Knowledge, Attitude and Practice regarding the effect of yoga on periodontal health questionnaire

1. Abstract

The Knowledge, Attitude and Practice regarding the effect of yoga on periodontal health questionnaire is a specialized psychometric assessment instrument designed to quantify cognitive, affective, and behavioral dimensions regarding mind-body interventions in oral medicine. Developed at the intersection of periodontology, behavioral medicine, and psychoneuroimmunology, the questionnaire evaluates how individuals understand, evaluate, and adopt yogic practices as adjunctive modalities for preventing and managing periodontal diseases. The scale contains 27 items structured across three distinct domains: Knowledge (cognitive comprehension of physiological links between chronic stress, systemic inflammation, salivary cortisol, and gingival pathology), Attitude (evaluative dispositions, receptivity, and beliefs regarding yoga as a therapeutic health behavior), and Practice (frequency and concrete implementation of asanas, pranayama, and meditation routines). The instrument incorporates a combination of dichotomous and ordinal Likert-type response formats. Psychometric validation conducted among 199 community-dwelling adults in India confirmed robust content validity, demonstrating a Scale-level Content Validity Index based on the average method (S-CVI/Ave) of 0.88. Structural properties of the knowledge subscale were calibrated using a one-parameter logistic (1-PL) Rasch Item Response Theory model, yielding item difficulty parameters ranging from 1.01 to 2.16. Temporal stability over a one-month retest interval demonstrated Intraclass Correlation Coefficients exceeding 0.60. Internal consistency analysis revealed domain-specific divergence characteristic of multidimensional inventories, with the Attitude domain exhibiting high homogeneity (Cronbach’s α = 0.923; Guttman split-half = 0.781), while the Knowledge (α = 0.632; split-half = 0.600) and Practice (α = 0.591) subscales demonstrated acceptable consistency for heterogeneous behavioral and factual inventories, culminating in an overall instrument alpha of 0.632. Total standardized scores classify respondents into low (<33), medium (34–40), or good (>41) KAP profiles, providing clinical and public health researchers with an empirically grounded instrument to support targeted lifestyle and stress-reduction interventions in oral healthcare.

2. Keywords

Periodontal health, Yoga, Complementary and alternative medicine, KAP model, Psychoneuroimmunology, Oral-systemic connection, Periodontitis, Stress management, Behavioral dentistry, Psychometrics, Salivary cortisol, Rasch analysis

3. Authors

The scale was developed and psychometrically validated by an interdisciplinary team of researchers and clinicians specializing in periodontology, public health dentistry, orthodontics, and oral surgery:

• Madhurya N. Kedlaya — Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
• Lakshmi Puzhankara (Corresponding Author) — Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India. Email: [email protected].
• Mansi Mahendra — Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
• Vineetha K. — Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.
• Suraj Prasad Sinha — Consultant Craniofacial Orthodontist, Manipal, Karnataka, India.
• Anupam Singh — Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
• Shaswata Karmakar — Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.

4. Purpose

Periodontal diseases, encompassing gingivitis and periodontitis, are among the most widespread chronic non-communicable inflammatory disorders globally. While microbially initiated by dysbiotic dental biofilm, the clinical destruction of periodontal supporting structures—including the alveolar bone, periodontal ligament, and cementum—is largely driven by host inflammatory immune responses. Extensive psychoneuroimmunological research has demonstrated that psychological stress, depression, and maladaptive coping mechanisms significantly amplify host susceptibility to tissue destruction. Psychosocial stress stimulates the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system, leading to sustained elevations in glucocorticoids (such as salivary cortisol) and pro-inflammatory cytokines (including interleukin-1 beta, interleukin-6, and tumor necrosis factor-alpha). These biological alterations impair microcirculation, compromise host immune defense, alter subgingival microbial ecology, and accelerate periodontal breakdown.

Despite accumulating evidence establishing yoga and allied mind-body practices as potent interventions for down-regulating the HPA axis, diminishing systemic oxidative stress, and attenuating chronic inflammatory cascades, conventional periodontics has predominantly remained focused on mechanical debridement and plaque control. While standardized inventories exist for evaluating conventional oral hygiene behaviors—such as brushing frequency, flossing compliance, and dental attendance—there has been a complete absence of standardized, psychometrically sound measurement instruments capable of assessing how patients perceive, conceptualize, and practice mind-body modalities in direct relation to oral health.

