If a person is suffering from a sudden tooth ache, what will you do?

Ask him to bear the pain until it subsides

Advice him analgesic and refer to a nearby dentist

Refer to nearby dentist

Refer to nearby general physician

3

137

91

19

1.2%

54.8%

36.4%

7.6%

18

If a person is a tobacco chewer, what kind of problems can develop in oral cavity?

Burning sensation

Mouth Ulcer

Gum disease

Oral cancer

9

26

31

184

3.4%

10.4%

12.4%

73.8%

Most of the participants (73%) responded that Gum infections were responsible for bleeding from gums and 53% answered that yellow or greenish yellow color deposition near gum is due to calculus and plaque. 33% respondents agreed that yellow color near gum is due to food deposits. Majority of them (65%) had sufficient knowledge for detection of dental caries as black spot and cavity. Fibrous food is ideal diet to maintain healthy teeth as per 56% respondents. 58% of respondents reported that a person should visit a dentist every 6 months. 57% respondents said that they will advise to clean gum pads and teeth with plain water whereas, 29.6% will advice the mother to give water to infant after feeding and before going to bed. 55% respondents had adequate knowledge about management of toothache as they said analgesics should be given and refer to nearby dentist should be done. Majority of them were of the view that tobacco is a risk factor for developing oral cancer.

Knowledge About Dentistry (Table 4, Fig. 5)

 
Table 4

Frequency Distribution of Participants regarding Knowledge about Dentistry

Question

Number

Questions

Options

Frequency

Percentage

19

How many specialties are there in dentistry?

7

9

11

5

31

95

76

48

12.4%

38%

30.4%

19.2%

20

What does a periodontist do?

Filling of teeth

Extraction of teeth

Gum treatment

Replacement of teeth

24

76

90

60

9.6%

30.4%

36%

24%

21

What does a prosthodontist do?

Filling of teeth

Extraction of teeth

Gum treatment

Replacement of teeth

31

49

73

97

12.4%

19.6%

29.2%

38.8%

22

If a specialist provides root canal therapy for a patient, what is the specialty called?

Endodontist

Orthodontist

Oral Surgery

Oral Pathology

75

58

66

51

30%

23.2%

26.4%

20.4%

23

Like community nursing, what is the specialty in dentistry called?

Pedodontia

Oral Surgery

Public Health Dentistry

Oral Pathology

16

34

164

36

6.4%

13.6%

65.6%

14.4%

There are 9 specialties in Dentistry. Periodontist do Gum Treatment and Teeth replacement is done by Prosthodontist. Public Health Dentistry is a similar branch in Dentistry like Community Nursing. 38% respondents reported correctly about number of branches in Dentistry. 36% answered that Periodontist do gum treatment. 39% reported that teeth replacement is done by Prosthodontist and 30% responded that Endodontist do root canal treatment. Almost 66% had sufficient knowledge about Public Health Dentistry.

Other Knowledge (Table 5, Fig. 6)


 
Table 5

Frequency Distribution of Participants regarding Other Knowledge

Question

Number

Questions

Options

Frequency

Percentage

24

As a nursing graduate, where do you think your service is at most required in the field of dentistry?

Pedodontia

Public Health Dentistry

Oral Surgery

Periodontia

16

175

43

16

6.4%

70%

17.2%

6.4%

25

As a nursing graduate do you think you should know more about oral cavity and oral diseases?

No

Yes

Not Necessary

No Comments

4

226

18

2

1.6%

90.4%

7.2%

0.8%

70% were interested in doing work in Public Health Dentistry, because they thought that is the field which required their services. Finally, majority of the respondents wanted to gain more knowledge of the oral cavity and oral diseases.

Discussion

Oral care is important for patient’s health and well-being for a variety of reasons. Not only is the mouth vital for eating, drinking, taste, breathing, verbal and non-verbal communication, but also saliva has antibacterial properties and is part of the body’s defense against infection. Poor oral hygiene is well known to be associated with painful, unpleasant diseases such as gingivitis, dental caries, halitosis, xerostomia and more recently, has been linked to chest infections and pneumonia.25,26,27 Regular oral care by a Professional can prevent aspiration pneumonia and reduce the onset of fever.28 Dental caries, Periodontitis and Oral cancer are major public health challenges in India. Providing oral health care that include treatment and prevention of oral diseases should be an important part of our health care delivery system.29,30,31

