Oral health awareness and practices in pregnant females: A hospital-based observational study.

BACKGROUND: The aim of this study was to assess the oral health awareness, methods adopted to maintain hygiene, prevalent myths regarding oral health in pregnancy, and importance of oral health during pregnancy, to help formulate oral health program for pregnant females in partaking hospital.
MATERIALS AND METHODS: A total of 225 pregnant females participated in the study. After complete demographic assessment of participants, a questionnaire was provided to them. Questionnaire included simple multiple choice questions on how they maintained oral hygiene, their oral health status, visit to the dentist, and barriers in seeking treatment. This was followed by a questionnaire regarding common myths and understanding of the importance of oral health during pregnancy which had three choices: true, false, and do not know. The results were expressed in percentages, and one sample t-test for percentages was applied where ever required.
RESULTS: Majority of participants self-reported some form of oral health problems with bleeding gums as a chief complaint leading the survey. Around half of the participants had never visited a dentist, and an abundant number of pregnant females reported safety concerns for developing the child as a reason for not taking any treatment during pregnancy. A highly significant number of participants were unaware of the importance of oral health during pregnancy and believed in age-old myths.
CONCLUSION: The oral health care still remains on the backseat in care provided to pregnant female. A complete overhaul of understanding through individual, family, and community counseling is required to spread awareness.

INTRODUCTION

Oral tissues are known to be affected by the hormonal influences during pregnancy. Most profound of these effects are visible on gingival tissues.[1] Higher levels of estrogen and progesterone in pregnancy may induce edema and hyperemia and bleeding in periodontal tissue as well as a higher incidence for gingival enlargement.[2] A connection has been suggested between the higher levels of pregnancy hormones in plasma and declining periodontal health status.[3] The oral health status of a pregnant female can affect the health of the unborn child within the womb. Plenty of evidence suggests that an association exists between periodontal disease and preterm low birth weight deliveries. This correlation now is not only restricted to preterm babies but also rather has been expanded to adverse pregnancy outcomes, miscarriage, stillbirth, preeclampsia, and intrauterine growth retardation.[456]

Periodontal disease can be prevented as well as treated.[7] The chances of adverse outcomes of pregnancy give all the more reason for oral health-care professionals to engage with expectant mothers to spread awareness. The general awareness about oral health among the low socioeconomic group remains low, and the myths about oral hygiene in pregnant females remain prevalent.[89] Pregnancy is an opportunity to improve women's oral health practices. Aiming to improve pregnant women's knowledge of oral hygiene will, in turn, improve the oral health of infants and children. With the exposure to media and national oral health program in running, an improvement in the awareness of oral hygiene and health is expected.

The aim of this survey was to assess pregnant women knowledge of oral hygiene practices and common Indian myths about oral hygiene during pregnancy. The survey also assessed the women's awareness on the effect of oral hygiene on adverse pregnancy outcomes.

MATERIALS AND METHODS

The participants included in this cross-sectional survey were the pregnant females reporting to the Outpatient Department of Obstetrics and Gynecology over a period of 2 months. A total of 225 participants were included in the study. The study was reviewed and approved by the Institutional Ethics Committee.

The demographic data, educational status, and history of previous pregnancy were obtained from the participants. A questionnaire was developed to assess women's oral health practices, oral health knowledge, and effect of oral hygiene on pregnancy. The questionnaire was in both languages – English and Hindi, according to the preference of the patient. The questionnaire was validated before the start of the study. Eligible women were given information pamphlet regarding the study, and an informed written consent was taken before providing the questionnaire. A facilitator was provided for the females who were illiterate and not able to fill out the questionnaire on their own.

Descriptive statistics such as mean and standard deviation for continuous variables and frequency and percentage for categorical variables were calculated and tabulated. The level of statistical significance used was <0.05.

