|Year : 2013 | Volume
| Issue : 2 | Page : 102-108
Awareness and attitude towards maintenance of oral health during pregnancy among patients and clinicians attending obstetrics and gynecology ward
Reddy Sudhakara Reddy1, Swapna Lingam Amara1, Ramesh Tatapudi1, Pradeep Koppolu2, Vijaya Laxmi Nimma1, Reddy Lavanya Reddy1
1 Department of Oral Medicine and Radiology, Vishnu Dental College, Vishnupur, Bhimavaram, West Godavari District, Andhra Pradesh, India
2 Consultant Periodontist, Andhra Pradesh, India
|Date of Web Publication||21-May-2013|
Reddy Sudhakara Reddy
Department of Oral Medicine and Radiology, Vishnu Dental College, Vishnupur, Bhimavaram, West Godavari District, Andhra Pradesh - 534 202
Source of Support: None, Conflict of Interest: None
Aim : To assess the oral health status and pH of saliva in pregnant women in comparison to non-pregnant women and to appraise the awareness and attitude towards regular dental checkups and oral health maintenance among patients and clinicians attending a hospital gynecology ward.
Study Design: The oral health status and extra-oral manifestations of 220 healthy women,including 110 pregnant women, attending the government hospital, Bhimavaram were considered. The findings were recorded along with a questionnaire and documented in a specially designed proforma. The response to another set of questions answered by 60 clinicians attending the gynecology ward was recorded in a separate proforma.
Results: The clinical manifestations showed statistical significance (P = <0.001) values with 91% patients positive for gingivitis and 85% patients with ptyalism during their pregnancy. There were only 14.5% of pregnant women who consulted a dentist for their oral health problems during pregnancy, and only 35% of the clinicians have advised their patients regarding maintenance of good oral hygiene and routine dental checkups during pregnancy.
Conclusion: Results show that certain oral manifestations were more prevalent among the pregnant women, and very few expecting mothers know about these changes related to pregnancy and follow maintenance of good oral hygiene and routine dental checkups. Hardly any gynecologists advised these women regarding the maintenance of good oral hygiene during pregnancy. Hence, oral health intervention programs should be targeted to the risk groups.
Keywords: Dental caries, gingivitis, oral hygiene, pregnant women, pre-term low birth weight babies, salivary pH
|How to cite this article:|
Reddy RS, Amara SL, Tatapudi R, Koppolu P, Nimma VL, Reddy RL. Awareness and attitude towards maintenance of oral health during pregnancy among patients and clinicians attending obstetrics and gynecology ward. J NTR Univ Health Sci 2013;2:102-8
|How to cite this URL:|
Reddy RS, Amara SL, Tatapudi R, Koppolu P, Nimma VL, Reddy RL. Awareness and attitude towards maintenance of oral health during pregnancy among patients and clinicians attending obstetrics and gynecology ward. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Mar 31];2:102-8. Available from: http://www.jdrntruhs.org/text.asp?2013/2/2/102/112334
| Introduction|| |
Pregnancy is a physiological condition evidenced by several momentary changes. These can be presented as a variety of physical signs and symptoms that can influence the patient's health, perceptions, and interactions with others in her environment. Many women complain of various symptoms that develop during this time. The most common complaints include nausea and vomiting, nasal congestion, heartburn, alteration in taste and food cravings, hyperventilation and shortness of breath, and fatigue. These symptoms are often caused by the physiologic changes of various systems, including the cardiovascular, respiratory, gastrointestinal, musculoskeletal, endocrine, and hematological systems, which may sequentially cause alterations in the oral cavity and increased susceptibility to oral infection. ,,,, These hormonal changes during pregnancy and neglected oral hygiene practices tend to increase the incidence of dental diseases such as gingivitis and may even contribute to allow salivary pH,in turn, leading to increased incidence of dental caries. 
