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  1. J BaghCollege Dentistry Vol. 30(1), March2018The ImpactofPedodontics, Orthodontics and Preventive Dentistry76The Impact of Mother-Infant Bonding on Periodontal Health Status in the Postpartum PeriodRula Nabeel Issa, B.D.S. (1)Ban Sahib DiabB.D.S, M.Sc., Ph.D. (2)ABSTRACTBackground:Mother-infant bonding is an important psychological step postpartum and disturbed relationship may carrydramatic consequences as a psychological disorder which may affect the periodontal health of the mother. The aim of the present study was to assess theeffect of the postpartum Mother-infant bonding on their periodontal condition.Materials and Methods:Mothers in the postpartum period with age range 20-35 years were subjected to postpartum Bonding Questionnaire (PBQ). Periodontal health status was assessed by measuring probing pocket depth and clinical attachment level.Results:The mean valuesof both probing pocket depth (PPD) and clinical attachment loss (CAL) were higher among disordered mothers than mothers with normal bonding relationship. The mean percentage of PPD according to different thresholds of severity and CAL (1-2 mm) was higher among thedisordered mothers.Conclusion:Mother-infant bonding disorder could influence the periodontal health status of the mother.Key words:Mother-infant bonding, periodontal health, postpartum.(J Bagh Coll Dentistry 2018; 30(1): 76-79)INTRODUCTIONIn the postpartum period, the initiation and progression of the connection between the mother and her infant is an important psychological step that presented as a challenge to the mother. Bonding is the term usually used to describe this relationship (1).The negative response of the mother toward the infant’s stimuli is called ‘Maternal bonding disorder(2).There are many manifestations of bonding disorder: delay, ambivalence or loss in maternal response, threatened or established rejection, pathological anger, and infant abuse (3).The attachment theory that was constructed by Bowlby (4)proposed that the person requires or needs to form an affectionate connection with a caregiver (mainly the mother) from the unborn phase and as getting older and this emotional requisite is beyond the feeding needs. As a child, these psychological actions are wanted to create comforting, protecting, warm, and loving feelings. Some factors have the potential to create barrier that affect the bonding process which include a lack of support, the riskiness of the pregnancy, maternal fatigue, and lack of confidence in parenting abilities (5), other factors that influence negatively or positively the bonding relationship include:pattern of infant feeding(6), depression (7), separation of the premature infant from the mother after birth (8,9), and others.The quality of the maternal-newborn relationship can have a significant impact on the mother’s mental health and newborn’s well-being, development, and adaptation throughout life(10).(1) M.Sc. Student, Department of Pedodontics and Preventive Dentistry,University of Baghdad, Baghdad-Iraq(2) Professor. Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad.Several questionnaires have been produced to evaluate the bonding status, even thoughthe postpartum bonding questionnaire (PBQ)which is introduced by Brockington et al. had been largely studied regarding the validity and reliability which waseasy to be applied (11,12).Periodontal disease is a term used to describe spectrum of diseases that are caused by infection and inflammatory response which affect the gingivaand the supporting bone and it is one of the two major oral diseases that affect human populations across the world with high progression rate(13,14).Many studies had attempted to evaluate the relationship between psychosocial factors and periodontal disease development (15).Stress, depression, ineffective coping, and anxiety negatively affect the periodontal health (16).On the other hand, increase the psychological perception of social environment as not stressful is associated with positive oral health attitudes and accordingly good periodontal health(17).MATERIALS AND METHODSThe selected sample composed of 100 mothers aged 20-35 years. The participants were informed about the aim of the study and were freely allowed to accept the examination. Informed consent and ethical approval had been obtained. The participantswere selected and examined in health centers of Baghdad city (Karkh Sector). Exclusion criteria involved mothers who were on contraceptive pills or other medications, pregnancy, smoking, and systemic diseases.The Postpartum Bonding Questionnaire (PBQ) was used to estimate the mother-infant bonding relationship status. The PBQ has twenty-fivestatements, each followed by 6 alternative replies
