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 Table of Contents  
Year : 2018  |  Volume : 10  |  Issue : 5  |  Page : 229-236

Oral hygiene status, self-reported oral malodor, oral hygiene practices, and oral health knowledge: A cross-sectional study in a group of Muslim Thai pregnant women

1 Department of Conservative Dentistry; Common Oral Diseases and Epidemiology Research Center, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Thailand
2 Department of Preventive Dentistry, Faculty of Dentistry, Prince of Songkla University, Hat Yai, Thailand

Date of Web Publication24-Oct-2018

Correspondence Address:
Dr. Supawadee Naorungroj
Department of Conservative Dentistry, Faculty of Dentistry, Prince of Songkla University, 15 Kanjanavanich Road, Hat Yai, Songkhla
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_184_18

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Objective: The aim of this study is to determine oral hygiene status, self-reported oral malodor, oral hygiene practices, oral health knowledge, and the differences across educational levels in a group of Muslim Thai pregnant women. Subjects and Methods: This was a cross-sectional study conducted at Yaring, Pattani, Thailand. A total of 88 pregnant women were invited to participate in this study. The enrolled patients answered a self-administered questionnaire comprising sociodemographic data, self-perceived oral malodor, oral hygiene practices, as well as their knowledge about the causes and effects of gingivitis during the prenatal period. Gingival health, plaque deposit, and tongue coating were assessed using the modified gingival index (MGI), the plaque index (PI), and the Winkel index (WTCI), respectively. The associations of educational levels with clinical measures and questionnaire responses were analyzed using SPSS version 17. Results: The pregnant women had moderate levels of gingival inflammation (MGI = 1.36 ± 0.40), visible plaque deposit (PI = 1.43 ± 0.47), and thinly dispersed tongue coating (WTCI = 5.40 ± 2.82). MGI significantly decreased as educational levels increased (P = 0.041). Although 90% of the participants had knowledge pertaining to good oral hygiene habits, a high number of participants reported a short brushing time (77%), irregular tooth brushing after meals (66%), irregular tongue cleaning (46%), and a bad breath experience (71%). Furthermore, a significant number of pregnant women lacked knowledge of or misunderstood oral-systemic health relationships. Oral hygiene practices and oral health knowledge were not significantly different across educational levels. Conclusion: The majority of Muslim Thai pregnant women had fair oral hygiene, improper self-oral hygiene care, and inadequate knowledge of the importance of oral-systemic health relationships.

Keywords: Gingivitis, oral health, oral hygiene, oral malodor, pregnancy

How to cite this article:
Naorungroj S, Hunsrisakhun J, Talungchit S. Oral hygiene status, self-reported oral malodor, oral hygiene practices, and oral health knowledge: A cross-sectional study in a group of Muslim Thai pregnant women. J Int Oral Health 2018;10:229-36

How to cite this URL:
Naorungroj S, Hunsrisakhun J, Talungchit S. Oral hygiene status, self-reported oral malodor, oral hygiene practices, and oral health knowledge: A cross-sectional study in a group of Muslim Thai pregnant women. J Int Oral Health [serial online] 2018 [cited 2022 Aug 10];10:229-36. Available from:

  Introduction Top

From an oral health life-course perspective, pregnancy is a unique and sensitive period due to physical, hormonal, and emotional changes.[1] Pregnant women are more susceptible to gingival inflammation. Hormonal variations during pregnancy, estrogen and progesterone, could exacerbate the inflammatory response to dental plaque, resulting in severe gingivitis.[2],[3],[4],[5] Furthermore, during the first trimester, regular self-oral hygiene care, i.e., tooth-brushing, in some women is nearly impossible, especially in premolar and molar areas because of pregnancy-related nausea and vomiting symptoms.[6] This situation may notably impact the mother's quality of life.[7] Although the change in clinical parameters for gingival inflammation, i.e., bleeding on probing, was reversible at the end of pregnancy or after parturition,[2],[4],[6],[8] a previous study has showed that periodontal treatment during pregnancy improves quality of life.[7]

