Periodontal Health Knowledge and Awareness in Pregnancies

Title: Periodontal Health knowledge and awareness among pregnant females in Bangalore, India

ABSTRACT

There is plenty of evidence in the literature suggesting an association between periodontal diseases, pregnancy and even preterm low birth weight deliveries. The correlation has been expanded from periodontitis and preterm birth to various forms of periodontal infections and adverse pregnancy outcome, preterm birth, low birthweight, stillbirth, miscarriage, intrauterine growth retardation and pre-eclampsia.

Aims and Objective: The purpose of this study was to assess the awareness regarding periodontal health among pregnant females in Bangalore, India.

Materials and Method: Three hundred pregnant female patients who visited the OPD of Gynaecology Department of Government Hospital, K.R. Puram, Bangalore was evaluated for oral hygiene status. Awareness of the relationship between oral health and pregnancy, demographics, oral health knowledge, oral hygiene, and dental visits during pregnancy and their willingness for treatment was surveyed by self administered questionnaire from the patients who were willing to participate in the study. The data were collected, summarized and statistically analyzed.

Results: Awareness among pregnant women was found to be statistically non significant (p value > 0.05) irrespective of the age and educational qualifications (p value> 0.05).

Conclusion: Knowledge and awareness regarding periodontal disease, and its effect on the pregnancy and birth outcome are limited.

Key words- Pregnancy, Awareness, Periodontal Health

INTRODUCTION

Women’s life cycle changes presents unique challenges to the oral health care profession. Hormonal influences associated with the reproductive process alter periodontal and oral tissue responses to local factors creating diagnostic and therapeutic dilemmas. It is imperative, therefore, that clinician recognize, customize and vary periodontal therapy, according to an individual female and the stage of her life cycle.¹

Apart from the underlying systemic diseases, ceratin physiological condition can also aggravate the underlying gingival status, especially when the oral hyagiene is poor. Pregnancy being one of these conditions, is a time when the patient may experience the most profound physiologic and psychological changes in her life. There is plenty of evidence in the literature suggesting an association between periodontal diseases, pregnancy and even preterm low birth weight deliveries. The link between periodontal infections and preterm birth has been one of the frontiers in dental research. The correlation has been expanded from periodontitis and preterm birth to various forms of periodontal infections and adverse pregnancy outcome, preterm birth, low birthweight, stillbirth, miscarriage, intrauterine growth retardation and pre-eclampsia.^2,3,4

Pregnancy provides an ideal opportunity to improve women’s health practices. Prenatal care entails regular and frequent medical visits, so that women are or can be motivated to improve their health for the benefit of the developing fetus. Since maternal oral flora and oral hygiene practices are predictors of the oral flora and oralhealth of infants and children, a pregnant woman’s knowledge and actions concerning her oral health are critical to the oral health of her child or children and may be a key to childhood caries prevention.

Certain oral disease, such as periodontitis or periodontal infection, gingivitis or even caries can affect and influence not only the Maternal oral health but also the oral health of her child. Targeting pregnant women to increase their oral health knowledge may improve their oral health and, thus, the oral health of their children. Maternal oral flora and oral health are one of the greatest predictors of childhood oral flora and oral health.^1,2

The interaction between oral and systemic health has long been of interest. It has been shown that pregnant womenhave a higher incidence of gingival inflammation compared to non-pregnant women^2,3,4 According to literature in pregnant women the incidence of gingival inflammation observed from 36% to 100 %^3,5 These vascular and Hormonal changes can lead to exaggerated immune respone of gingival towards bacterial plaque. ^6,7

Good oral hygiene practices, however, can minimize gingival disease during pregnancy.^2,7Two case–control studies ^8,9 and cohort studies ^10,11,12showed that periodontal disease could be an independent risk factor for pre-term birth and low birthweight after adjusting for several known risk factors. ²In fact, treatment of periodontal disease has been shown to reduce pre-term birth. ^12,13Other studies have shown additional associations between periodontal diseaseand pregnancy, such as increased risk for development of preeclampsia during pregnancy.¹⁴

The purpose of the present study was to assess the awareness regarding periodontal health among pregnant females in Bangalore. The results obtained would serve asbaseline information for planning an oral health education program aimed at improving the oralhealth of pregnant women receiving care in the hospital.Specifically, it would identify areas of deficiency in thewomen’s knowledge and this would be helpful informulating the content of the oral health messages.

MATERIALS AND METHOD

The presentcross sectionalstudy was conducted in the Gynaecology Department of Government Hospital, K.R. Puram, Bangalore during June to August 2011.The minimum sample size wascomputed using the formula n= z²pq/d² where p (theprevalence of women with good knowledge) was set at40%. Thus the computed minimum sample size was 271 subjects. This was increased by 10% to 300subjects to accommodate attrition. Hence, three hundred pregnant females who visited the OPD of Gynaecology Department of Government Hospital, K.R. Puram, Bangalorewere taken instudy design using simple random sampling. The subjects were informed about the purpose of the study and only those who gave written voluntary consent were taken into the study. Also, ethical approval was obtained from the institutional review board and permission from the head of Government Hospital was also obtained.