  2. J BaghCollege Dentistry Vol. 30(1), March2018The ImpactofPedodontics, Orthodontics and Preventive Dentistry77which are:always, very often, quite often, sometimes, rarely, and never.Positive replies such as ‘‘I enjoy playing with my baby’’, are scored from 0(always) to 5 (never). Negative replies such as ‘‘I am afraid of my baby’’, are scored from 5 (always) to 0(never). A high score signals pathological condition. The questionnaire has four factors: general factor, rejection andpathological anger, anxiety about the infant, and incipient abuse (18).In thisstudy, a total score of 19 attainedthe maximum split between motherswith normal mother-infant relationship andthose with some typeof disorder, the total scores of all items of the questionnaire has a maximum of 125 but in this sample the range was 0-51, with a median of 18.The questionnaire was translated to Arabic language and conformation of translation was obtained and prepared to be used in Iraq. The mothers who attendedthe health centers were asked to complete all componentsof the Postpartum Bonding Questionnaire by themselves without assistance or discussing the answers with others.Oral examinations were done under standardized conditions according to the basic methods of oral health surveys of World Health Organization (19).The pocket depth was measured using calibrated periodontal probes (William’s probes) at four surfaces of all examined teeth except the third molars. The sites for measurements were mid-buccal, mid-palatal, mesiobuccal and distobuccal lines. A scale was used for ease of estimation(20):Score 0 1-3 mm Score 1 4-5 mm Score 2 6 mm and greater The attachmentloss was measured by using the periodontal probe at four sites for all examined teeth except third molarby:1.Measuring the distance from the free gingival margin to the cemento-enamel junction.2.Measuring the distance from free gingival margin to the bottom of the sulcus or pocket at each site. The interproximal recording should be secured at the buccal aspect of the interproximal contact.3.The attachment loss was obtained from subtracting the first measurement from the second one.4.Recession was recorded as a negative value that means the attachment loss was obtained from adding the first measurement to the second one.Clinical attachment loss readings were divided into 3 scores(21,22):Score 11-2 mmScore 23-4 mmScore 35mm and greaterRESULTSThe participants of the study were composed of 53 mother with normal mother-infant bonding status and 47 mothers with disorder in mother-infant bonding status. The data of the current study revealed a statistically significant difference in mean values of probing pocket depth (PPD) among disordered and normal mothers concerning bonding status with higher mean value among the disordered motheras shown intable 1.Extent (mean percentage of sites) of periodontal pocket depth according to different thresholds of severity among disordered and normal mothers is illustrated in table 2. The mean percentage of both PPD score 1 and PPD score 2 thresholds was found to be higher among disordered mothers than normal mothers in spite of non-significant difference in the mean value of score 2 between the two groups.Results concerning clinical attachment level (CAL) demonstrates that the difference in the mean value wasn’t significant, however the mean of CAL thresholds was higher among the disordered mothers.The extent of clinical attachment level (mean percentage) with different thresholds of severity among disordered mothers and normal mothers is seen in table 4. CAL with score 1 has a higher mean percentage among disordered mothers with significant difference statistically. Results exhibitedthat the mean percentage of CAL score 2 was lower among disordered mother, even though the difference wasn’t significant statistically.Table 1: Probing pocket depth (mean) among disordered and normal mothers.Mother-infantbonding statusMean±SETP-valueDisorder3.630.244.200.00Normal1.980.30Table 2: Extent (mean percentage) of periodontal pocket depth with different thresholds of severity in relation to mother-infant bonding status.PPDScoresMother-infantbonding statusMean±SETP-valuePPDscore 1(4-5)Disorder4.630.545.820.00Normal1.190.23PPDscore 2(≥6)Disorder0.280.160.660.51Normal.170.07
