RESEARCH PROPOSAL

By

NSANZIMANA Justin

And

KANSIIME Oliver

Submitted in Partial Fulfillment of the Requirements for the Advanced Diploma in

DEPARTMENT OF DENTISTRY

FACULTY OF ALLIED HEALTH SCIENCES

KIGALI HEALTH INSTITUTE

Supervisor: Dr MUMENA Chrispinus

Kigali August 2009

ASSESSMENT OF PERIODONTAL STATUS OF

PREGNANT WOMEN ATTENDING ANTENATAL

CLINIC AT MUHIMA HOSPITAL

Declaration

We do hereby declare that this Research Proposal submitted in partial fulfillment for the

Advanced Diploma, in Department of DENTISTRY, at KIGALI HEALTH INSTITUTE, is

our original work and has not previously been submitted elsewhere. Also, we do declare that

a complete list of references is provided indicating all the sources of information quoted or

cited.

NSANZIMANA Justin KANSIIME Oliver

Signature Signature

August, 2009

DEDICATION

KANSIIME Oliver

I dedicate this piece of work to the Almighty God, Secondly my family, relatives, my boy

friend and Mr. Joseph Kapkha of ILC consultancy as well as Mr. JEAN Baptist of UN.

DEDICATION

NSANZIMANA Justin

I dedicate this piece of work to the Almighty God, my parents and to my brothers as well as sisters and my relatives.

ACKNOWLEDGEMENT

First of all, the researchers would like to express their special appreciation and gratitude to

their Supervisor Dr MUMENA Chrispinus for his immeasurable assistance, and guidance

during the preparation of this research proposal.

Researchers also exceeding grateful to the staff and all lecturers of Dental Department

including Dr Muhumuza Ibra Head of the department for their piece of advices and

contributions where it seems to be tough.

Finally, the researcher would like to extend their sincere appreciation to Orphans of Rwanda

Inc for both material and financial support during this study. Finally, the researcher cannot

forget to thank all KHI administration in granting the permission to carry out this study in the

sphere of their administration

Almighty GOD blesses you all.

SUMMARY OF THE STUDY

Introduction

Periodontal diseases refer to a group of conditions that cause inflammation and destruction

to the supporting structures of the teeth that is gingival, alveolar bone, periodontal ligaments

and cementum. These chronic oral infections are characterized by the presence of a biofilm

matrix that adheres to the periodontal structures and serves as a reservoir for bacteria.

Periodontal diseases affect the majority of the population either as gingivitis or periodontitis.

Many recent studies have reported that maternal periodontal disease may be an independent

contributor to abnormal pregnancy outcomes such as low birth weight, preterm babies, and

risk for preeclampsia, mortality, as well as growth restriction.

Rationale:

The study will provide the baseline data on periodontal status of pregnant women, and this

information is important for planning and execution of oral health care to pregnant women at

all levels .The findings of the study may help to improve the health status of newborn babies.

Objectives

The main objective of the study is to assess the periodontal status of pregnant women

attending antenatal clinic at Muhima Hospital. Furthermore, the study will determine the

level of oral hygiene and assess the utilization of oral health services among pregnant women

attending antenatal clinic at Muhima Hospital. Nevertheless this study will determine the

proportion of pregnant women affected with gingivitis, periodontitis and characterize the

type of periodontal disease as well as determine the association between gingivitis,

periodontitis and the period of pregnancy.

Methodology

A descriptive cross sectional prospective study will be done at the antenatal clinic in Muhima

hospital over a period of two months. The sample size of 200 subjects will be selected

randomly from the pregnant women. Data collection tools will be a self administered

structured questionnaire followed by clinical examination for the pregnant women.

Conclusion

This project will cost a total of 3.123.500Rfw

Contents

Table of ContentsTABLES OF CONTENTS Page Declaration…………………………………………………………………ii Dedication…………………………………………………………………..iii Acknowledgement……………………………………………………….....iv Summary……………………………………………………………………v Tables of contents…………………………………………………………..vi Abbreviations and acronyms………………………………………………viii List of tables…………………………………………………………………ix List of figures………………………………………………………………..x

CHAPTER 1.INTRODUCTION…………………………………………… 1.1. Definitions of key terms pertinent to the study…………………………. 1.2. Background to the study ………………………………………………… 1.3 Problem statement……………………………………………………….. 1.4. Main objective………………………………………………………….. 1.5. Specific objectives………………………………………………………. 1.6. Study questions/Hypothesis……………………………………………… 1.7. Significance of the study………………………………………………… 1.8. Subdivision of the Project: Mention the main parts of the proposal

CHAPTER 2.LITERATURE REVIEW

CHAPTER 3.METHODOLOGY

CHAPTER 4.PRESENTATION OF THE RESULTS

LIST OF ABBREVIATIONS

Dr: Doctor Mr: Mister WHO: World health organization KHI : Kigali Health Institute LOA: Loss of attachment CEJ: Cemento-enamel junction HIV: Human Immune Virus AIDS: Acquired Immune Deficiency Syndrome UN: United Nation ILC: International limited Company MM: Millimeters LGE: Linear Gingival Erythema CPTIN: Community periodontal Index of Treatment Need %: Percentages

1:0 INTRODUCTION

 1.1 DEFINITIONS OF THE KEY TERMS/CONCEPTS

Antenatal clinics:

These are clinics that take care for the health of pregnant women by and their new born

babies.

Plaque:

This refers to the soft; sticky accumulation that occurs on the teeth and various other intra-

oral surfaces around the tooth .it is the host to a complex micro-system of micro-organisms

whose pathogenicity and virulence cause inflammatory diseases of the gingival and other

periodontal tissues and also can be removed by direct brushing or polishing from tooth

surfaces.

Pocket probing depth;

Refers to the distance from the gingival margin to the base of the pocket. Pocket depth refers

to the abnormal space developing between the tooth and the gum.

Gingiva recession

A condition when edge of the gum moves apically along the root surface of the tooth

resulting in exposure of the roots.

Gingivitis;

This is a superficial inflammation of gum tissue (gingival). The clinical feature of gingivitis

varies as they reflect the type and extend of inflammation present which may be either acute

or chronic.

Any or all of the following signs may be noted:

Discolouration of the gingival tissue from pink to bluish red.

Swelling of the gums and loss of stippling.

Retraction of the gingiva.

Bleeding: this is the most common symptom of the inflammation of the gum tissues.