It was reported that greater gingival inflammation during pregnancy was related to lower sociodemographic status, specifically low educational attainment.[6],[8] This relationship was explained by the possibility of poor awareness of the importance of oral hygiene, a lack of perceived need, and inaccessibility to dental clinics.[9],[10],[11],[12],[13] It was also noted that perceived stress and anxiety and low self-efficacy might lead to neglect of oral hygiene and contribute to the deterioration in periodontal health during pregnancy.[13] Furthermore, multigravida women were more likely to have more severe scores of clinical signs of diseases. A possible explanation was that multigravida women had already experienced a dental disease in their previous pregnancies and did not receive treatment.[6] Periodontitis, gingivitis, and poor oral health are common causes of oral malodor, which is a result of the generation of volatile sulfur compounds (VSC) by oral bacteria.[14],[15] Previous studies reported positive associations of periodontal disease, periodontopathic bacteria, and plaque deposits with the detection of VSC in the mouth air.[14],[16],[17] Oral malodor may be a cause of psychological problems to those who suffer from it.[14] Self-reported bad mouth breath had been reported as a common concern in young mothers from Tanzania, a developing country.[15]

However, there is no previous study that investigates oral hygiene status, practices, and oral health knowledge in Muslim Thai pregnant women in many of whose lives religion plays a pivotal role. The aim of this study was, therefore, to evaluate the level of oral hygiene, self-reported oral malodor, oral hygiene practices, and knowledge of oral health as well as the influence of education level among Muslim Thai pregnant women. The results of this study can provide baseline information for effective planning of oral health promotion and intervention programs during pregnancy.

  Subjects and Methods Top

Setting and study subjects

The study was approved by the ethics committee of the Faculty of Dentistry, Prince of Songkla University (EC 5808-23-L-HR). This study was a cross-sectional analysis of 88 pregnant women from Yaring district, Pattani province to describe oral hygiene status, self-reported oral malodor, oral hygiene practices, and the oral health knowledge of prenatal women. A total of 107 Muslim Thai pregnant women in the first and second trimesters from seven sub-districts were contacted on the day of attending the prenatal care clinic by employing convenient sampling during January 2016 and May 2017. The size of the survey sample was calculated based on the number of pregnant women from the selected districts who attended the prenatal care clinic in 2015 (n = 256). The analytical sample for this study (n = 88) represented about one-third of the target population. This calculated sample size was corresponding to a confidence interval level of 95% and a margin error of 10%. They were informed about the objectives and methods of the study protocol and were enrolled in the study according to the following inclusion and exclusion criteria. Inclusion criteria were 12–18 weeks pregnant women who had at least 20 natural teeth at the time of enrollment. Exclusion criteria were those who had dental caries, exposed pulp and had been diagnosed with periodontitis or having the 2nd degree tooth mobility. Subjects who had systemic diseases (i.e., diabetes mellitus, hypertension, cardiovascular disease, asthma, or epilepsy) before enrollment were also excluded from the study. Individuals who were using mouth rinses containing chlorhexidine, triclosan, essential oils, or cetylpyridinium were instructed to stop rinsing with such products for 2 weeks before dental examination. The patients completed self-administered questionnaires and received dental examinations after provided a written informed consent to participate in this study.


A self-administered questionnaire comprising sociodemographic status, medical and dental history, self-perceived oral malodor, oral hygiene practices, as well as their knowledge about the causes and effects of gingivitis and the importance of oral hygiene care during the prenatal period was used to collect baseline data. Study participants were also asked about their past dental visits and the reasons for such visits. The questionnaire was evaluated for its content validity by three experts from the Faculty of Dentistry, Prince of Songkla University. A face validity process was performed by questionnaire pilot testing in 10 women with pregnancy experience to assess comprehension and appropriateness of all questions.

Subjective oral malodor assessment

The participants were instructed to refrain from using scented personal products, eating breakfast and brushing their teeth for at least 2 h before the examination. Patients remained quiet and kept their lips closed for 3 min. They were then asked to exhale through the mouth briefly with moderate force and immediately smell the exhaled air. The participants were assessed for subjective oral malodor on a scale of 0 to 5 as follows: 0 = no odor; 1 = barely noticeable odor; 2 = slight but clearly noticeable odor; 3 = moderate odor; 4 = strong odor; and 5 = extremely foul odor.