  3. J BaghCollege Dentistry Vol. 30(1), March2018The ImpactofPedodontics, Orthodontics and Preventive Dentistry78Table 3: Clinical attachment level (mean) in relation to mother-infant bonding status.Mother-infantbonding statusMean±SETP-valueDisorder0.870.070.540.58Normal0.780.14Table 4: The extent of clinical attachment level(mean percentage) with different thresholds of severity in relation to mother-infant bonding statusCALScoresMother-infantbonding statusMean±SETP-valueCAL1(1-2)Disorder4.140.463.800.00Normal1.890.36CAL2(3-4)Disorder0.000.001.760.08Normal0.100.05DISCUSSIONSince there areno previousavailable Iraqi studies concerning the relationship between mother-infant bonding and periodontal health status, this study was conducted to investigate the impact of maternal bonding on periodontal health.Advanced periodontal disease is a persistent bacterial infection causing chronic inflammation in periodontal tissues which is characterized by formation of pathological periodontal pockets concomitantly with destruction of periodontal ligament fibers attaching teeth to the alveolar bone(23).Psychological status has an influence on periodontal health condition and the attachment pattern that affectsperiodontal disease (24).This also could be seen in the present study as the resultsreported a higher mean value of probing pocket depth and clinical attachment loss scores among disordered mothers.The reasonsbehind the effect of psychological factors on periodontal health might be attributed to: 1) behavioral factors which may aggravate certain lifestyle that are known to increase the likelihood of periodontal disease (e.g., neglect of oral hygiene, and changes in diet), 2) direct pathophysiologic effects on host defense (25).Other explanation may be attributed to the level of Oxytocin hormone which has a potential role in the onset of maternal behavior(mother-infant bonding)(26).Oxytocin hormone inducement in response to infant’s stimuli decreases the stress reaction(27), cortisol level, and anxiety(28), meanwhilestress in turn has detrimental sequels on the health of oral tissues (29).In addition, Oxytocin hormone contributes generally to wound healing process(30), as it reduces the release of Interleukin-6 which is involved in the inflammatory process(31).On conclusion, the maternal bonding disorder influences the periodontal health status of the mother, so recognition and identification of the bonding status would allow psychological intervention to improve the oralhealth of the mother. However,further studies are needed to determine the effect of biomarkers in relation to bonding status of the mother to investigate the exact impact of the bonding disorder on the oral health status.REFERENCES1.Brockington I. Postpartum psychiatric disorders. Lancet 2004;363: 303–10.2.Kumar RC.Anybody’s child: Severe disorders of mother-to-infant bonding. Brit J Psychiat1997; 171:175–81.3.Brockington IF, Oates J, George S, TurnerD, Vostanis P, Sullivan M, et al.A screening questionnaire for mother-infant bonding disorders. Arch Women's Ment Health2001; 3:133–40.4.Bowlby J. Attachment.2nded. New York: Basic Books,2008.5.Ross E. Maternal-fetal attachment and engagement with antenatal advice. Brit J Midwifery2012; 20(8):566-75.6.Kim P, Feldman R, Mayes LC, Eicher V, Thompson N, Leckman JF, Swain JE. Breastfeeding, brain activation to own infant cry, and maternal sensitivity. J Child Psychol Psychiatry2011; 52(8):907-15.7.O’Higgins M, Roberts IS, Glover V, Taylor A. Mother-child bonding at 1 year; associations with symptoms of postnatal depression and bonding in the first few weeks. Arch Women's Ment Health2013; 16(5): 381-9.8.Fegran L, Helseth S, Fagermoen M. A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. J Clin Nursing2008; 17(6):810-6.9.HenryS,Richard-YrisM,TordjmanS, Hausberger M. Neonatal handling affects durably bonding and social development. PlosONE2009; 4(4):1-9.10.Johnson K. Maternal infant bonding: A review of literature. Int J Childbirth Educ2013; 28(3):17-22.11.Garcia-Esteve L, Torres A, Lasheras G, Palacios-Hernández B, Farré-Sender B, Subirà S, ValdésIan M, Brockington IF. Assessment of psychometric properties of the postpartum bonding questionnaire (PBQ) in spanish mothers.Arch Women's Ment Health2016; 19(2): 385–94.12.Ohashi Y, Kitamura T, Sakanashi K, Tanaka T. Postpartum bonding disorder: factor structure, validity, reliability and a model comparison of the postnatal bonding questionnaire in Japanese mothers of infants. Healthcare2016; 4:50.13.Petersen PE.The World Oral Health Report: Continuous improvement of oral health in the 21stcentury.The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol2003; 31(1):3-24.14.Centers for disease control and prevention. Periodontal Disease,2015.15.Peruzzo DC, Benatti BB, Ambrosano GMB, Nogueira-Filho GR, Sallum EA, Casati MZ, et al.A systematic review of stress and psychological factors