Calculus;

refers to the calcified deposits on the teeth ;formed by the continuous mineralization of

presence of dental plaque ,and also its surface provides an ideal medium for the further

plaque formation and threatening the health of the gingiva.

Root planning;

This refers to the procedure used to treat periodontal condition by scaling the roots of the

teeth to establish a smooth area and send calculus free from teeth surface and usually requires

local anesthesia to prevent pain during procedure and to avoid trauma to the client.

Gingiva (Gum):

This is a portion of the soft tissue that lines the oral cavity, covering and attaching to the

alveolar bone and cervical regional of the teeth. Normally it is salmon pink, stippled and

generally terminates coronally in a knife-edge relationship with the tooth surface. Apiccaly it

extends to the mucogingival line of the vestibular fornix and floor of the mouth. It is firmly

and well attached to the tooth. That part of the gum which forms a point between the teeth is

called the gingiva papilla.

Collagen fibres:

The major portion of the connective tissue of the free and attached gingiva consists of dense

net working of collagen fibres which interdependently fulfil numerous functions and provide

firmness to the gingiva and to the attachement of the gingiva to the underlying cementum and

alveolar bone.

The collagen fibres go in various directions and intimately blended

They are classified into groups based on their functions, location and insertion.

The periodontal ligament:

These connect the tooth with surrounding alveolar bone and it is consequently situated in the

narrow space normally between 0.1mm to 0.25mm in width and it is visual through

radiograph as radioluscent line surrounds the root. The width depends on the age and the

functioning of the tooth,mobility may occur if the width is increase ligaments are partially

lost

The cementum:

This covers the surface of the root; fibers of the periodontal ligaments are attached to this

layer. The thickness of the cementum at the cemento-enamo junction is about 5mm in the age

group and its deposition continues periodically throughout the life

Alveolar bone;

Alveolar processes are the parts of the maxilla and mandible providing the housing for the

roots of the teeth, they develop in accordance with tooth formation and eruption and they are

subjected to atrophy if the teeth are lost

Periodontitis;

Refers to both inflammation and destruction of the supportive tissues around the teeth

(periodontium)

Periodontium;

refers to periodontal tissues and it includes:gingiva(gums),periodontal ligaments,cementum

and alveolar bone.

The structure below summarises the different parts of the tooth mentioned above and

their location

1:2: Background of the study

Periodontal diseases refer to a group of conditions that cause inflammation and destruction

to the pe r iodon t ium/ supporting structures of the teeth that is gingival, alveolar bone,

periodontal ligaments and cementum. These chronic oral infections are characterized by the

presence of a biofilm matrix that adheres to the periodontal structures and serves as a

reservoir for bacteria. Periodontal diseases affect the majority of the population either as

gingivitis or periodontitis. Recently there have been many studies that link or seek to find a

relationship between periodontal disease and other systemic dis- eases including,

cardiovascular disease, diabetes, stroke, and adverse pregnancy outcomes (compend contin

Educ Dent Suppl 2000)). The disease affects all ages and sexes without ratio or sex

predilection (ref).

Many recent studies have reported that maternal periodontal disease may be an independent

contributor to abnormal pregnancy outcomes including preterm birth, low birth weight,

risk for preeclampsia, mortality, and growth restriction. However, the causality of how

periodontitis influences pregnancy outcomes has not been established.(Bogges et al. 2006,

Lopez et al. 2002, Dosanayake et al. 1996, Offenbacher et al. 2001, Offenbacher et al. 1996)

Preterm birth has been identified as one of the most important perinatal health problems in

both un developed and developing countries (ref). The rate of preterm birth has not changed

despite improvement in health delivery systems in many countries (ref). Preterm birth is the

leading cause of mortality in neonates (ref). There is about 56.2% of infant mortality

reported

1.3 PROBLEM STATEMENT

The association of periodontal diseases in pregnant women with the bad health status of

newborn has been observed and reported worldwide (Bogges et al. 2006, Lopez et al. 2002,

Dosanayake et al. 1996, Offenbacher et al. 2001, Offenbacher et al. 1996). There is available

literature from developed countries that documents the high prevalence of periodontal

diseases in pregnant women (Bogges et al. 2006, Lopez et al. 2002, Dosanayake et al. 1996,

Offenbacher et al. 2001, Offenbacher et al. 1996). This has increased the emphasis of

integrating the oral health care in antenatal clinics so as to prevent the complications of

periodontal diseases in the newborn babies. The periodontal status of pregnant women in

Rwanda remains unknown, whether oral health care should be integrated in antenatal clinics

or not has never been considered. Nevertheless, a high proportion of pregnant women with

dental problems including periodontitis were observed during the period of clinical

placement at Muhima Hospital in 2008.

There is no available literature documenting magnitude of periodontal diseases of pregnant

women in Rwanda.

1.4 STUDY OBJECTIVES

I. MAIN OBJECTIVE

To assess the periodontal status of pregnant women attending antenatal clinic at

Muhima Hospital.

II. SPECIFIC OBJECTIVES

To determine the level of oral hygiene among pregnant women attending

antenatal clinic at Muhima Hospital.

To assess the utilization of oral health services among pregnant women

attending Muhima Hospital.

To determine the proportion of pregnant women affected with gingivitis

To determine the proportion of pregnant women affected with periodontitis

at Muhima Hospital

To characterize the type of periodontal disease affecting the pregnant

women Muhima hospital

To determine the association between gingivitis and the period of

pregnancy

To determine the relationship between periodontitis and the period of

pregnancy

1:5: STUDY QUESTIONS/HYPOTHESIS

I. Alternative hypothesis

There is a high proportion of pregnant women affected with periodontal disease in Rwanda.

II. Null hypothesis of the study

Periodontal disease in pregnant women is not a serious problem in Rwanda

1.6 SIGNIFICANCE/RATIONALE OF A STUDY

This study will provide the baseline information about the periodontal status among pregnant

women attending at Muhima Hospital. This information is important for planning and

execution of oral health care to pregnant women at all levels. The findings of the study may

help the policy makers on how better to improve the health status of newborn babies.

 

CHAP 2. LITERATURE REVIEW:

Clinical presentation of periodontal diseases:

Two major categories of periodontal diseases (Gingivitis and periodontitis) have been

described (American Dental Association 1986 )and more than that within each category

there are specific types of diseases that have been identified. The severity, the predisposing

factors and the clinical presentation of these forms differ widely.