About 80% of dentists work in major cities in India; whereas more than 70% of the Indians reside in the rural areas. Very little oral health care services are provided in the rural areas, however; oral healthcare seeking behavior is also very low, especially among the rural population.32 A mismatch exists between distribution of Dental Surgeons and the population which they serve. Only 15–20% of people in India are able to get dental services through national schemes.33 Access and quality of public health services have been below desirable standards. Although huge unmet treatment needs exists, there is lack of accessibility of dental facilities in rural parts of India. Primary health care approach with respect to dental care is major missing link in India.34,35

Oral health is not an issue concerning dental surgeons, social services and hospitals but also an issue of social justice. The community health nurse must be prepared to play a much wider role than is offered by her work in hospitals.36 Nurses are the firsts to interact with patients in a Government or Private Hospitals in India. If they have sufficient knowledge about oral health, they can give positive reinforcement to patients for improvement of oral health and also refer them to higher centers.37

Oral health is important during pregnancy.38 Many Evidence based Studies suggested that a strong association does exist between periodontal disease and pregnancy outcomes such as preterm and low birth weight. It is well established that poor maternal oral health can increase the risk of infants developing dental decay. Maintaining good oral hygiene during the prenatal period improves the oral health outcomes of the mother and the baby and may potentially improve pregnancy outcomes. Nurses get an excellent opportunity to offer preventive oral services by providing oral health assessment, education and referrals for pregnant women attending Hospitals.39,40

In the present study, the oral health knowledge and attitude of nurses was found to be insufficient. In this study 81% participants were aware that the number of permanent teeth, but only 60% of nursing personnel were aware of 20 teeth are present in child’s oral cavity. Similar results were reported by Senthil and Bhat in their study.21 58% participants answered that fluoridated tooth paste should be used. Higher response rate was reported by Senthil and Bhat and Ajithkrishnan et al in their study.21,22 In the present study 57% participants said that soft toothbrush is ideal for brushing which is comparatively higher to 51% as reported by Senthil and Bhat in a similar study.21 Almost 46% respondents stated that the tooth brush should be changed every 3 months and this result is in accordance with the study conducted by Senthil and Bhat in India.21

66% participants were of the view that a person should do brushing twice daily whereas Kaira et al and Udoye & Aguwa reported the same as 49% and 43% respectively.41,42 Naveen Kumar B. et al reported that only 27% participants brushed their teeth twice daily which is quite low as compared to our study results.23

58% said that individual should visit dentist once in 6 months. Considerably higher correct response rate was reported by Senthil and Bhat and Preston et al.21,43 Kaira et al reported that almost 50% respondents visited the dentist only when they were suffering from dental pain.42

56% of study participants knew about ideal diet for healthy dentition and regarding management of toothache which is quite high as compared to 49% and 36% reported in a study conducted in South India by Senthil and Bhat.21 The study revealed that nursing students and staff are interested in getting more knowledge related to oral health promotion and prevention of oral diseases; which is in accordance with the study conducted by Senthil and Bhat and Ajithkrishnan et al.21,22

Nurses had an inadequate knowledge in identifying the duties of prosthodontist, endodontist and periodontist. But they were able to correlate with public health dentistry correctly and understood that their services are more required in the field of Public Health Dentistry as compared to other branches of Dentistry. This study emphasized these variables as a baseline data for further studies.

Conclusion

Overall oral health knowledge and attitude of nursing students and staff was insufficient. Only half of the study participants were aware of various aspects of oral health. Being health professionals, Nurses should have basic knowledge about oral health and diseases. Nurses should be familiar with the various risk factors to appropriately manage oral care; help make appropriate referral and intervention decisions. Having proper education and tools to assess risk can be used in conjunction with other risk assessments to help guide early detection, prevention and referral practices.

This study found that the nursing students and staff had interest in doing services for common people of India and knowing more about oral health. It is recommended that a dental curriculum should be introduced in the nurses undergraduate training program which can be housed in Public Health Dentistry department as a part of community nursing. This will increase their knowledge and interest in working for Indian People which will subsequently improve the awareness and knowledge of oral health in the community through the nurses.

Declarations

Acknowledgements 

The authors are thankful to all the participants and authors of the references used in article.

All authors have no conflicts of interest.

The authors did not receive support from any organization for the submitted work.

No funding was received to assist with the preparation of this manuscript.

No funding was received for conducting this study.

No funds, grants, or other support was received.