The questionnaire wasdeveloped and pre-tested on 25 pregnant women toallow for refinement of the questions in order tofacilitate answering(Table 1). Questionnaires wereadministered to all consenting pregnantwomen who attended the antenatal clinic during thestudy period.The questionnaire contained two segments. The first part contained inquiries on the participant’s sociodemographic qualities, for example, age, occupation, monthly income and educational status.

The second part contained fifteen questions pertaining to participant’s awareness regarding knowledge of relationship between oral health and pregnancy, knowledge about oral health, knowledge about oral hygiene, dental appointment during pregnancy, advice regarding necessity of dental health in pregnancy, presence of bleeding gums and whether any of the possible actions were taken to treat or reduce the gingival problems along with their compliance for the treatment.

Each question answered “Yes” was given a score of 1 while for “No”, score 0 was given. Thus, the maximum achievablescore was 15 with a higher score indicating a high level of awareness. Individuals with scores of 11 and abovewere graded as having high awareness, those having scores from 6 to 10 were having average awareness while those with scores 5 or less were having low awareness. Awareness of periodontal health, according to age and educational qualifications of the pregnant females was also considered in the study.

The results obtained from the periodontal health awareness questionnaire were compiled and subjected to statistical analysis using SPSS version 19.0. Descriptive statistics were reported as well as cross-tabulations by age, parity, education and occupation. For the purpose of analysis thelevel of education was categorized as low (primaryeducation only), middle (secondary education) andtertiary (post secondary education).Inference on the cross-tabulations were performed, using chi-square tests to test for general association. A probability value of <0.05 was taken as statistically significant.

RESULTS

Sociodemographic features of study participants

The mean age of our studypopulation was 24.97+4.343years (range 18–35 years)with the majority of the study population in the 18-25 (59.3%) and 26-30 (33%) years old categories. Over half (53.7%) of the respondents wereprimigravida while the remaining women had between1 and 5 children. Out of the total study population, 2.3% had primaryschool education, 10.7% secondary schooleducation, 33.3% attained post secondary educationand 53.7% attended university (Table 2). Most of the study participants were unemployed(78.3%), followed by “employee” (21.7%) (Table 2).On theutilization of dental services, 285 (62.9%) respondentsreported ever visiting a dental facility.

The mean of questions answered correct by the subject was 4.53 +1.814 with a range of 1 – 8.Majority, i.e. 60 percent subjects had low awareness and only 40 percent with average awareness and 0 percent with high awareness (Table 3). The results of awareness among pregnant women came out to be statistically non significant (p value > 0.05) irrespective of the age.The results of awareness among pregnant women came out to be statistically non significant (p value > 0.05) irrespective of educational qualifications.

DISCUSSION

It is worth sayin that good oral health in pregnancy is very important factor, as recent trends showed that the poor oral health can lead to unfavourable pregnancy results. This is important in context of developing countries like india, where high mortality rate present.Most of the common oral diseases present during pregnancy (i.e. periodontal disease) are preventable only by using simplest measures like regular flossing and tooth brushing.A person’s knowledge, attitude and oral health would influence and generate such positive behaviour which is the ultimate result of person’s awareness.¹⁵ Thus, this study wasdesigned to provide a view of periodontal awareness among pregnant females in Bangalore.

The present study showed low awareness(60%) among majority of the study population followed by average awareness among rest 40% of the participants. The results of the present study were similar to study conducted by HA Alwaeli SH Al-Jundi (2005)¹⁶who concluded that knowledge and awareness for pregnant women about their teeth and gingival condition is generally poor. Pregnant women need accurate information about their teeth and oral health. Simple educational preventive programmes on oral self-care and disease prevention before and during pregnancy should be provided to improve oral health.Another similar kind of study was conducted by Kim A. Boggess; Diana M. Urlaub, Merry-K Moos etal (2011)¹and concluded that pregnant women have some oral health knowledge, which varied according to maternal race or ethnicity. Their beliefs varied according to their education levels. Including oral health education as a part of prenatal care may improve knowledge regarding the importance of oral health among vulnerable pregnant women, thereby, improving their oral health and that of their children.

The awareness among pregnant women came out to be low below 25 years of age.The awareness among pregnant women came out to be average above 25 years of age.When the results were compared of above and below 25 years of age the awareness came out to be nonsignificant with average awareness among above 25 years of age.

This study is not without limitations. Onelimitation is its reliance on self-reported data, which isoften subject to biases inherent to questions being askedsuch as recall bias. Nonetheless, the results wouldserve as a veritable tool for designing and specifyingappropriate oral health education messages forpregnant women receiving antenatal care.

CONCLUSION

A majority of the pregnant women has good knowledge and information about general health; however, their knowledge and awareness regarding periodontal disease, and its effect on the pregnancy and birth outcome is limited. Most pregnant women need more information about oral health, and prevention of gingival and periodontal diseases. Longitudinal studies are needed to assess the long-term effect of oral health education programs in maternity care centers on dental health knowledge and behavior of pregnant women. Further studies are needed to determine if there is a strong correlation between periodontal disease and premature labor and whether periodontal therapy or prevention can reduce the risk of premature labor. Studies to assess the role of dental hygienists in designing and promoting information regarding periodontal health awareness and practices among pregnant women in maternity care centers.