Gingivitis is the earliest form of the disease usually present in a variety of forms depending

the causes and the associated predisposing conditions. Five forms have been documented as

commonly occurring and may all present in pregnant women depending on the accompanied

systemic condition (ref).

Plaque-Associated Gingivitis: This is the commonly and simplest form of the disease

caused by poor oral hygiene, but it can be modified by a number of factors therefore

enhancing speed and severity. Normally this form clinically will appear with bleeding of the

gums on probing without loss attachment.

Necrotizing Ulcerative Gingivitis: This is a special type of periodontal disease also known

as “trench mouth” or “Vincent’s infection”. It may be mild or severe, acute or chronic. It is

seen in people of all ages; young people of 15-30 years seem to develop the disease most

easily. It has been found that when emotional tension increases, the infection gets worse. If

the destruction extends into the soft tissues, then it is called Noma or Cancrum Oris. This

condition has been described mostly in tropical African countries where the disease has been

associated with predisposing systemic diseases such as meascles, small pox, malaria and

secondary anemia. These observations strongly suggest that while the initiating factors are

bacterial in origin, the resultant severity and extent of the disease is markedly affected by the

resistance of the host. Patients diagnosed with Necrotizing Ulcerative Gingivitis may present

with the following clinical findings: Papillary necrosis, bleeding, pain and fetor oris (odor).

No any study reported this in pregnant women.

Hormone-Induced Gingival Inflammation (pregnancy gingivitis or epulis):

This form occurs commonly due to changes in the circulating level of hormones such as

estrogen and progesterone. Such hormonal changes induce gingival hyperplasia, this can

occur at puberty or during pregnancy. Clinically this form present with the following features

gingival redness, bleeding upon probing, edema and gingival enlargement associated with

proliferation of blood vessels.

Drug-Influenced Gingivitis: This is another form of gingivitis but occurs in patients on

systemic medications for treatment of other systemic medical conditions such as epilepsy.

The use of some antibiotics is also associated with such changes. Medications known to

bring gingivitis are such as Dilantin, Cyclosporine or Procardia often present with gingival

overgrowth.

Clinical findings in this form include: Fibrotic gingival response, pseudo pockets and

bleeding upon probing.

Linear Gingival Erythema (LGE):

A form of gingivitis occurring in Patients that have HIV/AIDS. In this form there is a linear

band or fiery red band 2 to 3 mm along the gingival margin, and less plaque. This form of

gingivitis is reported to be associated with candidal infection.

Periodontitis is the progression of gingivitis that has not been adequately treated or not

completely treated. This involves the chronic inflammation and destruction of the supporting

bone and parts of the periodontal membrane. As the fibres of the periodontal membrane are

destroyed and the margin of the gums detaches from the tooth, pockets are formed. Pockets

are spaces between the teeth and the surrounding tissues where formerly the attachment was

situated. From pockets pus sometimes can be discharged. As the pockets get deeper, the teeth

get looser. Teeth frequently become abscessed and eventually can even fall out. The clinical

picture of periodontitis therefore in addition to the above mentioned signs of gingivitis,

include pocketing and loosening of teeth. Several forms of periodontits are well known

depending on the aetiological factors, the age of the affected invidividual and the severity.

Aggressive periodontitis : This is a form of the periodontitis that occurs in the patients who

are clinically healthy and common features include rapid attachment loss ,bone destruction

and facial aggression

Chronic periodontitis: This is a form of the periodontal disease resulting in inflammation

with in the supporting tissues of the teeth, progressive attachment loss and bone loss and also

it is characterized by pocket formation, recession of the gingiva. .It is recognized as the most

frequently occurring form of periodontitis which is prevalent in adults but can occur in any

age.

Necrotizing periodontal diseases: an infection characterized by necrosis of gingival tissues,

periodontal ligaments and alveolar bone. These lesions most commonly observed in

individual with systemic conditions including but not limited to HIV infection, malnutrition

and immunosuppressant

Juvenile periodontitis: A common form with onset in adolescence and puberty and

relatively well defined clinical features.

Adult Periodontitis: This is the most common chronic form of periodontitis. The presence

of local factors such as plaque is usually comparable with the disease progression. Usually it

is the progression of simple plaque induced gingivitis.

Picture of Plaque-Associated adult Periodontitis (slowly progressing periodontitis)

Measurement of periodontal disease:

Pathognomic feature of periodontal disease is the destruction of the collagen fibres of the

periodontal ligaments that may result in a loss of bone support of the tooth. Clinically the

condition is defined as measurable loss of attachement (LOA) in relation to cementoenamel

junction (CEJ). This is associated with the presence of an inflammatory reaction which

clinically is recognized as bleeding, erythema, edema, and occasionally suppuration out of

the marginal periodontal tissues. Other commonly identified signs include periodontal pocket

formation, recession of the gingival margin and eventually radiographic bone loss

Prevalence

Epidemiological studies from many countries document that 5 to 20% of the adult population

suffers from severe forms of periodontal disease (periodontitis), depending on the measure of

disease applied (Pilot and Miyazaki 1991, Hugoson et al. 1998, Brown and Loe 1998). In

developing countries such as Thailand the prevalence and severity has been reported to be

generally high. The above findings were obtained by using the WHO community periodontal

index of treatment needs (CPITN), that demonstrated that periodontitis was found in 1.1,

37.2 and 61.6% of subjects aged 15, 35-44 and 60-74 years respectively. Data for child

bearing age was not available therefore not reported.

Causes of periodontal diseases

For many years, it was believed that specific pathogenic bacteria found within dental

plaque biofilm were solely responsible for periodontal diseases. While it is known that

pathogenic bacteria are one facet of the disease process and are consistently present, it is

not the only cause of periodontitis. The host response to the bacterial insult modulates

the severity of the disease by activating the immune system to mediate the disease

process. How well the host responds to the pathogenic bacteria modulates how the

disease is initiated and progresses. This is evidenced by the fact that gingivitis does not

always progress into periodontitis.

Over the years, several risk factors for periodontitis have been identified. For example, stress,

poor dietary habits with high sugar intake, smoking and tobacco use, obesity, age, and poor

dental hygiene all contribute to the development of periodontal disease. Other major risk

factors include clinching or grinding teeth, genetic factors, other family factors, other medical

diseases such as diabetes, cancer, or AIDS, defective dental restorations medication use, and

conditions that change estrogen levels such as puberty, pregnancy, menopause

(http://www.perio.org/consumer/2a.html, http://www.nidcr.nih.gov/nidcr.nih.gov) Eighty

percent of individuals with periodontal disease have at least one risk factor that increases

their susceptibility to the infectious process and subsequent tissue damage. Often multiple

factors are present (http://www.perio.org/consumer/2a.html,

http://www.nidcr.nih.gov/nidcr.nih.gov).