The Knowledge, Attitude and Practice regarding the effect of yoga on periodontal health questionnaire was created to fill this specific clinical and methodological void. The primary purpose of the scale is threefold:

1. Diagnostic Baseline Profiling: To assess baseline community and clinical awareness regarding the systemic and biological mechanisms linking stress reduction, yogic practices, and periodontal health preservation.
2. Intervention Design and Behavioral Tailoring: To enable dental practitioners, health psychologists, and public health educators to identify specific cognitive deficits, skepticism, or practical barriers preventing patients from adopting complementary stress-mitigation strategies.
3. Outcome Evaluation: To serve as a sensitive longitudinal evaluation metric in clinical trials and lifestyle medicine interventions, determining whether psychoeducational and mind-body programs successfully transition patients from theoretical knowledge to active behavioral adherence.

By framing periodontal preservation within the Common Risk Factor Approach (CRFA), this instrument bridges the gap between conventional prophylactic dentistry and holistic, patient-centered behavioral health.

5. Psychological Construct

The questionnaire operationalizes a composite, multidimensional construct centered on the behavioral integration of complementary mind-body therapies within periodontal disease prevention. Rooted in applied cognitive and social psychology, the instrument partitions this construct into three functionally interacting dimensions:

1. Knowledge (Cognitive Domain)

The Knowledge domain quantifies an individual’s factual and conceptual understanding of yoga, physiological stress pathways, and their direct bearings on periodontal pathology. Rather than assessing superficial familiarity with yoga poses, this dimension examines mechanistic health literacy. Specifically, it assesses whether the respondent is aware that:

• Psychological stress elevates systemic inflammation and exacerbates gingival bleeding, attachment loss, and impaired wound healing.
• Sustained stress increases systemic and salivary cortisol levels, which modulate immune function and oral mucosal integrity.
• Yogic practices—encompassing physical postures (asanas), regulated breath control (pranayama), and mindful meditation (dhyana)—enhance cellular antioxidant enzymes (e.g., glutathione) and reduce systemic oxidative stress markers.
• Yoga exerts documented therapeutic benefits across comorbid systemic conditions that share common bidirectional pathways with periodontitis, such as type 2 diabetes mellitus, cardiovascular disease, and hypertension.

Responses within this subscale are evaluated through dichotomous and categorical objective items, discriminating between individuals possessing accurate scientific knowledge and those holding misconceptions or lacking awareness.

2. Attitude (Affective and Evaluative Domain)

The Attitude subscale captures respondents’ emotional resonance, philosophical openness, subjective value attribution, and motivational predisposition toward integrating yoga into preventative healthcare. Drawing upon cognitive appraisal theory, this domain explores whether individuals view yoga as an efficacious, credible, and viable adjunctive therapeutic option or dismiss it as pseudoscience, cultural ritualism, or a superfluous time commitment. Sub-dimensions evaluate:

• Perceived utility and efficacy: The degree to which respondents believe that practicing yoga can actively preserve teeth, arrest gum recession, and decrease oral inflammation.
• Openness to integrative dentistry: Willingness to receive stress-management counseling from dental practitioners alongside traditional scaling and root planing.
• Subjective importance: The priority assigned to mental relaxation and lifestyle modifications within overall personal oral hygiene regimens.

This affective component is measured via standardized Likert-type items designed to quantify subtle variations across the acceptance-rejection continuum.

3. Practice (Behavioral and Action Domain)

The Practice domain assesses tangible behavioral execution, frequency, and real-world compliance. Within health psychology, the transition from possessing knowledge and favorable attitudes to actual behavioral implementation represents the “intention-behavior gap.” This subscale captures:

• The regular execution of specific yogic modalities (e.g., daily or weekly sessions of pranayama, meditation, or asanas).
• The temporal consistency and longevity of practice (e.g., beginner vs. established practitioner exceeding six months of sustained adherence).
• Behavioral adaptation under stress: whether the individual proactively utilizes yogic breathing or relaxation techniques during acute stress episodes known to trigger oral parafunctional habits (e.g., bruxism, clenching) or periodontal flare-ups.
• Contextual barriers and facilitators: documenting whether lack of time, physical limitations, lack of instructional access, or environmental constraints prevent regular execution.