REFERENCES

Boggess KA, Urlaub DM, Moos MK, Polinkovsky M, El-Khorazaty J, Lorenz C. Knowledge and beliefs regarding oral health among pregnant women. J Am DentAssoc. 2011;142(11):1275-82.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta odontol scand. 1963;21:533-51
Jensen J, Lilijmack W, Bloomquist C. The effect of female sex hormones on subgingival plaque. J Periodontol1981;52: 599–602.
Nuamah I, Annan BD. Periodontal status and oral hygiene practices of pregnant and non-pregnant women. East Afr Med J. 1998;75:712-4.
Ferris GM. Alteration in female sex hormones: their effect on oral tissues anddental treatment. Compendium. 1993 ;14:1558-64.
Zachariasen RD. The effect of elevated ovarian hormones on periodontal health:oral contraceptives and pregnancy. Women Health. 1993;20:21-30.
Raber-Durlacher JE, van Steenbergen TJ, Van der Velden U, de Graaff J,Abraham-Inpijn L. Experimental gingivitis during pregnancy and post-partum:clinical, endocrinological, and microbiological aspects. J Clin Periodontol. 1994;21:549-58.
Offenbacher S, Katz V, Fetik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996; 67: 1103–1113.
Dasanayake A. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol 1998; 3: 206–212.
Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC.Periodontal infection and preterm birth: results of a prospective study. J AmDent Assoc. 2001;132:875-80.
Offenbacher S, Leiff S, Boggess KA, Murtha AP, Madianos PN, Champagne CM, etal. Maternal periodontitis and prematurity. Part 1: Obstetric outcome of prematurity and growth restriction. Ann Periodontol 2001; 6: 164–174.
Lopez NJ, Smith P, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birthweight in women with periodontal disease. J Periodontol 2002; 73: 911–924.
Jeffcoat MK, Hauth JC, Geurs NC, Reddy MS, Cliver SP, Hodgkins PM, etal. Periodontal disease and preterm birth: result of a pilot intervention study. J Periodontol 2003;74: 1214–1218.
Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternalperiodontal disease is associated with an increased risk for preeclampsia. ObstetGynecol. 2003;101:227-31.
Al Habashneh R, Guthmiller JM, Levy S, Johnson GK, Squier C, Dawson DV, FangQ. Factors related to utilization of dental services during pregnancy. J ClinPeriodontol. 2005;32:815-21.
Alwaeli HA, Al-Jundi SH. Periodontal disease awareness among pregnant womenand its relationship with socio-demographic variables. Int J Dent Hyg. 2005;3:74-82.

TABLE 1: Questionnaire used for the study

PERIODONTAL HEALTH AWARENESS QUESTIONNAIRE

Name:

Age:

Address:

Occupation:

Education:

Monthly income:

Habits if any:

Gestational age:

Parity:

Oral Hygiene Status Good Fair Poor

Do you brush your teeth? Yes No
If no, then do you use any other oral hygiene method? Yes No
Do you brush your teeth after every meal? Yes No
Do you use interdental cleaning aids? Yes No
Do you think that extra care of oral hygiene is needed during pregnancy?

Yes No

Have you heard about the possible correlation between oral health and pregnancy?

Yes No

Do you know that Cavities (tooth decay) and gum disease are caused by infection in the mouth?

Yes No

Do you think that gum disease could have a relation with premature labor and low birth weight babies?

Yes No

Have you ever suffered from premature labor or low birth weight babies in the past? Yes No
Have you ever visited a dentist during or before your pregnancy? Yes No
Do you know that Pregnancy makes your gums bleed, swell, become red?

Yes No

Do your gums bleed during tooth brushing after conception? Yes No
If you are diagnosed with periodontal disease (gum disease) now, will you undergo treatment for the same during pregnancy? Yes No
If you are diagnosed with periodontal disease (gum disease) now, will you undergo treatment for the same after delivery? Yes No
Did your gynecologist recommended oral check up before or during pregnancy? Yes No

Signature

Table 2: Socio-demographic characteristics of study population

Socio Demographic Characteristics

Frequency

Percentage

Age

18-25

26 – 30 years

31 years and above

Total

178

101

21

300

59.3

33.7

7.0

100.0

Level of education

Primary

Secondary

Tertiary

University

Total

7

32

100

161

300

2.3

10.7

33.3

53.7

100.0

Parity

Primigravida

1-5 children

Total

161

139

300

53.7

46.3

100.0

Occupation

Unemployed

Employed

Total

235

65

300

78.3

21.7

100.0

Table 3: Percentage awareness among study population regarding periodontal health

Periodontal health awareness

Percent

Valid Percent

Low awareness

60.0

60.0

Average awareness

40.0

40.0

High awareness

0

0

Total

100 100