Periodontal Disease and Other Systemic Conditions

There is convincing evidence that link between oral and systemic health. Current evidence

suggests that periodontal disease is associated with an increased risk for cardiovascular dis-

ease (Spahr et al. 2006, Holmlund et al. 2006), diabetes (Jansson et al. 2006, Al-

Shammari et al. 2006), community and hospital acquired respiratory infections

(Azarpazhooh and Leake 2006), and adverse pregnancy outcomes (Beck et al. 2005, Bogges

et al. 2006, Lopez et al. 2002). Individuals with periodontal disease have approximately a 1.5 –

1.9 increased odds for developing cardiovascular disease (Spahr et al. 2006, Dosanayake et al.

2003). There appears to be a bidirectional relationship between periodontal disease and

diabetes with a 2- to 3-fold increased risk for diabetes among individuals with tooth loss.

Teeth and periodontium may serve as a reservoir and may contribute to respiratory infections.

Individuals with poor oral hygiene such as dental decay have 2- to 9-fold increase odds for

pneumonia (Azarpazhooh and Leak 2006).

Periodontal disease and preterm birth

Recent research suggests that the presence of maternal periodontitis has been associated

with adverse pregnancy outcomes, such as preterm birth, (Offenbacher et al. 1996,

Offenbacher et al. 2001, Jeffcoat et al. 2001) preeclampsia (Bogges et al. 2003), gestational

diabetes (Xiong et al. 2006), delivery of a small for gestational age infant (Bogges et al.

2006), and fetal loss (Moore et al. 2004). The strength of these associations ranges from

a 2-fold to 7-fold increase in risk. The increased risks suggest that periodontitis may be an

independent risk factor for adverse pregnancy outcomes.

1. The remote sites infection contribution to preterm birth has been supported by a number

of studies (Collin et al. 1994). The non disseminating low level challenge with

porphyromonas gingivalis which an important periodontal pathogen has been found to

elicit significant fetal weight reduction. Immunonization before experimental induction

were reported not to provide protection from a challenge during pregnancy, rather

potentiated the effects. This suppressive effect on the fetal weight was accompanied by a

proportional rise in TNFα and PGE2 (Ann Periodontol. 1998.).

Study by Offenbacher and collegues (1998) to determine relationship of current periodontal

status to current pregnancy outcome revealed that gingival crevicular fluid (GCF)-PGE2

levels were significantly higher in spontaneous preterm birth(SPB) mothers compared with

normal term delivery controls. Furthermore it was revelaed that there were significant inverse

association between birthweight (gestational age) and the GCF-PGE2 for current births

among mothers. This suggests dose response relationship for increasing GCF-PGE2 as a

marker of current periodontal disease activity and decreasing birthweight.

Jeffcoat et al. (2001) through their prospective study revealed that patients with periodontal

status were at increased risk of preterm birth despite the other risk factors such as smocking,

parity, race and marternal age. The risk of preterm birth increases from 3 to 7 fold in patients

with the most severe periodontitis, demonstrating dose relationship as revealed by other

studies.

Offenbacher et al. (1997) observed that mothers with periodontal disease are seven times

more likely to give birth to premature and low weight babies. Jeffcoat et al. (2001) found

similar results and stated that the risk of premature and low weight births increases four- to

sevenfold according to the severity of periodontal disease. Data from Louro et al.(2001)

support the results found so far, demonstrating that mothers with severe periodontal disease

are seven times more likely to have preterm low birth weight. Glesse, Saba-Chujfi(2003)

demonstrated a 12-fold increase in the chances of a woman with severe gingival

inflammation, associated to generalized periodontitis or not, delivering a premature, low

weight baby. Konopka et al. (2003) stated that women with severe/generalized periodontitis

are three times more likely to deliver a premature, low weight baby. According to Mokeem et

al. (2004), the risk of delivering a premature, low weight baby increases fourfold with an

increase of periodontal disease prevalence, regardless of the control of other risk factors such

as age, smoking, and social extraction. Cruz et al.(2005) found a positive association

between periodontal disease and low birth weight especially among the mothers with

schooling of less than or equal to four years. López et al. (2005) underlie such association,

their data showing that periodontal disease increases the chances of delivering premature,

low weight babies fourfold. Romero and collogues (2002) have documented the risk of

preterm delivery and low birth in pregnant women with current periodontal disease in their

study to establish relationship between periodontal disease in pregnant women and the

condition of their newborns.

Periodontal disease status during pregnancy:

It is well accepted that periodontal tissues can be affected by pregnancy. Pregnancy related

changes are the most frequent and marked in the superficial part of periodontal tissues which

is the gingival. Pregnancy does not cause gingivitis but may aggravate preexisting disease.

The most marked changes are seen in gingival vasculature. Characteristics of pregnancy

gingivitis are that the gingival is dark red, swollen, smooth and bleeds easily (Laine 2002).

Women with pregnancy gingivitis may sometimes develop localized gingival enlargements

known as gingival epulis.

During pregnancy gingival inflammation increases significantly from the first trimester (Loe

and Silness 1963, Cohen et al. 1969) with a maximum increases in the second trimester

(Samant et al. 1976) and a decrease at the end of third trimester (Loe and Silness 1963,

Cohen et al. 1969). Periodontal disease presentation has been shown to be significantly in a

group of pregnant women compared to with non pregnant controls, despite the fact that the

oral hygiene of the 2 groups was comparable (Miyazaki et al. 1976).

CHAP 3 METHODOLOGY OF THE STUDY

STUDY AREA:

This study will be carried out in antenatal clinic at Muhima hospital for a period of 2 month from

June to August 2009.

The hospital is located in Muhima sector in Nyarugenge District, found in Kigali city in the

peripherals of Kigali few metres from Nyabugogo high way below the Kinamba and Yamaha road.

The hospital was constructed by the PSP and the world Bank  and officially opened on 13 June

2001.This hospital is one among the districts referral  hospitals and it is special for pregnant women

in Kigali city. .

 

STUDY DESIGN;

 

A descriptive cross –sectional prospective study.

 

STUDY POPULATION

 

All pregnant women attending antenatal clinic at Muhima hospital will be eligible for study. Only

pregnant women who fulfill the inclusion criteria will be studied.