Collectively, these three subscales provide a holistic behavioral profile, identifying whether an individual is constrained by cognitive gaps, affective resistance, or behavioral non-compliance.

6. Theoretical Framework

The design and operationalization of this assessment tool are grounded in established social cognitive and behavioral health theories, primarily the Knowledge, Attitude, and Practice (KAP) model, supported by Albert Bandura’s Social Cognitive Theory and the Health Belief Model (HBM).

The KAP Structural Paradigm

Originating in educational and demographic research during the 1960s and subsequently adapted for public health epidemiology, the KAP model postulates a progressive, cumulative trajectory toward sustained health behavior change. The foundational paradigm asserts that:

Knowledge → Attitude → Practice

Under this linear-rationalist framework, acquiring accurate knowledge (K) acts as the fundamental catalyst. Knowledge alters cognitive schema and dispels misconceptions regarding the pathophysiology of disease and the mechanisms of preventive actions. This intellectual comprehension shapes affective orientation, fostering positive attitudes (A), values, and perceived self-efficacy. A favorable evaluative attitude then generates behavioral intentions which, when sustained over time, solidify into stable, long-term health practices (P).

While classical health psychology acknowledges that the KAP continuum is not strictly linear—recognizing reciprocal causation where habitual practice can reinforce knowledge and reshape attitudes—the triadic structure remains the premier framework for diagnosing where community health interventions fail. If an individual possesses high knowledge but negative attitudes, educational pamphlets will prove ineffective; conversely, if positive attitudes exist alongside zero practice, interventions must target environmental barriers and habit formation.

Integration with Psychoneuroimmunology and the Health Belief Model

The questionnaire integrates KAP principles with the constructs of the Health Belief Model, specifically perceived susceptibility, perceived severity, and perceived benefits. Within the context of chronic periodontitis:

• Perceived Susceptibility and Severity: Patients must understand that systemic stress leaves their periodontal tissues vulnerable to microvascular dysregulation, suppressed polymorphonuclear leukocyte chemotaxis, and increased collagenase activity.
• Perceived Benefits versus Barriers: Patients evaluate whether the physiological benefits of yoga (parasympathetic activation, decreased cortisol, reduced interleukin-6) outweigh perceived barriers, such as time constraints, physical exertion, or skepticism toward non-allopathic modalities.

Furthermore, the scale incorporates Bandura’s concept of outcome expectancy: an individual’s conviction that engaging in yogic stress reduction will produce a measurable biological improvement in oral health (e.g., reduced gingival bleeding, stabilized clinical attachment levels). By mapping these theoretical constructs across its 27 items, the questionnaire serves as a rigorous operational translation of mind-body behavioral theory into dental clinical practice.

7. Validity

Validation of the Knowledge, Attitude and Practice regarding the effect of yoga on periodontal health questionnaire involved multiple methodological stages to establish content, construct, and structural validity.

Content Validity

Content validity was established using a deductive item-generation strategy followed by structured expert panel evaluation. An interdisciplinary panel of content experts—comprising senior academic periodontists, public health dentists, biostatisticians, and certified yoga therapists—evaluated an initial pool of candidate items. Experts systematically evaluated each item for semantic clarity, clinical accuracy, cultural appropriateness, and construct representation using standard four-point relevance ordinal scales.

Quantitative verification was established via the Scale-level Content Validity Index based on the average method (S-CVI/Ave). The scale achieved an S-CVI/Ave of 0.88, comfortably exceeding the widely accepted psychometric threshold of 0.80 established by Polit and Beck (2006). Items exhibiting low item-level content validity (I-CVI < 0.78) or ambiguous phrasing were iteratively revised or eliminated, confirming that the final 27 items adequately represent the intended theoretical domain.

