A single centred parallel randomized controlled study was carried out at a tertiary care hospital’s Department of Obstetrics and Gynaecology at Yenepoya Medical College Hospital, Yenepoya Deemed to be University, an institute of higher education located in Mangalore, Karnataka, India. 84 pregnant women aged 18 and above, who attended the hospital for prenatal treatment and had gestational ages ranging from 8 to 30 weeks, participated in this randomised controlled trial. Data for the study were collected between February 1st and April 30th, 2022. Before initiating the study, official permission was obtained from the Head of the Department of Department of Obstetrics and Gynaecology at Yenepoya Medical College Hospital, Yenepoya Deemed to be University.

With an effect size of 0.575 derived from a pooled standard deviation of 5.2 as reported in a significant article by Bahri et al., ¹² the sample size of the research was determined using the G*Power software with a 5% level of significance and 80% power. The total sample size for each group was 38. The final total sample size was modified to 84, with 42 participants in each group, to account for a 10% non-response error rate.

Participants were selected using simple random sampling. Following oral examinations, eligible participants were randomly allocated to two groups using the lottery method. The total sample comprised two groups: Group 1 utilized a cross-platform messaging application (WhatsApp messenger), while Group 2 underwent Motivational Interviewing for oral health education. The enrolment of participants is depicted through the CONSORT diagram ( Figure 1).

The random allocation sequence was implemented using sequentially numbered containers. Steps were taken to conceal the sequence until interventions were assigned by ensuring that the containers were opaque and sealed. This process helped maintain the integrity of the randomization process and prevented any potential bias in the assignment of interventions until the participants were allocated to their respective groups. Statistician with expertise in research methodology generated the random allocation sequence but not directly involved in participant enrolment or intervention assignment to maintain the randomness and reduce bias. Research assistant performed participant enrolment. Research assistant explained the study, obtained informed consent, and ensured that participants meet the inclusion criteria. The assignment of participants to intervention groups was carried out by research coordinator (research guide) who was blinded to participant characteristics to ensure unbiased allocation.

This study was done in accordance with the principles outlined in the Declaration of Helsinki. Before initiating the study, official permission was obtained from the Head of the Department of Department of Obstetrics and Gynaecology at Yenepoya Medical College Hospital, Yenepoya Deemed to be University. The protocol was reviewed and approved by institutional ethics committee (Yenepoya Ethics Committee-2 of Yenepoya (Deemed to be University), Mangalore, India on 26/02/2021 with reference number YEC2/636. Written informed consent was obtained from eligible participants prior to the study. ¹³

The study included participants who met the following criteria: confirmed pregnancies, aged 18 years and older, with a gestational age between 8 and 30 weeks, and those who provided informed consent. ¹³ Additionally, participants needed to possess a smartphone at the time of allotment and be familiar with the usage of WhatsApp. The minimum educational qualification required was completion of schooling up to the 7th standard, with the ability to read and write in English, Kannada, or Malayalam.

Exclusion criteria comprised individuals with a history of smoking and alcohol consumption. Women with conditions like COVID-19 that could make dental examinations difficult were also excluded from being permitted to participate in the study.

Examiner training and calibration

The principal investigator underwent training for Motivational Interviewing from MITC (Motivational Interviewing Training and Consulting), accredited with the American Psychological Association and the New Mexico Counselling and Therapy Practice Board. The format for the interview questionnaire was derived from a study carried out by Bansal et al, (2019). ¹⁴ Questions were modified and validated by two subject experts. The survey questions were designed to evaluate knowledge, attitude, and behaviours and oral health-seeking behaviour among pregnant women, and the accurate responses to these questions and were provided. ¹³

Baseline examination

Data collection involved face-to-face interviews and subsequent oral examinations. The one-on-one interviews were conducted in a designated room where participants comfortably sat on chairs. The primary investigator performed interviews to assess pregnant women’s knowledge, attitudes, and practices related to oral health care. Oral examinations were conducted under natural light, supplemented by torch lights when necessary, and performed by a single examiner with the assistance of an assistant. The OHI-S index ¹⁵ has been used to evaluate the status of oral hygiene, while The Loe and Silness Gingival Index ¹⁶ was employed to measure gingival inflammation. Contact information, including WhatsApp numbers, was collected from all participants.

Using both English and their respective regional languages (Kannada/Malayalam), participants in Group I received WhatsApp messages with information on oral health care for expectant mothers and children.