 

STUDY SAMPLE

 

The sample size of 200 subjects will be selected randomly from the pregnant women attending the

antenantal clinic at Muhima hospital.

 

INCLUSION CRITERIA:

Pregnant women from first month to eighth month of conception and who does not have pregnancy

hypertension, or any other medical condition that will make her be uncomfortable for clinical

examination. 

 

EXCLUSION CRITERIA:

Pregnant women who are in the last month of pregnancy, with pregnancy hypertension or any other

medical condition that prohibits her to sit for a long time (30 minutes) for clinical examination.

SAMPLING TECHNIQUE:

Random sampling technique will be used to gather the 200 subjects for study.

DATA COLLECTION TOOLS

QUESTIONNAIREs

A self administered structured questionnaire containing close and open ended questions will be used

to collect information on biodata, knowledge on periodontal diseases and oral health behavior.

 Thereafter clinical examination will be performed, in data collection the questionnaire formulation

will be based on the literature review and specific objectives. The questionnaire will be distributed to

participants and there after the researchers will immediately collect them.

The following tools will be used for questionnaire construction:

Pen, pencil, papers, desk top computer and ----

 

CLINICAL EXAMINATION FORM:

Clinical examination form will be used to collect clinical examination findings.

 

CLINICAL EXAMINATION INSTRUMENTS:

 

        Periodontal probe

        Mouth mirror

        Pair of twizzer

        Air blower

        Gauzes

 

LIMITATIONS AND THE PROBLEM OF THE STUDY.

 

Financial position of the participants may be the limiting factor during the study because some of the

pregnant women may not be able to come to the hospital due to insufficient amount of money and it

can lead to the missing of some important information regarding the study.

 

Cultural beliefs of using traditional healers, particularly traditional birth attendants may cause lack of

certain information in pregnant women regarding to this study.

 

An Introvert behavior in some people may cause lack of certain information during data collection

therefore affecting the study.

 

 

DATA ANALYSIS

 

The data will be analyzed by using a statistical package microsoft excel software.

 

 ETHICAL CONSIDERATION

 

Ethical clearance will be sought form the ethical clearance committee. A covering letter

recommending the researcher for the permission to carry out this study will be first obtained from

Kigali Health Institute (KHI) administration and later on it will be presented to the administration of

Muhima Hospital which granted the researcher permission for carrying out the study.

 

 

QUESTIONNAIRE FOR ASSESSMENT OF PERIODONTALDISEASES IN PREGNANT

WOMEN ATTENDING AT ANTENATAL CLINIC AT MUHIMA HOSPITAL

 

1: 0 BIODATA/

1:1 ID

     

 

1:2 AGE:

   

1.3: OCCUPATION (tick the appropriate)

 

I. Employed

II. Business woman

III. Un employed

 

1.4: MARITAL STATUS

 

I. Single

II. Married

III. Divorced

IV. Widower

V. Separated

 

1.5: EDUCATIONAL LEVEL

I. Primary

II. Secondary

III. Institute

IV. None

 

 1.6: REGION

I. Nyarugenge

II. Gasabo

III. Kicukiro

IV. Other ________________________________________

 

 

 

1.7: Period of pregnancy

I. First trimester   (1-3 months)

II. Second trimester  ( 4-6months)

III. Third trimester  (7-9 months)

2.0.Main theme

2:1 Do you clean your teeth? (tick the appropriate)

        1= Yes                

2= No (if no go to question No 2.2)

 

 

2.1:1 What do you use to clean your teeth?  

I. Modern tooth brushing

II. Wooden tooth brush

III. None

IV. If others, mention………………………

 

2.1.2. How many times do you clean your teeth?

I. Once per a day

II. Twice a day,

III. Thrice a day

IV. None

 

 

2.2 Have you ever visited a dentist or any dental practitioner?

                    1= Yes

                     2= No (If no go to question No 2.3)

 

2:2:1 If yes, why did you go to the dentist?

I. Because of dental pain

II. Was referred

III. For dental check up

IV. Others, mention_______________________________________

 

2.2:2 When was your last dental visit?

 

2:3 Do you see or spit blood during and after tooth brushing?

         1= Yes

          2= No

 

2:4 Are your gums swollen in this moment of pregnancy?

          1= Yes

          2= No

2:5 Are your gums painful in thus period of pregnancy?

        1= Yes  

         2= No

2.6. Do you have any bad smell from your mouth?

         1= Yes

        2= No

2.7 Has anyone of your side in the family had gum problems or treated with similar problem?

       1= Yes                                      

        2= No

2:8 Do you smoke?

        1= Yes

         2= No

2:9 Do you take alcohol or have you ever   taken any alcohol in this moment of pregnancy?

         1= Yes

          2= No

 2:10 Do  have any medical condition/illness/diseases like

I. HIV/AIDS

II. Heart problems

III. Diabetes mellitus

IV. Respiratory diseases

V. Epilepsy

VI. Others  mention__________________________________________

 

 2:11 Are you on any medication for any of the problem you ticked above?

                   1= Yes

        2= No 

2:11:1 If yes mention__________________________________________

           

 

                                             

UBUSHAKASHATSI KU BUZIMA BWO MU KANWA KU BADAMU BATWITE BAFITE

HAGATI Y’UKWEZI KUMWE KUGEZA KU MEZI ICYEDA BABARIZWA KU BITARO BYA

MUHIMA.

  1: 0 IRANGAMIMERERE1:1 UMWIRONDORO

       1:2 IMYAKA:

   

1.3: ICYO UKORA (hitamo igisubizo nyakuri) 

I. Ufite akaziII. Umucurizikazi

III. Nta kazi ufite  1.4: IBYEREKERANYE N’URUSHAKO  

I. IngaraguII. Warashatse

III. Watanye n’uwo mwashakanyeIV. UmuphakaziV. Ntimubana

  1.5: AMASHURI WIZE

I. Amashuri abanzaII. Amashuri yisumbuye

III. KaminuzaIV. Ntiwize   1.6: AHO UBARIZWA

I. Nyarugenge II. Gasabo

III. Kicukiro IV. Ahandi     

-1.7: Igihe umaze utwite 

I. Kuva ku mezi (1-3 ) II. Kuva ku mezi  ( 4-6 )

III. Kuva ku mezi  (7-9 )

2.0.Ingingo nyamukuru

2:1 Ese ujya usukura amenyo yawe? (hitamo igisubizo nyakuri)        1= Yego

                   2= Oya (Niba ari oya, jya ku kibazo cya No 2.2)   

2.1:1 Ni iki ukuresha mu gusukura amenyo yawe?   I. Uburoso bw’amenyo

II. Agati cyangwa umutozoIII. Nta na kimweIV. Niba hari ikindi, kivuge………………………

  2.1.2. Ese ni kangahe usukura amenyo yawe nibura ku munsi?

I. Rimwe ku munsiII. Kabiri ku munsi

III. Gatatu ku munsi cyangwa birenzehoIV. Nta na rimwe

   

2.2 Ese hari ubwo waba warigeze kujya kwa muganga w’amenyo cyangwa uwita ku menyo?                                          1= Yego                      2= Oya (Niba ari oya, jya ku kibazo cya No 2.3)  2:2:1 Niba ari yego, ni iyihe mpamvu yatumye ujyayo?