Dental examination

All subjects received oral examinations at the first appointment to establish their baseline measurements. Gingival health and plaque deposits were assessed on the 6 Ramfjord sample teeth using the modified gingival index (MGI) and the plaque index (PI), respectively.[18],[19] The presence of tongue coating using the Winkel index (WTCI) was also evaluated. The dorsum of the tongue was divided into six sextants. The coating density of each sextant was evaluated as follows: no coating = 0; light coating = 1; and severe coating = 2. The tongue coating value was obtained by the addition of all six scores, ranging from 0-12.[20] The pregnant women were examined by six trained dental hygienists, who have had experience of working in the Dental Public Health Unit at Yaring district for at least 2 years. Inter-examiner reproducibility was assessed using kappa statistics which were 0.6–0.8 for MGI; 0.6–0.9 for PI; and 0.6–1.0 for WTCI.

Statistical analysis

The data were entered into a computer and analyzed using Statistical Package for Social Sciences (SPSS) version 17 (SPSS Inc., Chicago, IL, USA). Frequency distribution, means, and standard deviation were calculated to describe the study participants' sociodemographic characteristics, self-reported oral problems, oral hygiene status, oral health behaviors, and oral health knowledge of the pregnant women. For those who reported bad breath, the frequencies of psychological effects were reported. The associations between MGI, PI, WTCI and the level of education were analyzed using one-way analysis of variance. In addition, the associations of oral health status, oral health behaviors, and oral health knowledge with the level of education were analyzed using Chi-square and Fisher's exact test. The level of statistical significance was set at P < 0.05.

  Results Top

A total of 88 women with a mean age of 26.95 ± 5.09 completed the questionnaire. An average of gestational age of the study participants was 16.25 ± 2.58 weeks, and about one-fourth was a first-time pregnancy. A majority of the pregnant women were housewives, attained ≤12 years of education, and had low incomes. The burden of oral conditions was considerable. About two-thirds of the pregnant women reported bad breath (70.9%) and pregnancy-related vomiting (73.9%). Furthermore, 27.3% and 51.1% of participants experienced dry mouth and subjectively perceived signs of gingival inflammation, for example, bleeding gums, while brushing their teeth [Table 1].
Table 1: Sociodemographic characteristics and self-reported oral problems of the study participants (n=88)

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Sixty-one pregnant women reported bad breath experience; however, up to 41% (n = 25) were not sure or able to detect an odor when they were asked for oral malodor self-testing by smelling their breath in the cupped hands. Approximately three-fourths reported that bad breath occurred when waking, while only 5%–10% had bad breath when thirsty or hungry, feeling fatigued, or talking with others. About 75% was anxious about bad breath when talking to people. Approximately, one-fourth stated that peers had informed them regarding their bad breath and that had affected relationships with friends and family members. Among pregnant women with bad breath experience, more than half reported using chewing gum or sucking on a candy after meals to reduce bad breath, while only about 15% visited a dentist or a medical doctor for bad breath treatment [Table 2].
Table 2: Psychological effects of oral malodor (n=61)

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On an average, the pregnant women had moderate levels of gingival inflammation (MGI = 1.36 ± 0.40) and visible plaque deposits (PI = 1.43 ± 0.47). MGI and PI tended to decrease as educational levels increased; however, a statistically significant association was observed only for MGI (P = 0.041). The average score of tongue coating was 5.40 ± 2.82. Although no significant difference across educational level was found, the WTCI scores tended to be greater for pregnant women who had higher education [Table 3].
Table 3: Gingival inflammation and oral hygiene status by educational levels of the study participants (n=87)

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About 75%–80% of the participants reported good oral hygiene habits, for example, regular tooth brushing in the morning and before bedtime. While only 30% reported regular tooth brushing after meals and < 10% reported regular dental flossing or mouth rinse use. Most of the participants used fluoride toothpaste and spent 1–2 min on tooth brushing. Approximately half of the participants stated that they had regular tongue cleaning and had visited a dentist for a dental check-up during pregnancy. About one-fourth stated that they also had sweets between meals 3–4 times/week or more. None of the self-reported oral health behaviors was significantly associated with the level of educational attainment [Table 4].
Table 4: Associations between self-reported oral health behaviors and educational levels of the study participants (n=87)