Pregnancy gingivitis is characterized by increased redness, edema, and higher tendency towards bleeding and inflammation that occurs as a result of increased circulating levels of progesterone and its effects on the microvasculature. Estradiol and progesterone can contribute to inflammation by stimulating prostaglandin synthesis in the gingiva of pregnant women. In the intervening time, these hormones serve as essential growth factors for Prevotella-intermedia, which show a marked increase in the subgingivalplaque during pregnancy.  Hence, the interproximal papillae become red, edematous, and tender to palpation, and bleed easily if subjected to trauma. In few patients, the condition will progress locally to become a pyogenic granuloma or "pregnancy tumor," which is most commonly seen on the labial surface of the papilla. ,,,
The effect of maternal periodontal health on prematurity and low birth weight babies has been documented in previous studies. , Although the mechanisms by which periodontal diseases may cause pre-term birth and/or low birth weight have not been elucidated, one proposed mechanism relates to the seeding of urinary tract infections with bacteria from periodontal disease in the mother. ,,,, Another proposed mechanism is the nature of the periodontal disease itself, where the inflamed periodontal tissues produce significant amounts of pro-inflammatory cytokines, mainly interleukin-1-beta(IL-1β), IL-6, prostaglandin E 2 , and tumor necrosis factor alpha (TNF-α), which may have systemic effects on the host. Endotoxin derived from periodontal pathogens in pregnant women with periodontal disease might signal pre-term labor through primed monocyte-macrophage commencement in the peripheral blood. ,,,, Although there is ample literature regarding the oral health status of expecting mothers, insufficient data is available from the Indian subcontinent regarding their awareness and motivation of these pregnant women towards maintenance of good oral hygiene and regular dental checkups during pregnancy. , Thus, a need arises to know the awareness of these patients regarding their motivation towards regular dental checkups during pregnancy.
| Materials and Methods|| |
A total of 220 women attending the outpatient clinic at government hospital, Bhimavaram in the month of December 2010 comprised the study population. All of the women present on the days of the survey were considered for inclusion in the study. Among which, 110 patients were confirmed of their pregnancy status (group I) clinically by an obstetrician/gynecologist. All the women were checked for the preliminary pregnancy test confirmation and were included in the study. Those who were experiencing labor pain, or having serious systemic illness, along with those who were uncooperative or unwilling to give consent were excluded. A similar number of 110 non-pregnant women (group II) was categorized as the control group. These women attended the same hospital for some other reasons during the survey period. The subjects were also asked if any medical staff who were monitoring them had drawn their attention to these dental conditions or offered any advice. The clinical staff managing these women was also enquired by giving a questionnaire if they were aware of these conditions or if they offered any advice to their patients.
The socio-demographic information was recorded by one observer usingpersonal interviews with the patients. The clinical examination was done by a second observer. The socio-economic status and the educational qualification of the participants were comparatively similar. Very few of these women had primary school education, and the rest of them had received little or no formal education. Many of the women who participated in this study were women helped in supporting their family by working as daily wage workers in agriculture. Clinical examination was done based on the WHO criteria  for periodontalassessment using the CPI probe, and the pH of saliva was measured using color-coded pH strips. CPIwas done for assessment of periodontal status, using mouth mirror and CPI (Manipal) probe, which is a specifically designed periodontal probe, with a 0.5 mm ball tip and black band between 3.5 and 5.5 mm and rings at 8.5 and 11.5 mm from the ball tip. According to WHO protocol,the dentition is divided into 6 sextants defined by tooth numbers: 18-14, 13-23, 24-28, 38-34, 33-43, and 44-48. The results were coded as following: Code 0- Healthy periodontium, 1- Bleeding on gentle probing, 2- Calculus deposition, 3- Pocket 4-5 mm (black band on the probe partially visible), Code 4- Pocket 6mm or more (black band on probe not visible), Code X-Excluded (less than two teeth present).
Patients were asked to pool the saliva on the tongue, and the pH strip was placed to wet it. The color change was immediately matched directly with the scale provided with the strip, and the pH value was recorded in the specially designed proforma.
The relevant findings including the response to the questionnaire was documented in a specially designed data collection form from both the patients and the clinicians attending the gynecology ward. Informed written consent was obtained from all the participants, and ethical clearance was obtained from ethical committee of Vishnu Dental College and Hospital, India. Patients were asked if they had received any professional advice from any medical staff (doctor or nurse) in the past or present and if they had consulted only elders in the family for the relief of any oral health problems during pregnancy.
Data collected was entered into spreadsheets and was subjected to statistical analysisby SPSS 15.0. Stata 10.1, (SPSS Inc., USA), and Med Calc 9.0.1 were used for the analysis of the data, and Microsoft word and Excel have been used to generate graphs, tables etc .
Student t-test (two tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups and inter group analysis on metric parameters, Chi-square/Fisher Exact test has been used to find the significance of study parameters on categorical scale between two or more groups.
| Results|| |
Among 110 pregnant women who were aged in the range of 18 to 31 years, 13 were in the first trimester while 52 and 45 were in the second and third trimester, respectively.