I. Kubera ububabare bw’amenyoII. Bamunyoherejeho

III. Kwisuzumisha amenyo IV. Ibindi, bivuge_______________________________________  2.2:2 Ese ni ryari uheruka kwisuzumisha amenyo?   2:3 Ese ujya ubona cyangwa ugacira amaraso igihe usukura mu kanwa?

         1= Yego

         2= Oya 

2:4 Ese ishinya yawe yaba ifite ikibazo cyo kubyimba muri iki gihe utwite?          1= Yego         2= Oya

 

2:5 Ese ishinya yawe yaba ikubaba muri iki gihe utwite?         1= Yego        2= Oya                                        

  2.6. Ese hari ubwo waba ugira ikibazo cy’impumuro idasanzwe mu kanwa muri iki gihe utwite?

        1= Yego        2= Oya

  2.7 Ese haba hari undi muntu wo mu muryango wanyu waba waragize ikibazo cy’ishinya cyangwa wivujije ikibazo nk’icyo?

       1= Yego                                              2= Oya

    2:8 Ese waba unywa itabi muri iki gihe utwite?

        1= Yego        2= Oya

  2:9 Ese waba unywa inzoga cyangwa warayinyweye muri iki gihe utwite?

         1= Yego         2= Oya

   2:10 Ese haba hari bumwe muri ubu burwayi waba ufite?

I. HIV/ SIDAII. Indwara z’umutima

III. Indwara ziterwa n’isukaliIV. Indwara z’ubuhumekero V. Igicuri

VI. Izindi, zivuge__________________________________________    2:11 Ese haba hari imiti ya zimwe mu ndwara zavuzwe haruguru ufata?                    1= Yego

       2= Oya

2:11:1 Niba ari yego, yivuge__________________________________________      

NSANZIMANA Justin and

KANSIIME Oliver

Dental department

P.O.Box 3286 Kigali

E-mali:nsanzijust2020@yahoo.fr

kansol2you@yahoo.com

Mobile phone :(+250)0788578553

(+250)0788754519

August, 2009

Administration of MUHIMA Hospital.

RE: Request to carry out a study.

We are NSANZIMANA Justin and KANSIIME Oliver, third year students of Dental department in

Kigali Health Institute.

We would like to conduct a study on ‘Assessment of periodontal status of pregnant women attending

antenatal clinic at Muhima hospital:

We humbly wish to request the authorization to carry out this research among MUHIMA Hospital as

a part of our sample population.

Your response will be highly appreciated.

Yours faithfully,

NSANZIMANA Justin

And

KANSIIME Olive

4.0 PRESENTATIONS OF RESULTS (DUMMY TABLES)

TABLE 1: Age marital status distribution table.

Age Single Married Widower Separated Divorced Total

No % No % No % No % No % No %

10-15years    

16-20years    

21-25years    

26-30    

31-35    

36-40

41-45

Total

 

 

  TABLE 2: Marital status education distribution table

Education level Single Married Widower Separated Divorced Total

No % No % No % No % No % No %

No education    

Primary

education

   

Secondary

education

   

High learning

institution

   

Total

 

 

TABLE 3: Relationship between Pregnancy period and gingivitis distribution table

Months of pregnancy Bleeding gums

Yes No Total

No % No % No. %

0-3 months    

4-6 months    

7-8 months    

Total

 

 

TABLE 4. Distribution table showing relationship between Pregnancy period and periodontitis

Months of pregnancy Periodontitis

Yes No Total

No % No % No. %

0-3 months    

4-6 months    

7-8 months    

Total

 

TABLE 5 Distribution table showing tooth brushing tool and the periodontal status.

.

Type of

tooth brush

Periodontal status Total

Periodontitis Gingivitis Health No. %

No. % No. % No. %

Modern

tooth brush

Wooden

tooth brush

Finger

None

Total

TABLE 6:Distribution table showing relationship between frequency of tooth cleaning and

Gingivitis

Months of

pregnancy

Gingivitis Total

Yes No No. %

No % No %

0-3 months    

4-6 months    

7-8 months    

Total

TABLE 7:Distribution table showing relationship between frequency of tooth cleaning and

Periodontitis

Frequency Periodontitis Total

Yes No No. %

No. % No %

Once  per day    

Twice per day    

Thrice per day    

Total

TABLE 8: Distribution table showing oral hygiene status and monthly pregnancy

Monthly

pregnancy

Plaque formation Total

Yes No No. %

No. % No %

0-3 months    

4-6 months    

7-8 months    

Total

TABLE 9:Distribution table showing relationship between periodontitis and other systemic diseases

 

Systemic diseases Periodontitis Total

Yes No No. %

No. % No. %

HIV/AIDS    

Diabetic Mellitus    

Heart diseases    

Respiratory  diseases    

Others    

None

Total

                

TABLE 10:Relationship between gingivitis and other systemic diseases

 

Systemic diseases Gingivitis Total

Yes No No. %

No. % No. %

HIV/AIDS    

Diabetic Mellitus    

Heart diseases    

Respiratory  diseases    

Others    

None

Total

PROFILE OF KIGALI HEALTH INSTITUTE

Kigali Health Institute (KHI) is an institution of higher education established in 1996 by the Ministry

of Health in collaboration with Ministry of Education .The institute was created to solve the

problems of inadequate health personnel both in quality and quantity

VISION OF  KIGALI HEALTH INSTITUTE

“To be center of Excellency in training  and development of human professionals”

MISION OF KIGALI HEALTH INSTITUTE

:To train and improve the  capacity of the health workers”