References

  1. World Health Organization (2005 Sept). The Liverpool Declaration: Promoting Oral Health in the 21st Century. [Internet] A call for action. [Cited 2022 Oct 16] Retrieved from: https://www.who.int/oral_health/%20events/orh_liverpool_declaration_05.pdf.
  2. World Health Organization (2012 April). Oral Health. Fact sheet no 318. [Internet] [Cited 2022 Oct 15] Retrieved from: https://www.who.int/mediacentre/%20factsheets/fs318/en/index.htm.
  3. Oral Health Information for Maternal & Child Health Nurses, & Victoria, A. (2011). [Internet] [Cited 2022 Oct 16] Retrieved from: http://www.dhsv.org.au/__data/assets/pdf_file/0011/3989/teeth-oral-health-information-for-maternal-and-child-health-nurses-manual.pdf
  4. World Health Organization. [Internet] [Cited 2022 Oct 16] Retrieved from: https://www.who.int/health-topics/oral-health#tab=tab_1
  5. Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019). [Internet] Seattle: Institute of Health Metrics and Evaluation (IHME); 2020. [Cited 2022 Oct 16] Retrieved from http://ghdx.healthdata.org/gbd-results-tool.
  6. Imaroon, A., Boonyawong, P., Klanrit, P., Prasongtunskul, S., & Thongprasom, K. (2006). Characterization of Oral Pemphigus Vulgaris in Thai Patients. Journal Of Oral Science, 48(1), 43–46.
  7. Chi, A. C., Neville, B. W., Krayer, J. W., & Gonsalves, W. C. (2010). Oral Manifestations of Systemic Disease. Am Fam Physician, 82(11), 1381–1388.
  8. Kamala, R., Sinha, A., Srivastava, A., & Srivastava, S. (2011). Primary Tuberculosis of Oral Cavity. Indian Journal Of Dental Research : Official Publication Of Indian Society For Dental Research, 22(6), 835–838.
  9. Stoica, S. A., Valentini, G., Dolci, M., & Agostino, S. D. (2022). Diabetes and Non-Surgical Periodontal Therapy: What Can We Hope for? Journal of Hygiene, 2, 85–93.
  10. Gulati, S., & Mishra, A. (2014). Sugar Intake, Obesity, and Diabetes in India. Journal of Nutrients, 6, 5955–5974.
  11. Kim, K., Han, K., & Yang, S. (2020). Association between overweight, obesity and incidence of advanced dental caries in South Korean adults: A 10-year nationwide population-based observational study. Plos One, 15(2), e0229572.
  12. Suzuki, N., Yoneda, M., Naito, T., Iwamoto, T., Masuo, Y., Yamada, K., Hisama, K., Okada, I., & Hirofuji, T. (2008). Detection of Helicobacter pylori DNA in the saliva of patients complaining of halitosis. Journal Of Medical Microbiology, 57, 1553–1559.
  13. Lee, Y. H., & Wong, D. T. (2009). An emerging biofluid for early detection of diseases Saliva. American Journal Of Dentistry, 22(4), 241–248.
  14. Estevez, P. T., Satoguina, J., Nwakanma, D. C., West, S., Conway, D. J., & Drakeley, C. J. (2009). Human saliva as a source of anti-malarial antibodies to examine population exposure to Plasmodium falciparum. Malaria Journal, 10, 104.
  15. Correa, M. C., Lerco, M. M., Cunha, M. L., & Henry, M. A. (2012). Salivary parameters and Teeth erosions in patients with Gastroesophageal reflux disease. Journal of Arq Gastroenterol, 2012; 49:(3) 214–218.
  16. FDI World Dental Federation (2015). A report on Oral Health Worldwide. [Internet] [Cited Oct 16] Available at: https://www.fdiworlddental.org/sites/default/files/2020-11/2015_wohd-whitepaper-oral_health_worldwide.pdf.
  17. Demographics of India. [Internet] [Cited 2022 Oct 16] Retrieved from: https://en.wikipedia.org/wiki/Demography_of_India
  18. Khan, A. A., Jain, S. K., & Shrivastav, A. (2008). Prevalence of Dental Caries among the population of Gwalior (India) in relation of different associated factors. European Journal of Dentistry, 2008; 2, 81–85.
  19. National Oral Health Policy of India (2021). Ministry of Health and Family Welfare. [Internet] [Cited 2022 Oct 16] Retrieved from: https://main.mohfw.gov.in/sites/default/files/N_56820_1613385504626.pdf.
  20. Smith, A., & Singh, R. (2012). A nurse’s role-public health in dental practice. Dental Nursing, 8(6), 352–354.
  21. Senthil, M., & Bhat, P. K. (2011). Oral Health knowledge and attitude among final year Nursing Undergraduate Students in Bangalore City, India. JIAPHD, 17, Suppl. 1,389–396.