  4. J BaghCollege Dentistry Vol. 30(1), March2018The ImpactofPedodontics, Orthodontics and Preventive Dentistry79as possible risk factors for periodontal disease. J Periodontol2007; 78:1491-504.16.Cayci E, Guzeldemir-Akcakanat E. Therelationship between psychosocial factors and periodontal disease. Dentistry2014; 4:223.17.Reddy KS, Doshi D, Kulkarni S, Reddy BS, Reddy MP. Correlation of sense of coherence with oral health behaviors, socioeconomic status, and periodontal status. J Indian Soc Periodontol2016; 20(4):453-9.18.Brockington IF, Fraser C, Wilson D. The Postpartum Bonding Questionnaire: a validation. Arch Women’s`Ment Health2006; 9: 233–42.19.World Health Organization. Oral health surveys basic methods. 4thed. Geneva, Switzerland, 1997.20.Omer BR. Correlation between salivary Visfatin and creatine kinase levels with periodontal health status of patients with coronary atherosclerosis and chronic periodontitis. Master Thesis, College of Dentistry,University of Baghdad,2015.21.American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol2000; 71(5): 847-8.22.Caranza FA. Clinical periodontology 11thed.Philadelphia. WB Saunder Company, 2012.23.Pussinen PJ, Alfthan G, Rissanen H, Reunanen A, Asikainen S, KnektP. Antibodies to periodontal pathogens and stroke risk. Stroke2004; 35: 2020–3.24.Graetz C, Ehrenthal JC, Senf D, Semar K, Herzog W, Dörfer CE. Influence of psychological attachment patterns on periodontal disease -a pilot study with 310 compliant patients. J Clin Periodontol2013; 40(12):1087-94.25.Dumitrescu AL. Psychological perspectives on the pathogenesis of periodontal disease. Rom J Intern Med2006; 44(3):241-60.26.Bick J, Dozier M. Mothers'and children's concentrations of oxytocin following close, physical interactions with biological and non-biological children. Developm Psychobiol2010; 52 (1):100–7.27.Seltzer LJ, Ziegler TE, Pollak SD. Social vocalizations can release oxytocin in humans. Pollak Proc Biol2010; 277(1694):2661-6.28.Handlin L, Jonas W, Petersson M, Ejdebäck M, Ransjö-Arvidson AB, Nissen E, et al. Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period. Breastfeed Med2009;4: 207-20.29.Abdul-Ameer AK. Stressful life events in relation to oral health condition and selected salivary constituents among 17-18 years old secondary school students in Baghdad City/Iraq. Master Thesis,Collage of Dentistry,University of Baghdad,2015.30.Gouin JP, Carter CS, Pournajafi-Nazarloo H, Glaser R, Malarkey WB, Loving TJ, Stowell J, Kiecolt-Glaser JK. Marital behavior, oxytocin, vasopressin, and wound healing. Psychoneuroendocrinology2010; 35(7):1082-90.31.Szeto A, Nation DA, Mendez AJ, Dominguez-Bendala J, Brooks LG, Schneiderman N, McCabe PM. Oxytocin attenuates NADPH-dependent superoxide activity and IL-6 secretion in macrophages and vascular cells. Am J Physiol Endocrinol Metab2008;295(6):1495-501.الخالصةخلفية: رابطة أالم والطفل هي خطوة نفسية مهمةفي فترة مابعد الوالدة وأي تخلخل في هذه العالقة كأضطراب نفسي من الممكن أن تحمل عواقبتؤثر على صحة أنسجة ماحول أالسنان عند أالم. الهدف من الدراسة الحالية هو تقييم تأثير رابطة االم والطفل مابعد الوالدة على صحة أنسجة ماحول االسنان عند أالم.المواد والطرق: أالمهات بنطاق عمر 02الى 53سنة في فترة مابعد الوالدة عرض عليهن أستبيان رابطة مابعد الوالدة. حالة صحة أنسجة ماحول أالسنان قيمت عن طريق قياس عمق جيب اللثة و ومستوى انحسار اللثة.النتائج: قيم معدل عمقجيباللثة ومستوى انحسار اللثة كانت أعلى بين أالمهات ألالتي يعانين من اضطراب في عالقة االم والطفل من أالمهات الالتي يتصفن بعالقة طبيعية. نسبة معدل عمق جيب اللثة بالنسبة الى حدة الحالة و مستوى انحسار اللثة بين 1و 0ملمكانت أعلى بين أالمهات الالتي يعانين من االضطراب.أالستنتاج: أضطراب عالقة االم والطفل من الممكن أن تؤثر على صحة أنسجة ماحول أالسنان عند أالم.الكلمات المفتاحية: رابطة أالم والطفل, صحة أنسجة ماحول أالسنان, بعد الوالدة.
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