Kigali Health Institute  has two campuses:

a. The main campus in Kigali city

b. Environmental health sciences at Nyamishaba campus in Karongi District

MANAGEMENT OF KIGALI HEALTH INSTITUTE

The academic team structured as follows:

A.Kigali Health institute composed of faculties and departments

1. Faculty of Allied Health Sciences

       -Department of Dentistry

       -Department of Aneasthesia

       -Department  of Medical Laboratory

       -Department of Physiotherapy

        -Department of Medical Imaging  Sciences

         -Department of Ophthalmology

 

2. Faculty of Nursing sciences

      -Department of  Genaral Nursing

      -Department of Midwifery

      -Department of Mental Health

 

3.. Faculty of Health Development

     -Department of Environmental Health sciences

 

B. ADMINISTRATION  OF THE INSTITUTE

 

Rector :Doctor Major NDUSHABANDI  Desire

 

Vice Rector in charge  of the academic Affairs and Research :          Doctor

 

KABAGABO   Chantal

Vice Rector in charge of Administration and Finance:Mr KAZIGE Eugene

 

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12. Collins JG, Windley HW III, Arnod RR, Offenbacher S. effect of Porphyromonas

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13. Cruz SS, Costa MCN, Gomes Filho IS, Vianna MIP, Santos CT. Maternal periodontal

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17. Glesse S, Saba-Chujfi E. An influência da doença periodontal no trabalho de parto pré-

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25. Konopka T, Rutkowska M, Hirnle L, Kopec W, Karolewska E, Rutkowska M et

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67(10):1103-13.

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I: Obstetric outcome of pre- maturity and growth restriction. Ann Periodontol. 2001;6(1):

164-74.

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National Institute of Dental and Craniofacial Research.

http://www.nidcr.nih.gov/nidcr.nih.gov.

40. Pester, B. J., S. K. Boches, J. L. Galvin, R. E. Ericson, C. N. Lau, V. A. Levanos, A.

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(page 1809_1820)

42. Pilot T, Miyazaki H. Periodontal conditions in Europe. J. Periodontol 1991; 18:353-7

43. Review strength of evidence linking oral conditions and systemic diseases .compend contin

Educ Dent Suppl 2000; (30):12.23 quiz .65(http/ww.mcbi,nlm,gov)

44. Romero BC, Chiquito CS, Elejalde LE, Bemadoni CB. Relationship between periodontal

disease in pregnant women and the nutritional condition of their newboens. J. periodontal

2002; 73(10):1177-83

45. Samant A, Malik CP, Cabra SK, Devi PK. Gingivitis and periodontal disease in

pregnancy. J. Periodontol 1976; 47:415-8

46. Spahr A, Klein E, Khuseyinova N, et al. Periodontal infec- tions and coronary heart

disease: role of periodontal bac- teria and importance of total pathogen burden in the

Coro- nary Event and Periodontal Disease (CORODONT) study. Arch Intern Med.

2006;166(5):554-9.

47. Xiong X, Buekens P, Vastardis S, Pridjian G. Periodontal dis- ease and gestational

diabetes mellitus. Am J Obstet Gynecol. 2006;195(4):1086-9

48. Ann Periodontol. 1998 Jul;3(1):40-50.

APPENDIX I

WORK PLAN

TASK TO BE

PERFORMED

PLANNED

PERIOD

PERSONNEL

ASSIGNED TO

TASK

PERSON-DAYS

REQUIRED

1.Reseach proposal

preparation

7 weeks

01/06-09/07/2010

Researchers (2) 2 persons x35days

=70

2.Finalising the

research proposal and

its submission

8-9weeks

12/07-23/07/2010

Researchers(2)

Supervisor (1)

3personsx10days

=30

3.Ethical clearance and

permission to carry out

the study

10-11weeks

26/07-06/08/2010

Researchers (2) 2persons x10 days

=20

4.Contacting the

administration of

Muhima Hospital and

community contact to

orient to the project

12-13weeks

09/08-20/08/2010

Researchers (2)

Supervisor (1)

3persons x 10 days

=30

5.Data collection 14-17weeks

23/08-10/09/2010

Researchers (2) 2persons x 10 days

=20

6.Data coding, and

entry into computer

18 week

13-17/09/2010

Researchers (2) 2persons x 5 days

=10

7.Data analysis 19week

20-24/09/2010

Researchers (2)

Statistician (1)

3persons x 5 days

=15

8.Report writing(first

draft)

20week

27/09-01/10/2010

Researchers (2) 2persons x 5 days

=10

9.Report presentation 21week Researchers (2) 3persons x 5days

04-08/10/2010 Supervisor

=15

10. Report writing(final

draft)

22week

11-15/10/2010

Researchers (2) 2persons x 5 days

=10

11.Submission of final

report

23week

18-22/10/2010

Researchers (2) 2persons x 5 days

=10

12.Feedback to the

Director of Muhima

hospital

24week

25-29/10/2010

Researchers (2) 2persons x5 days

=10

Appendix II

GANTT CHART

TASKS TO

BE

PERFORMED

Year 2010

June July August September October

1. Research

proposal

preparation

XXXX

*** **

X

2. Finalizing

the research

proposal and

its submission

XX

3. Ethical

clearance and

permission to

carry out the

study

X X

4. Contacting

the

administration

of Muhima

Hospital and

community

contact to

orient to the

project

XX

5. Data

collection

X

** ***X

6. Data coding,

and entry into

computer

X

7. Data

analysis

X

8. Report

writing(first

draft)

**** *

9. Report

presentation

X

10. Report

writing(final

draft)

X

11. Submission

of final report X

12. Feedback

to the Director

of Muhima

hospital

X

Key items :

X : 1week=5days

*: 1day

Appendix III

PROJECT ORGANISATION

The fallowing persons have been involved in different tasks in the project organization.

RESEARCHER: Perceived the idea of doing the study, and carry out all activities of the

project

SUPERVISOR: Will assist the academic quality of project and give orientation to it

STATISTICIAN: Organization of statistical soft ware, put information on a spread sheet and

data analysis

LECTURER: Lecturer who has most knowledge and information about the topic will be

always consulted

KHI: Will provide an introductory letter for the researcher to MUHIMA Hospital, requesting

for permission to carry out the study and also funds for the study

APPENDIX IV

BUDGET FOR THE PROJECT

.