There was gingivitis among 91% andptyalism among 77.3% of the individuals in the study group. There was increased burning sensation while swallowing among 34.5% of (group I) subjects, altered taste sensation found with 20% of the study sample and amplified tooth mobility among 17.3% of the pregnant women. These data have statistical significance when compared with non-pregnant women. [Table 1] In the intra-oral manifestations, incidence of recurrent apthous stomatitis and increased teeth mobility was more evident in the 3 rd trimester. Ptyalism and disguesia was more associated with 1 st trimester, but the difference was not statistically significant.
|Table 1: The Extra-Oral And Intra-Oral Manifestations Among Group I and Group II Participants|
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On recording the salivary pH by pH strips, it was observed that the pH among the group I participants (pregnant women) showed a mean of 5.89, which was comparatively less than the group II(non-pregnant women)who showed a pH of 7.15 [Table 2].
[Table 3] depicts that prevalence of shallow periodontal pockets (4-5 mm deep) is significantly more (P = 0.011) in group I compared to group II (20.0% vs. 11.8%).
From the response to the questionnaire, it is clear that these pregnant women received advice regarding their oral health problems during pregnancy from elders, nurses, or medical staff attending them. Only 16 participants among 110 pregnant women consulted a dentist for their oral health-related problems during pregnancy [Table 4].
None of the women with any specific oral mucosal pathology had been alerted to the condition and none with oral epulis, apthous ulceration, gingival bleeding, or any of the other specific oral pathologies were aware or bothered about their oral condition. This shows that these women were not aware of their oral health and may not have been motivated to seek regular dental care.
The response tothe questionnaire completed bythe clinicians attending the gynecology ward shows that only 35% of the clinicians have advised their patients regarding maintenance of good oral hygiene and to have routine dental checkups done during pregnancy. However, 68.3% of clinicians were aware that chronic periodontal infection would cause pre-term low birth-weight babies [Table 5].
|Table 5: Questionnaire for Staff at the Obstetrics and Gynecology Clinic|
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| Discussion|| |
The pregnant woman who presents for dental care requires special consideration. Understanding the physiologic changes associated with pregnancy and their effects on oral health are essential for providing quality care for pregnant women. The American Dental Association (ADA) suggests that elective dental care should be avoided, if possible, during the first trimester and the last one half of the third trimester. ,,,, California Dental Association Foundation Oral Health Care during Pregnancy and Early Childhood: Evidence-based Guidelines for Health Professionals  concluded that prevention, diagnosis, and treatment of oral diseases, including dental x-rays and the use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. 
All the women participating in our study were from the low socio-economic background andhad received minimal or no formal education. Therefore, any significant results, which may be dependent on the variation in socio-economic status and the educational qualification, could not be determined.
Recurrent apthous stomatitis, or RAS, is a common condition of uncertain etiopathogenesis, in which recurring ovoid or round ulcers affect the oral mucosa. Incidence of recurrent apthousstomatis has shown decreased presentation during pregnancy according to previous studies. ,,,,,, In our study, only 2.7% of the pregnant women were found to have apthous stomatitis when compared to the control population with 10.9% of them with recurrent apthous stomatitis. Though the mechanism of this ulceration is not clearly known, diet and cellular immune response (Type IV) may have their influence. Levels of corticosteroids in the body may affect the occurrence of stomatitis. This condition is known to be severe in the luteal phase of the menstrual cycle. 
Pyrosis (burning sensation while swallowing or feeling of heartburn) has been reported to occur in up to 70% of pregnant women and is thought to be the result of increase in intra-gastric pressure (caused by the presence of the fetus) and concomitant decrease in smooth muscle tone of the lower esophageal sphincter.Loss of lower esophageal sphincter tone is thought to be caused by the inhibition of motilin production by high levels of progesterone. ,, Our study showed similar results with 34.5% of the pregnant women showing pyrosis, which was statistically significant when compared to control group.
Salivary changes in the pregnant patient include changes in the pH and composition of salivary secretions. A lowered level of salivary pH creates an oral environment more favorable for dental decay development, which may be attributed tothe increased consumption of cariogenic food. ,,,, Women often mention increased hunger and strange food cravings, also known as "pregnancy picca," ,, during pregnancy. The pH of salivary secretions in the pregnant patients has a mean of 5.89, which was found to be lower than that of non-pregnant patients having a mean value of 7.15 in our study. Salivary secretions in the pregnant patient contain higher concentrations of potassium and estrogen and lower concentrations of sodium. Research has confirmed that increase in salivary estrogen levels can lead to increased rates of desquamation of the oral mucosa, which allows increased bacterial propagation and promotes dental decay. This may be further worsened by poor oral hygiene. This furthers the need for adequate dental hygiene habits and frequent dental recall visits for pregnant patients. ,,,,
As stated in previous studies, the probable reason for the increased periodontal pocket depth is the swelling and loosening of the gingival tissues around the teeth caused by inflammation, allowing the probe to penetrate deeper within the tissues. Alternatively, it may be due to increased levels of micro-organisms like Bacteroides, Prevotella, and Porphyromonas.The role of subgingival microbial species in the etiology of periodontal diseases has been extensively documented. ,,,, Incidence of pocket depths of 4-5 mm is significantlyhigher, seen in 20% of pregnant women, compared to 11.8% in non-pregnant women in the presentstudy.