In Group II, participants received a 20-minute talk based on the Motivational Interviewing (MI) approach, delivered by a dentist trained in MI, who also served as the Principal Investigator (PI). The MI approach encompassed four key aspects: Partnership, Acceptance, Compassion, and Evocation. The motivational interviewing process unfolded in two phases. During the first phase, efforts were made to establish rapport, build trust, and identify the problem of concern. The MI provider established rapport by posing open-ended questions concerning participants’ dental health, their child’s oral health, and their aspirations for both. These were questions that addressed several topics, including establishing commitment to change, seeing potential challenges, strengthening commitment to change, and finding challenges to change.

In the second phase, the approach shifted from contemplation to the action stage. Participants were asked to consider the benefits and drawbacks of change, along with potential barriers to action for each proposed change. The focus primarily revolved around collaboratively developing an action plan. The principal investigator effectively communicated with patients using the OARS method, which involves Open-ended questions, Affirmations, Reflective listening, and Summarizing.

Open-ended questions were employed to initiate a conversation between the PI and the patient, encouraging the patient to share thoughts and concerns. Affirmations acknowledged the challenges of behaviour change while highlighting the patient’s strengths to boost self-efficacy. Reflective listening involved actively understanding and comprehending the patient’s statements, fostering a collaborative exploration of behavioural change and motivation. Summarizing demonstrated attentive listening and provided a concise recapitulation of the conversation, aiding in addressing ambivalence.

During the one-month follow-up visit after the intervention, the PI conducted interviews with the participants to re-evaluate their knowledge, attitude, and behavior regarding oral health care, employing the same set of questions used during the baseline examination. The OHI-S index and Gingival Index were once again employed for oral health assessments.

During the study period, 5 participants were lost to follow-up, with 2 participants from Group 1 and 3 participants from Group 2 failing to complete the follow-up process. Consequently, the final sample size considered for analysis comprised 79 participants, with 40 participants in Group 1 and 39 participants in Group 2.

By evaluating the effectiveness of the two different therapies, the primary outcome of the study was to improve participants’ knowledge, attitudes, and behaviours related to oral health. A questionnaire was employed for this purpose. Enhancing the participants’ oral health status was the study’s secondary outcome, which was evaluated using the Gingival and OHI-S indices.

Data recorded in MS-Excel underwent statistical analysis using SPSS version 24.0. ¹³ While frequency and percentage were used to represent categorical variables, mean and standard deviation were used to express continuous variables. Descriptive statistics, including categorical data, were presented as frequency with percentage in brackets and a 95% confidence interval (CI). Fischer exact test/Chi-square test assessed associations between study variables.

For comparisons across groups, the Mann-Whitney U Test was employed, and for comparisons within groups, the Wilcoxon signed-rank test was utilised to assess the pre- and post-intervention measures. The Paired t test evaluated the mean change in knowledge scores within each group before and after the intervention, and the Independent Sample T test was used to compare mean knowledge scores between groups before and after the intervention. P<0.05 was set as a statistically significant.

This study examined into the effects of sociodemographic characteristics on pregnant women’s knowledge, attitudes, and behaviours related to oral health. Age, level of education, and religion, however, did not show statistically significant differences in oral health knowledge, attitude, behaviour, or oral hygiene. Conversely, El-Mahdi Ibrahim et al. ²⁴ found a strong correlation between age and dental health as well as attitude towards oral health. They also found that there was a strong correlation between education and oral health habits and oral health knowledge. Similarly, Avula et al. ²⁵ found statistically significant results regarding the educational qualifications of subjects. Women in different trimesters did not show significant variations in knowledge, which is in line with research by Pentapati et al. ²⁶ Furthermore, research by Mart nez-Beneyto et al. ²⁷ and Bamanikar et al. ²⁸ found a correlation between pregnant women’s educational attainment and dental health.

Understanding pregnant women’s oral health knowledge is essential considering the growing global burden of oral diseases. Their depth of knowledge has a direct impact on the oral health care they provide their children as the primary carers. Furthermore, mothers’ active involvement is crucial in influencing their children’s oral health behaviours, which has long-term benefits. In the current study, pregnant women, who make up a significant fraction of the sample, were found to have overall inadequate oral health awareness, indicating that there is a need to improve their understanding. According to a recent study, pregnant women have very little awareness about dental health. Among the participants only 15.2% were aware about the reason for gum disease was due to poor oral hygiene. It might be because, during their routine check-ups, most of them did not receive advice about the significance of dental health during pregnancy from an oral health team or a gynaecologist. The majority of the study subjects (53.2%) exhibited unawareness of other oral hygiene aids, which contrasts with findings from a study by George et al., ²⁹ where it was reported that 83% of respondents used other oral hygiene aids. This study indicates a knowledge gap among participants on the association between impaired oral health and unfavourable pregnancy outcomes, as well as the interconnected connection between pregnancy and oral health. This result is consistent with studies by Avula et al., ²⁵ and Gupta et al. ³⁰ Therefore, intensified education efforts are essential to enhance knowledge and alleviate suffering in this regard.