  22. Ajithkrishanan, C. G., Thanveer, K., & Nisarg, J. (2011). Chaudhary Oral Health Knowledge, Attitude and Practices among nursing students of Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat (pp. 36–39). JIAPHD. 18.
  23. Kumar, N., Ramesh, N., & Ravi Shankar, T. L. (2011). Oral Health Knowledge, Behaviour and Status among Nursing Students of Davanagere City. Karnataka JIAPHD, 18(Suppl.1), 491–495.
  24. Adams, R. (1996). Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24, 552–560.
  25. Malkin, B. (2009). The importance of patients' oral health and nurse’s role in assessing and maintaining it. Nursing Times, 105(17), 19–23.
  26. Ross, A., & Crumpler, J. (2007). The impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia. Intensive and Critical Care Nursing, 23, 132–136.
  27. Son, M., Jo, S., Lee, J. S., & Lee, D. H. (2020). Association between oral health and incidence of pneumonia: a population- based cohort study from Korea. Journal of Nature, 10, 9576.
  28. Koichiro, U. E. D. A. (2011). Preventing Aspiration Pneumonia by Oral Health Care, Research and Reviews. JMAJ, 54(1), 39–43.
  29. International Encyclopedia of Public Health. [Internet] [Cited 2022 Oct 16] Retrieved from: http://www.mah.se/upload/FAKULTETER/OD/Avdelningar/who/doc/EncycPubORHpep.pdf
  30. Ramya, K., Prasad, K. V. V., & Niveditha, H. (2011). Public oral primary preventive measures: An Indian perspective. J Int Oral Health, 3(5), 7–18.
  31. Kah, A., & Pau, H. (2012). Challenges in dental public health- An overview, Review Article. IeJSME, 2012; 6 (Suppl 1): S106-S112.
  32. Tandon, S. (2004). Challenges to Oral Health Workforce in India. Journal of Dental Education, 68(7), 28–33.
  33. Singh, A., & Purohit, B. (2012). Targeting poor health: Improving oral health for the poor and the underserved, International Affairs and Global Strategy, 3: 1–6.
  34. Kumar, S., Kumar, S., Saran, A., & Dias, F. S. (2013). Oral health care delivery system in India: An overview. IJBAMS, 3(2), 171–178.
  35. Gambir, R. S., Kaur, A., Singh, A., Sandhu, A. R. S., & Dhaliwal, A. P. S. (2016). Dental public health in India: An insight, Review Article. J Family Med Prim Care, 5, 747–751.
  36. Sleevama, C. H.Text book for the community health nursing – 1 including nutrition & hygiene1. Psychology & sociology [Internet] [Cited 2022 Oct 16] Retrieved from: http://bieap.gov.in/book.pdf
  37. Wooten, K. T., Lee, J., Jared, H., Boggess, K., & Wilder, R. S. (2011). Nurse practitioner’s and certified nurse midwive’s knowledge, opinions and practice behaviors regarding periodontal disease and adverse pregnancy outcomes. The Journal of Dental Hygiene, 85(2), 122–131.
  38. Oral Health Care during Pregnancy and Early Childhood, Guidelines, P., & Newyork, United States of America. [Internet][Cited 2022 Oct 16] Retrieved from: http://www.health.ny.gov/publications/0824/pda/windows_mobile/0824_child_health_professionals.pdf
  39. Cibulka, N. J., Forney, S., Goodwin, K., Lazaroff, P., & Sarabia, R. (2011). Improving oral health in low- income pregnant women with a nurse practitioner- directed oral health care program.Journal of the American Academy of Nurse Practitioners, 23: 2.S.49–257.
  40. George., A., Johnson, M., Blinkhorn, A., Ellis, S., Bhole, S., & Ajwani, S. (2010). Promoting oral health during pregnancy: current evidence and implications for Australian Midwives. Journal of Clinical Nursing, 19, 3324–3333.
  41. Udoye, C., & Aguwa, E. (2008). Oral Health Related Knowledge and Behavior among Nursing Students in Nigerian Tertiary Hospital.The Internet Journal of Dental Science, 7(2).
  42. Kaira, L., Srivastava, V., & Chopra, D. (2006). Oral Health- Related Knowledge, Attitude and Practices among Nursing Students of Rohilkhand Medical College and Hospital: A Questionnaire Study. J Orofac Res [Internet], 2(1), 20–23. Aspx Idhttp://www.jaypeejournals.com/eJournals/ShowText.
  43. Preston, A. J., Punekar, S., & Gosney, M. A. (2000). Oral Care of elderly patients nurse’s knowledge and views. Postgraduate Medical Journal, 76(892), 89–91.