Construct and Structural Validity: Rasch Measurement Model

Rather than relying exclusively on classical test theory (CTT) assumptions of linear additivity, the developers evaluated the structural and construct validity of the Knowledge domain using Item Response Theory (IRT). Specifically, a one-parameter logistic (1-PL) Rasch model was implemented using JMETRIK software, converting raw dichotomous and categorical performance into an interval-level latent trait continuum (θ).

The Rasch analysis demonstrated that the knowledge items exhibited unidimensional structural integrity, measuring a single underlying latent knowledge continuum. The calibrated item difficulty parameters (b) ranged from 1.01 to 2.16. In psychometric terms, this distribution demonstrates that the items avoid floor and ceiling effects. They possess adequate discriminant power across average and moderately high ability levels, ensuring the scale can differentiate between laypersons with minimal comprehension, moderately informed individuals, and highly knowledgeable wellness practitioners.

Face and Criterion Validity Considerations

Face validity was confirmed through cognitive debriefing and pilot testing among community adults, ensuring that item wording was readily understandable without professional dental or yogic jargon. In terms of criterion-related validity, preliminary correlational analyses revealed significant positive associations between total KAP scores, education level, and health-promoting behaviors, corroborating convergent theoretical assumptions regarding socioeconomic status and health literacy.

8. Reliability

The reliability of the questionnaire was evaluated through rigorous assessments of temporal stability (test-retest reliability) and internal consistency across the overall scale and each independent subscale.

Temporal Stability (Test-Retest Reliability)

To assess reproducibility over time, the questionnaire was administered to a subset of participants across a one-month interval. Temporal stability was quantified using the Intraclass Correlation Coefficient (ICC) for continuous/ordinal scores and Cohen’s kappa (κ) for categorical classifications:

• Items within the Attitude and Practice subscales demonstrated ICC values consistently exceeding 0.60, indicating substantial to excellent temporal stability under stable baseline conditions.
• Candidate items that demonstrated poor, slight, or unstable concordance during pilot evaluation (yielding negligible kappa coefficients) were systematically pruned from the final 27-item instrument.

Internal Consistency Metrics

Internal consistency was analyzed using Cronbach’s alpha (α) and Guttman split-half coefficients across the validation cohort (N = 199). The analyses revealed marked, theoretically predictable variations across the three domains:

• Attitude Subscale: Demonstrated exceptional internal consistency, with a Cronbach’s α of 0.923 and a Guttman split-half reliability coefficient of 0.781. This high coefficient reflects the homogeneous, unidimensional nature of the affective construct, wherein belief in the therapeutic efficacy of mind-body medicine operates as a coherent psychological disposition.
• Knowledge Subscale: Yielded a Cronbach’s α of 0.632 and a Guttman split-half coefficient of 0.600.
• Practice Subscale: Produced a Cronbach’s α of 0.591.
• Total Combined Scale: Demonstrated an overall Cronbach’s α of 0.632.

Psychometric Interpretation of Moderate Alpha Values in KAP Inventories

In psychometrics, while an alpha value above 0.70 is standard for single-trait psychological scales (e.g., depressive symptomatology), coefficients between 0.60 and 0.65 in Knowledge and Practice domains are common, well-documented, and methodologically acceptable. As Cortina (1993) and Streiner (2003) emphasize, Cronbach’s alpha is heavily dependent on item homogeneity and test length. Factual knowledge scales assess a diverse inventory of distinct biological facts (e.g., cortisol pathways, diabetes links, periodontal anatomy), where an individual may comprehend one physiological mechanism without knowing another. Similarly, the Practice subscale catalogs distinct behavioral habits (e.g., morning asanas versus midday breathwork) that do not necessarily intercorrelate perfectly. Thus, moderate alpha values in these domains reflect broad domain breadth rather than poor scale reliability.

9. Factor Analysis and Item Response Theory

Methodological evaluation of the questionnaire departed from standard exploratory (EFA) or confirmatory factor analysis (CFA) routines by prioritizing Modern Test Theory principles. Because the instrument combines dichotomous cognitive items with categorical behavioral responses, standard linear factor analysis models often risk producing pseudo-factors and distorted parameter estimates due to severe violations of multivariate normality.