In a study conducted on the Indian population, parents’ attitudes toward child dental health were reported to be unfavourable, accompanied by poor dental awareness and knowledge. ³⁰ Notably, participants who underwent Motivational Interviewing demonstrated enhanced knowledge across a broader spectrum of knowledge items compared to those who received oral health education through WhatsApp messages. This can be due to WhatsApp is flooded with random messages from relatives/friends and people have a common tendency to ignore lengthy messages. Mothers are usually conceived of as the caretakers for their children’s oral health, and the oral health outcomes of early childhood are influenced by their knowledge, beliefs, attitudes, and behaviour related to oral health.

Oral health education strategies targeting the enhancement of parental oral health knowledge have demonstrated effectiveness in improving pregnant women’s knowledge, attitudes, and behaviours. However, Motivational Interviewing has been shown to be particularly successful in this regard.

In addition, the results of this study showed certain general trends that are noteworthy even though they are not statistically significant. The first was a general lack of knowledge, attitude, and practice about oral health issues for children, including the ideal times to introduce a child to the dentist, start brushing their teeth, and bottle feed them at night.

The data showed that just 17.7% of the participating women had seen a dentist during the previous six to twelve months, with dental pain or issues pertaining to the teeth, gums, or mouth being their primary reason of consultation. None of the participants sought dental care for routine check-ups, and the majority (30.4%) never went to the dentist. This pattern is consistent with research conducted in the United States, which found that even in circumstances in which oral health issues were present, fewer than fifty per cent of pregnant women visited a dentist. ³¹ The literature has identified several reasons why pregnant women may choose not to seek dental care, which includes lack of time, unsatisfactory dental care, negative attitudes towards dental care providers, negative relationships with spouses, and perceptions of dental experiences. ³²

31.6% of participants in the current study exhibited poor oral hygiene, compared to the 55.7% who showed fair oral hygiene. In a study by Gupta et al., ³³ comparable outcomes have been observed. All participants had their Oral Hygiene Index-Simplified evaluated, and the results showed that 15.3% had good oral hygiene, 40.7% had fair oral hygiene, and 44.0% had poor oral hygiene.

A different study conducted in Belgaum, India, by Kashetty et al. ³⁴ discovered that the pregnant group had a significantly higher mean OHI-S status (2.68). The current study found that prior to the intervention, a greater percentage of pregnant women (55.7%) had poor oral hygiene. This indicates a considerable level of oral hygiene neglect. Pregnancy-related gingivitis may also intensify discomfort while brushing and regular dental care, which could accelerate the build-up of debris and calculus. ³⁵ Oral hygiene status of the participants improved after the intervention. 46.8% of the participants showed fair debris score after the intervention. Calculus score didn’t show much improvement after the intervention since the time of the study was only one month. This time is not enough for change in calculus score. 55.7% of the participants had fair oral hygiene score after the intervention.

Before the intervention, a higher proportion of pregnant women experienced a moderate form of gingivitis, and 31.6% of the participants had severe gingivitis. After the intervention, the percentage of participants with severe gingivitis decreased, with only 12.5% in Group 1 and 8.9% in Group 2 exhibiting severe gingivitis.

In a study conducted by Kashetty et al. ³⁴ in Belgaum city, Karnataka, a higher proportion of pregnant women (66.6%) suffered from severe gingivitis. The presence of pregnancy gingivitis might contribute to increased difficulty in brushing and regular dental care, potentially accelerating the deposition of local irritants like debris and calculus. ³⁶ The intervention in your study appears to have contributed to a reduction in the severity of gingivitis among the participants.

Considering this was the first study of its kind in the Indian population to evaluate women’s level of understanding regarding oral health as well as their attitudes and behaviours concerning dental health, the study’s strength is its novelty.

The study also investigates the impact of two distinct oral health education methods (Motivational Interviewing and Cross-platform messaging using WhatsApp) on women’s knowledge acquisition and improvement in oral health and hygiene.

However, the study has limitations. It relies on self-reported data, introducing potential biases inherent in this method, such as misclassification of the questions being asked. Additionally, most women completed the face-to-face questionnaire within a short time frame (5 to 10 minutes), and questions pertained to the last year, posing a risk of recall bias. Chance of social desirability bias was present since the method of data collection was face to face interview, it might cause might result in under reporting also. Study duration was too less to assess the change in Calculus index score and OHI-S score. There is a common tendency to ignore lengthy WhatsApp messages, so it might have affected the knowledge score after intervention. The study acknowledges certain limitations, particularly in terms of the sample size. It suggests that a longitudinal study involving a larger number of participants would be desirable to provide more robust and comprehensive findings.