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Approximately 66% were aware that poor oral health could affect general health. Half of the pregnant women answered correctly about the causes and effects of gingivitis during pregnancy, for example, “gingivitis during pregnancy is normal, there is no need for prevention” (“no” = 50.6%); “pregnant women are more susceptible to gingivitis due to hormonal change” (“yes” = 55.3%); and “gingivitis during pregnancy could have adverse consequences to the child” (“yes” = 52.4%). A high percentage (89.4%) of the pregnant women said that good oral hygiene routines included tooth brushing and tongue cleaning. Few pregnant women (7.1%) believed that frequent tooth brushing during pregnancy resulted in weakened teeth due to loss of calcium, though many of them (47.1%) were unsure [Table 5].
Table 5: Associations between oral health knowledge and educational levels of study participants (n=87)

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  Discussion Top

This study showed that the majority of Muslim Thai pregnant women had moderate gingival inflammation and fair oral hygiene. However, among the three clinical measures which were the primary outcomes of this study, a modest statistical association with educational level was observed only for MGI. They were concerned with oral malodor and aware of the necessity for good oral hygiene. However, some of the pregnant women had poor oral hygiene habits, low use of dental services, and many were not knowledgeable about the importance of the oral-systemic health relationships. These findings are in agreement with previous studies.[7],[8],[10],[12],[21],[22] In addition, oral health behaviors and oral health knowledge were not statistically significant difference across the educational level in this sample.

This is the first study to show the extension of gingival inflammation, oral hygiene care levels, oral health behaviors, and oral health knowledge in Muslim Thai pregnant women, who have special beliefs and cultural background. This study provides baseline information for a health-care provider to effectively plan oral health promotion and intervention in the study environment. However, the present study had some limitations. The recruitment of pregnant women for the study was somewhat difficult, resulting in a small sample size at the beginning stage of data collection. The main reason was that of a lower pregnancy rate at the starting point. To ensure that the study included a sufficient number of participants to adequately address the research question, the time frame of data collection was extended up to ending May 2017. This study used a non-random sampling method. Thus, the findings of this study cannot be generalized to other Muslim Thai pregnant women. Moreover, with a limitation of a cross-sectional observation, the effects of pregnancy on oral health status should be interpreted with cautions, as there was no information on pre-existing periodontal inflammation and dental plaque to take into account. Finally, a self-administered questionnaire was used to collect the data. The pregnant women completed the survey without on-going feedback from a trained examiner. Therefore, the results were subjected to recall bias and the incompleteness of survey responses.

Pregnancy gingivitis is well accepted as an aggravation of inflammatory response to the local irritants due to an increased concentration of sex hormones, estrogen, and progesterone during pregnancy. The hormonal changes affect the periodontal tissue microvascular system, leading to gingival bleeding, swelling, and an increase in the risk of bacterial infections.[2],[3],[4],[5],[6] Previous longitudinal studies reported that the severity of gingivitis gradually increased throughout the pregnancy period.[4],[23] It was also noted that though the gingival index of pregnant women peaked in the third trimester and dropped at 3 months postpartum, the plaque levels remained unchanged.[4] Pregnant women in this cross-sectional study were in the second trimester and showed moderate plaque deposit and gingivitis. Their mean gingival index score was generally similar to pregnant women in India and Sri Lanka;[4],[23] however, the PI score was considerably higher than that of Sri Lankan women (PI = 1.43 vs. 0.65–0.69).[4] The difference may be due to a deviation in the clinical examination protocol or the poorer oral hygiene practices of our study samples. Our research examined six index teeth, while Tilakaratne et al. examined all teeth.[4]

Compared to nonpregnant women, pregnant women exhibited poorer oral hygiene status.[4],[6],[23],[24] One explanation of higher plaque deposits and the connection with gingival inflammation during pregnancy might be nausea and vomiting during the first weeks of pregnancy. Most women in the pregnant group reported difficulty in tooth brushing, especially in posterior teeth because of pregnancy-related nausea and vomiting.[6] In this study, a high proportion of the pregnant women reported vomiting during pregnancy, which may be related to the short duration of tooth brushing and infrequent tongue brushing during pregnancy. These improper oral health practices may explain the high level of plaque deposit and self-perceived oral malodor, especially in the morning in this study.