One-Parameter Logistic (1-PL) Rasch Modeling

To evaluate the structural architecture of the Knowledge subscale, the authors utilized the 1-PL Rasch measurement model via the JMETRIK psychometric software package. In the Rasch paradigm, the probability of an individual responding correctly to a given knowledge item is modeled as a logistic function of the difference between the person’s latent knowledge trait (θ_n) and the item’s intrinsic difficulty (b_i):

P(X_ni = 1 | θ_n, b_i) = exp(θ_n − b_i) / [1 + exp(θ_n − b_i)]

Applying this model provided several psychometric insights:

• Item Calibration: The calibrated item difficulty parameters (b) clustered between 1.01 and 2.16 logits. This range indicates that the knowledge items possess sufficient difficulty to challenge respondents without being psychometrically intractable, allowing accurate estimation along the mid-to-high continuum of health literacy.
• Unidimensionality and Item Fit: Rasch fit statistics (Infit and Outfit mean squares) confirmed that the items conformed satisfactorily to model expectations, demonstrating that the items align along a single underlying cognitive dimension without disruptive redundant or erratic items.
• Invariance Property: By establishing Rasch scalability, the scale satisfies the requirement of sample-free item calibration, meaning the estimated item difficulty parameters remain theoretically stable across independent demographic groups of comparable ability.

Dimensional Integration of Attitude and Practice

While the Knowledge domain was calibrated using IRT, the Attitude and Practice dimensions were analyzed structurally through inter-domain correlational analysis and split-half reliability. The strong unidimensionality of the Attitude subscale (α = 0.923) confirms that evaluative sentiments toward yoga load onto a dominant affective factor. The tri-component architecture provides clinical researchers with distinct subscale profile scores alongside a composite overall score, accurately reflecting the multidimensional nature of behavioral adoption in lifestyle medicine.

10. Instrument / Measurement Tool

The operational characteristics, administration protocols, and scoring guidelines of the scale are structured as follows:

• Instrument Name: Knowledge, Attitude and Practice regarding the effect of yoga on periodontal health questionnaire.
• Test Type: Standardized self-report multidimensional survey inventory.
• Administration Mode: Self-administered via web-based digital survey platforms (e.g., Google Forms) or paper-and-pencil clinical forms.
• Target Population: Adults aged 18 years and older from general community cohorts, dental outpatient clinics, and wellness centers.
• Estimated Completion Time: Approximately 8 to 12 minutes.
• Total Item Count: 27 items distributed across three theoretical domains: Knowledge, Attitude, and Practice.
• Item Architecture and Response Format:
  • Knowledge Domain: Composed of objective items utilizing a mix of dichotomous formats (e.g., Yes / No; Correct / Incorrect) and categorical multiple-choice response options.
  • Attitude Domain: Evaluative statements measured via standardized categorical and Likert-type agreement rating options.
  • Practice Domain: Behavioral indicators capturing frequency, duration, and specific types of yogic exercises via categorical and Likert-type response formats.
  • Source-Specified Response Format: 27 items, utilizing a mix of dichotomous (right/wrong) and categorical/Likert-type response formats across different domains.
• Scoring and Transformation Rules:
  • Correct knowledge responses and favorable attitude/practice endorsements are assigned designated numeric point values according to the standardized coding key.
  • Subscale raw scores are calculated by summing points across domain-specific items.
  • A Total KAP composite score is generated by aggregating the standardized subscale scores across all 27 items.
• Clinical and Normative Interpretation Guidelines:
  • Total Score < 33: Low KAP Profile — Indicates substantial knowledge deficits regarding oral-systemic connections, negative or indifferent attitudes toward mind-body modalities, and negligible or non-existent yogic practice. Targeted basic educational interventions required.
  • Total Score 34 – 40: Medium KAP Profile — Reflects moderate cognitive awareness and generally positive attitudes, but inconsistent, sporadic, or unguided behavioral implementation. Patients benefit from barrier-reduction and habit-formation counseling.
  • Total Score > 41: Good KAP Profile — Demonstrates comprehensive understanding of stress-periodontal biology, highly supportive attitudes, and sustained, habitual yoga practice.
  • Normative Reference Value: The empirical derivation sample yielded a mean KAP score of 37.19 (SD ± 4.82).