Tooth mobility is an indication of periodontal disease and is caused by mineral changes in the lamina dura, as well as disorder in the periodontal ligament attachments. It is associated with the presence of a hormone called relaxin. This hormone helps to organize the birth passage and may also cause relaxation of the periodontal fibers, which hold teeth in position. In addition, vitamin C deficiency aggravates this problem, so the patient should be advised accordingly. Removal of local gingival irritants, therapeutic doses of vitamin C, and delivery typically result in reversal of the tooth mobility. , In the present study, increased tooth mobility among 17.3% of the pregnant women was noted.This is statistically significant when compared with non-pregnant women in relevance with the previous studies. ,
Tooth erosion is a slow progressive process that leads to the loss of the protective hard tissues of the tooth caused by exposure to acids for long periods of time.Perimolysis is a kind of chemical erosion produced by acids in the diet. Usually seen in the cervical third of the tooth's labial surface, this mineral loss is characterized by shallow, rounded, smooth, and highly glazed cavities. , Erosion of the teeth associated with pregnancy was not particularly significant in this study. Severe vomiting was recorded only among 8 patients. In these cases, the cause of tooth erosion was not very clear and cannot be attributed to severe vomiting alone. Other factors, such as consumption of acidic beverages for a prolonged duration, may be contributory to the erosion of the enamel. The risk of perimolysis can increase if gastric symptoms are also present, especially when the patient has a psychological eating disorder such as anorexia nervosa or bulimia. Our study did not record the general dietary habits of the participants in the past and during pregnancy.
Ptyalism, which was noticed in the initial stages of pregnancy as documented in earlier studies, was significant among the participants in this study with 77.3% showing increased salivation. Recent studies concluded that there was no actual increase in the salivary flow. , The spitting seen commonly in pregnancy may be related to the nauseous sensation more than an increase in the flow of saliva. Our study did not include the measurement of salivary flow among the subjects. From the response to the questionnaire by the pregnant women, only 14.5% of the patients consulted a dentist for their dental health-related problems during pregnancy. 20.9% of patients were influenced by the suggestions given by elders and followed home remedies to resolve any dental problem during pregnancy. The results were similar to previous studies, suggesting that the pregnant women were less motivated to approach a dentist for their dental problems during pregnancy. ,,
The response by the clinicians attending the gynecology ward shows, only 35% of the clinicians advised their patients regarding maintenance of good oral hygiene and to have routine dental checkupsduring pregnancy. According to a previous study, (68%) did not advise women to include a periodontal evaluation as part of their prenatal care, and about 32% general doctors felt that periodontal disease can be treated safely during pregnancy. , In our study, although 68.3% of clinicians were aware that chronic periodontal infection may cause pre-term low birth-weight babies, none checked for the oral status of these patients or referred them to dentists.
| Conclusion|| |
This study shows that the women included in this study were not conscious of conditions occurring in the oral cavity during pregnancyand the need for meticulous management of oral hygiene and treatment by a dentist. Awareness of these hormonal changes and associated conditions is crucial. Often the effects or the complications arising from them can be minimized and managed successfully until childbirth, when these conditions may spontaneously regress. It is helpful forthe patient to bemade aware of the transitory nature of some of these conditions and re-assured accordingly. It is hope that thisstudy will makethe clinicians attending pregnant women understand that oral health maintenance is important and should be monitored frequently throughout pregnancy. Physicians do not routinely advise their patients to seek dental care during pregnancy. General practitioners were less informed about oral health importance and the oral hygiene practicesin pregnant women. A public health programsuggested educating healthcare providers to encourage pregnant women on the need for a regular dental check-up during pregnancy.
| Acknowledgement|| |
The authors are thankful to Dr. K. P. Suresh, Scientist (Biostatistics), National Institute of Animal Nutrition and Physiology. We are grateful to the management of government hospital, Bhimavaram and the clinicians attending the gynecology ward for their co-operation to carry out this study. We wish to thank all the women who took part in our study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]