1.Preparation of the research proposal

No Items Number

of persons

Number

of days

Number

of

persons-

days

Unit

price(Rwf)

Total(Rwf)

1. Research

proposal

preparation

2 35 70 5000 350.000

2. Finalizing the

research

proposal and

its submission

3 15 30 5000 150.000

3. Ethical

clearance and

permission to

carry out the

study

2 10 20 5000 100.000

4. Contacting the

administration

of Muhima

Hospital, the

community to

orient

members to

the project

3 10 30 5000 150.000

Sub-total 1 800.000

2. Research activities

Activities Number

of

persons

Number

of days

Number of

persons/days

Unit

price(Rwf)

Total(Rwf)

1. Contacting the

administration of Muhima

Hospital, the community

to orient members to the

project

3 10 3x10=30 2000 60.000

2.Data collection 2 15 2x15=30 2000 60.000

3.Transport 3 130 3x130=390 1500 585.000

4.Restauration 3 130 3x130=390 1500 585.000

Sub-total 1.290.000

3. Statitionay and materials

No Items Quantity of

items

Unit price(Rwf Total(Rwf

1. Flash disk 1 15000 15000

2. Ream of papers 2 3000 6000

3. Pencils 1 dozen 2500 2500

4. Pens 1 dozen 1500 1500

5. Folder 2 3000 6000

6. Printing 410 copies 100 41000

7. Mineral water 50 bottles 300 15000

8. Dental mirrors 215 500 107500

9. Periodontal

probes

215 500 107500

10. Gloves for

examination

3 boxes 3000 9000

11. Gauzes 1box 3500 3500

12. Trays 215 2000 450000

13. Antiseptic

solution(alcohol)

2 tubes 4000 8000

Sub-total 764.500

4. Production of the report

No Items Quantity

of items

Number of

days

Number of

persons-

days

Unit

price(Rwf)

Total

(Rwf)

1. Crosscheck

and

verification

of data

1 3 3 8000 24000

2. Entering

data into

computer

2 5 10 3000 30.000

3. Data

analysis

3 3 9 5000 45.000

4. Report

writing(firs

t draft)

2 5 10 1500 15000

Sub-total 114.000

5. Report presentation/Validation

No Items Quantity

of items

Number of

days

Number of

persons-

days

Unit

price(Rwf)

Total

(Rwf)

1. Projector 1 1 - 70.000 70.000

2. Computer 1 1 - 50.000 50.000

3. Feedback

to the

Direction

of

Muhima

Hospital

3 1 3 5000 15.000

4. Room for

rent

1 1 - 20.000 20.000

Sub-total 155.000

6. BUDGET SUMMARY

No DESCRIPTION TOTAL

1. Preparation for research

proposal

800.000

2. Research activities 1.290.000

3. Stationary and materials 764.500

4. Production of the report 114.000

5. Report

presentation/Validation

155.000

GENERAL TOTAL 3.123.500

BUDGET JUSTIFICATION

The budget of the study is 3.123.500 Rfw which will be sufficient amount for finishing the all

activities planned during the study from the preparation of the research proposal up to the

report presentation/Validation

The financial support to accomplish the research will be KHI and other sponsors who will be

interested by the Project.

CURCULUM VITAE OF THE APPLICANT

No.1

I. IDENTIFICATION

Fist name: NSANZIMANA

Surname: Justin

Father’s name: GWIZA Faustin

Mother’s name: NYIRABAMBARI Aurélie

Marital status: Single

Current address: Kigali Health Institute

Cell: Cyabusheshe

Sector: Gitoki

District: Gatsibo

Province: Eastern

Country: Rwanda

Nationality: Rwandese

Mobile phone :( +250)0788578553

E-mail:nsanzijust2020@yahoo.fr

II.SCHOOL ATTENDED

Name Level Year

Cyanika Primary school 1993-1999

Ndera Minor Seminary O-Level 1999-2002

Rwankuba Secondary School A-Level 2003-2005

(With the Option of BIO-CHEMISTRY)

Kigali Health Institute Institution 2007-2009

Other educational profile

Knowledge of Computer Microsoft word, Microsoft Excel,

Microsoft Power Point, Internet.

III. LANGUAGES

KINYARWANDA: Excellent

ENGLISH: Good

FRENCH: Good

KANSIIME OLIVER

Mobile phone: (+250)0788754519

Email: kansol2you@yahoo.com

EDUCATION:

KIGALI HEALTH INSTITUTE(KHI) 2007-2010

Candidate for Bachelor of Science in Dentistry Kigali,

Rwanda

FAWE GIRLS’ SCHOOL 2003-

2006

Advanced Level Certificate in Biochemistry Kigali,

Rwanda

OTHER RELEVANT EXPERIENCE:

Muhima Hospital October

2007

Intern Kigali,

Rwanda

Assisted medical staff in care of patients in the department of radiology, volunteer care

treatment of HIV patients and maternity services

Living Positive Organization Nov 2008-January 2009

Intern Nairobi, Kenya

Worked as a nurse distributing medication for HIV patients and assisted with the counseling program.

LEADERSHIP EXPERIENCE

Orphans of Rwanda, Inc. 2007-2009

Group House Leader

Counseled and advised members of the group house on residence life issues.

Served as liaison between students and Orphans of Rwanda’s administration.

Kigali Health Institute May

2008

Participant in Oral Health Promotion Training

Attended week long training on oral health pathology related to trauma and prevention

methods.

Developed and implemented a treatment plan for five hundred primary and secondary school

students

Kigali Health Institute Jan 2007-

Dec 2007

Language Coordinator for EPLM

Coordinated the work of all class leaders and organized all language activities for the entire

campus.

Served as link between class leaders and Kigali Health Institute administration.

Secretary General in Dental student Association(KHIDSU) Present

2009

Awards and Honors

Orphans of Rwanda,Inc

Jan2007-Present

Scholar

Recipient of competitive scholarship that covers full university tuition and provides comprehensive

support services including tutoring, mentoring ,career development and life skills training

SKILLS

Microsoft Word, Microsoft Excel, and Internet-Proficient

LANGUAGES:

Kinyarwanda: Fluent, oral and written; English: Fluent, oral and written, French:

Intermediate, oral and written, Swahili: Basic, oral

REFERENCES:

RWAGATARE Joseph, Former FAWE Director, Tel: 0788517145

RUKESHANSHURO Charles Orphans or Rwanda, Tel: 0788486421

NTAKIRUTIMANA Jean Baptiste Former country Director ORI O788301303