11. Permissions & Fee and Test Year

• Test Year of Publication: 2023.
• Primary Validation Publication: Published open-access in F1000Research (Kedlaya et al., 2023).
• Copyright and Licensing: The original validation study is published under an open-access Creative Commons Attribution (CC BY 4.0) license. The research questionnaire and associated data are deposited in online supplementary repositories (including figshare).
• Commercial and Academic Usage Fee: There is no fee required for academic, non-commercial research, or clinical educational use.
• Permissions and Access Protocol: While the methodological framework, scoring rubrics, and psychometric validation data are fully documented in open literature, researchers seeking the full, authorized clinical survey instrument and item coding manuals are advised to consult the open-access supplementary repository on figshare (DOI: 10.6084/m9.figshare.24003657.v2) or contact the corresponding author, Dr. Lakshmi Puzhankara, Department of Periodontology, Manipal College of Dental Sciences ([email protected]). Proper formal citation of the original validation paper is mandatory in all published scholarly works.

12. References

The following peer-reviewed literature underpins the development, psychometric validation, and biological theory of the scale:

• Alam, B. F., Budirahardjo, R., & Siregar, E. (2022). Relationship of BMI with the diet, physical activity and oral hygiene practices amongst the dental students. BMC Oral Health, 22(1), 1–9. https://doi.org/10.1186/s12903-022-02318-8
• Balouchi, A., Mahmoudirad, G., Hastings-Tolsma, M., Shorofi, P. E., Shahdadi, H., & Abdollahimohammad, A. (2018). Knowledge, attitude and use of complementary and alternative medicine among nurses: A systematic review. Complementary Therapies in Clinical Practice, 31, 146–157. https://doi.org/10.1016/j.ctcp.2018.02.008
• Bhattacharya, S., Pandey, U. S., & Verma, N. S. (2002). Improvement in oxidative status with yogic breathing in young healthy males. Indian Journal of Physiology and Pharmacology, 46(3), 349–354.
• Carrizales-Sepúlveda, E. F., Ordaz-Farías, A., Vera-Pineda, R., & Flores-Ramírez, R. (2018). Periodontal disease, systemic inflammation and the risk of cardiovascular disease. Heart, Lung and Circulation, 27(11), 1327–1334. https://doi.org/10.1016/j.hlc.2018.05.102
• Chan, C. K., & Tam, H. L. (2023). Physical activity as a modifiable risk factor for periodontal disease. Frontiers in Oral Health, 4, Article 1266462. https://doi.org/10.3389/froh.2023.1266462
• Cortina, J. M. (1993). What is coefficient alpha? An examination of theory and applications. Journal of Applied Psychology, 78(1), 98–104. https://doi.org/10.1037/0021-9010.78.1.98
• Dolińska, E., Pietruska, M., Milewski, R., & Paniczko-Resztak, M. (2022). Periodontitis-related knowledge and its relationship with oral health behavior among adult patients seeking professional periodontal care. Journal of Clinical Medicine, 11(6), 1517. https://doi.org/10.3390/jcm11061517
• Ferreira, M. C., Dias-Pereira, A. C., Branco-de-Almeida, L. S., Martins, C. C., & Paiva, S. M. (2017). Impact of periodontal disease on quality of life: A systematic review. Journal of Periodontal Research, 52(4), 651–665. https://doi.org/10.1111/jre.12436
• Hegde, S. V., Rao, R. R., & Kurpad, A. V. (2018). Knowledge, attitude, and practice of yoga in medical students: Assessment of anthropometry and lifestyle factors. International Journal of Yoga Therapy, 28(1), 9–14. https://doi.org/10.17761/2018-00005R1
• Kean, J., & Reilly, J. (2018). An introduction to item response theory and Rasch analysis of the Eating Assessment Tool (EAT-10). Brain Impairment, 19(1), 91–102. https://doi.org/10.1017/BrImp.2017.31