Previous studies also showed that socioeconomic status, education, age, multiple pregnancies, and oral hygiene habits were contributory factors to the aggravation of gingival inflammation.[6],[8] It is apparent that most of the pregnant women in this study had low income, low educational attainment, and perhaps low oral health literacy. The association between periodontal health status and low literacy levels highlighted the notion that pregnant females with strong knowledge of oral health exhibit a better oral health status.[6],[8] Broadly, individuals with low oral health literacy skills are more vulnerable and have poorer oral health outcomes as they are unable to make sound oral health decisions in their everyday lives. While a recent systematic review and meta-analysis found that oral health literacy was associated with oral health knowledge, there was inconclusive evidence regarding the association between oral health literacy and oral health behaviors, oral health perception, and dental utilizations.[25] This was seen in the present study. Though the majority of the pregnant women demonstrated a concern for oral malodor, good oral hygiene routines, and understood the association between poor oral conditions and systemic health, a considerable proportion of study samples reported improper routine self-care behaviors, for example, irregular dental flossing, tooth brushing and tongue cleaning, or a short duration of brushing time. These findings underscore the importance of oral health promotion, including education and health-care services program during pregnancy.[9],[22],[26],[27],[28] A recent qualitative study among Iranian pregnant women suffering from gingivitis indicated that performing oral self-care behaviors to prevent gingivitis was influenced by multiple factors including the supportive role of family and government; dentists' experience, communication skill, and commitment in oral health training; awareness of the risk and severity of oral diseases; perceived benefit of maintaining oral health in mothers; oral hygiene self-efficacy; and cultural making.[28] To design oral health education interventions for Thai Muslim pregnant women, it is therefore essential for health professionals and researchers to further investigate which factors were important for performing oral self-care behaviors. Cultural making among pregnant women through education of girls in school, improvement of beliefs related oral health, and advertising via media in maintaining and promoting women's oral health have been suggested as methods to promote oral self-health care behaviors.[28]

Interestingly, there was less use of dental services among these pregnant women, although free dental care was available in their communities. There also appeared to be no difference in dental care use across educational levels. To guide the healthcare team breaking barriers for not receiving dental service, their primary concern for the poor use of dental service needs to be further explored. Poor access to dental care during pregnancy has been previously related to various factors and situations that may be simultaneous, for example, lack of insurance coverage, race and ethnic disparity, lack of education and income, lack of perceived need, and personal stressors.[26] A recent systematic review conceptually classified determinants that influenced dental care attendance during pregnancy in five categories: demographic, socioeconomic, psychosocial, behavioral, and perceived need factors.[27] A previous study in Nigeria demonstrated that poor periodontal status was directly associated with a lack of previous dental visits. Such lack of periodic dental cleaning visits can lead to increased plaque accumulation and result in gingival bleeding and periodontal inflammation.[22] It was suggested that periodontal treatment during pregnancy promoted an improvement in periodontal health, the patients' perspective, stress-related hormone, and their quality of life.[7],[29]

Furthermore, a high number of the pregnant women responded to several oral health knowledge questions with “unknown.” It can be interpreted that these individuals truly lacked oral health knowledge or they may have limited ability to read and comprehend oral health information (i.e., oral health literacy). Interestingly, our results showed no significant association between the level of education with either oral hygiene practices or oral health knowledge. In the study, we did not measure the oral health literacy of the pregnant women; however, this raised a further research question of the need to assess oral health literacy among this vulnerable group and its association with oral health outcomes. It was suggested that to effectively improve individuals' oral health status, oral health education materials must be appropriate to the literacy level, language, and culture of the patients. Moreover, the characteristics of the dental practice and the community it serves are important.[30]

  Conclusion Top

Poor self-reported compliance with regard to oral health and oral health knowledge were in evidence among these pregnant women. To improve oral health status, effective oral health promotion including oral health education and intervention programs are needed.


Faculty of Dentistry, Prince of Songkla University and Johnson & Johnson Company funded this study. We are grateful to Dr. Narisa Heemsuree and staffs from Yaring hospital, Dental public health unit and Rural Oral Health Center, Faculty of Dentistry, Prince of Songkla University for their cooperation in subject enrollment and data collection. Indeed, we are very thankful all pregnant women who consented to participate in this study; otherwise this study would have been impossible.

Financial support and sponsorship

Faculty of Dentistry, Prince of Songkla University and Johnson & Johnson Company funded this study.

Conflicts of interest

There are no conflicts of interest.

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

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