• Kedlaya, M. N., Puzhankara, L., Mahendra, M., Vineetha, K., Sinha, S. P., Singh, A., & Karmakar, S. (2023). Knowledge, attitude and practice regarding the effect of yoga on periodontal health questionnaire. F1000Research, 12, 1146. https://doi.org/10.12688/f1000research.140245.2
• Kirkwood, G., Rampes, H., Tuffrey, V., Richardson, J., & Pilkington, K. (2005). Yoga for anxiety: A systematic review of the research evidence. British Journal of Sports Medicine, 39(12), 884–891. https://doi.org/10.1136/bjsm.2005.018069
• Kumar, D., Bajaj, S., & Mehrotra, R. (2006). Knowledge, attitude and practice of complementary and alternative medicines for diabetes. Public Health, 120(8), 705–711. https://doi.org/10.1016/j.puhe.2006.04.010
• Kumar, P., & Balhara, Y. P. S. (2020). A pilot cross-sectional survey on awareness and practice regarding Type 2 Diabetes mellitus and its management with Yoga. Journal of Ayurveda and Integrative Medicine, 11(2), 106–109. https://doi.org/10.1016/j.jaim.2020.01.001
• Mishra, A., & Hankey, A. (2020). Knowledge, attitude, and practice of yoga in rural and urban India, KAPY 2017: A nationwide cluster sample survey. Medicines, 7(2), Article 8. https://doi.org/10.3390/medicines7020008
• Orlandi, M., Graziani, F., & D’Aiuto, F. (2022). Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review. Journal of Clinical Periodontology, 49(Suppl 24), 314–327. https://doi.org/10.1111/jcpe.13554
• Patini, R., Gallenzi, P., Pedullà, E., & Cordaro, M. (2018). Relationship between oral microbiota and periodontal disease: A systematic review. European Review for Medical and Pharmacological Sciences, 22(18), 5775–5788. https://doi.org/10.26355/eurrev_201809_15903
• Pihlstrom, B. L., Michalowicz, B. S., & Johnson, N. W. (2005). Periodontal diseases. The Lancet, 366(9499), 1809–1820. https://doi.org/10.1016/S0140-6736(05)67728-8
• Selvaraj, S., Puranik, M. P., & Sowmya, K. R. (2022). Development and validation of oral health knowledge, attitude and behavior questionnaire among Indian adults. Medicina, 58(1), Article 68. https://doi.org/10.3390/medicina58010068
• Sengupta, P. (2012). Health impacts of yoga and pranayama: A state-of-the-art review. International Journal of Preventive Medicine, 3(7), 444–458.
• Sheiham, A., & Watt, R. G. (2000). The common risk factor approach: A rational basis for promoting oral health. Community Dentistry and Oral Epidemiology, 28(6), 399–406. https://doi.org/10.1034/j.1600-0528.2000.028006399.x
• Singh, K., Sinha, S. P., & Singh, S. (2017). Effect of yoga on promotion of oral health. International Journal of Dentistry Research, 2(1), 18–21. https://doi.org/10.7860/JCDR/2015/12851.6021
• Sinha, S., Singh, S. N., Monga, Y. P., & Ray, U. S. (2007). Improvement of glutathione and total antioxidant status with yoga. The Journal of Alternative and Complementary Medicine, 13(10), 1085–1090. https://doi.org/10.1089/acm.2007.0567
• Sudhanshu, A., Sharma, U., Handa, S., & Bhatnagar, A. (2017). Impact of yoga on periodontal disease and stress management. International Journal of Yoga, 10(3), 121–127. https://doi.org/10.4103/0973-6131.213468
• Van der Linden, W. J. (Ed.). (2017). Handbook of item response theory, volume 3: Applications. CRC Press. https://doi.org/10.1201/9781315117430
• Veena, K. M., & Kedlaya, M. N. (2021). Effect of yoga on periodontal health – A systematic review and meta-analysis. Journal of Dental Research and Review, 8(4), 241–249. https://doi.org/10.4103/jdrr.jdrr_139_21
• West, J., Otte, C., Geher, K., Johnson, J., & Mohr, D. C. (2004). Effects of Hatha yoga and African dance on perceived stress, affect, and salivary cortisol. Annals of Behavioral Medicine, 28(2), 114–118. https://doi.org/10.1207/s15324796abm2802_6
• Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4(2), 49–54. https://doi.org/10.4103/0973-6131.85485

13. Items of the Scale