RESULTS

The sociodemographic and obstetric characteristics of participants are compiled in Table 1. A total of 225 women participated and completed the survey. The age of participants ranged from 20 to 39 years with a mean of 27.07 ± 3.91 years. Majority of females were in the age group of 18–34 years, i.e., 92.9%. All of the participants had some form of formal education, and none of them were illiterate. Most of the participants were unemployed and homemakers (80%). Almost equal number of participants was in the first, second, and third trimester of pregnancy while for the majority of them, it was not their first pregnancy (76.88%).

Table 1

Sociodemographic and obstetric characteristics of participants

Characteristics	Number of respondents (%)
Age
18-34	209 (92.9)
35-54	16 (7.1)
Educational qualifications
Profession or honors	0
Graduate or postgraduate	64 (28.4)
Intermediate or posthigh school diploma	0
High school certificate	44 (19.5)
Middle school certificate	55 (24.4)
Primary school certificate	62 (27.5)
Illiterate	0
Employment status
Profession	0
Semiprofession	7 (3.1)
Clerical, shop owner, farmer	12 (5.3)
Skilled worker	26 (11.5)
Semiskilled worker	0
Unskilled worker	0
Unemployed	180 (80)
Parity
Primipara	52 (23.11)
Multipara	173 (76.88)
Period of gestation
First trimester	75 (33.3)
Second trimester	69 (30.6)
Third trimester	81 (36)

Majority of participants self-reported some form of oral health problems (72.3%) with bleeding gums as a chief complaint leading the survey (31.1%) [Table 2]. Only one-third of the participants (36.8%) reported any effect on eating choices due to oral problems. A disturbing fact emerging from this survey was that around half of the participants had never visited a dentist in their entire life. Similarly, an abundant number of pregnant females reported safety concerns for developing child as a reason for not taking any treatment during pregnancy.

Table 2

Self-reported oral health status of the participants

Characteristics	Number of respondents (%)
Self-reported oral health problem
None	62 (27.5)
One problem	110 (48.8)
Two or more problems	53 (23.5)
Type of health problems (more than one choice)
Cavity	62 (27.5)
Pain	37 (16.4)
Bleeding gums	70 (31.1)
Sensitivity	32 (14.2)
Bad odor	58 (25.7)
Gingival enlargement	1 (0.4)
Dental problems affecting what to eat
Never	142 (63.1)
Sometimes	62 (27.5)
Often	21 (9.3)
Last visit to dentist
Last week	26 (11.5)
Last month	0
3-6 months	44 (19.5)
6 months-1 year	38 (16.88)
More than 1 year	19 (8.4)
Never	98 (43.5)
Barrier in seeking dental treatment
Safety concerns regarding treatment during pregnancy	102 (45.3)
Dental cost	0
Time constraints	21 (9.3)
Oral health not seen as priority	18 (8)
Advised by others not to take treatment	84 (37.3)

The methods adopted for oral hygiene maintenance in participants are compiled in Table 3. A large number of participants (62.2%) used paste and toothbrush as oral hygiene aids. The use of other aids taken together was significantly less (P < 0.05) than toothbrush and paste. While most of the participants (79.5%) brushed at least once daily, the participants not brushing at all were significantly less (t = 3.774, P < 0.001). The frequency of brush change was seen equally at 3 months (37.7%) and 6 months, (35.1%) and nearly, half of the participants (53.7%) rinsed their mouth after a major meal.

Table 3

Oral health practices among participants

Characteristics	Number of respondents (%)
Means of cleaning teeth
Manjan	27 (12)
Datun	15 (6.6)
Tooth powder	35 (15.5)
Paste and brush	140 (62.2)
Others	8 (3.5)
Frequency of brushing per day
None	16 (7.1)
Once	179 (79.5)
Twice	25 (11.1)
More than twice	5 (2.2)
Frequency of brush change
Less than monthly	0
Monthly	32 (14.22)
3 monthly	85 (37.7)
6 monthly	79 (35.1)
Yearly	29 (12.8)
More than yearly	0
Rinsing of mouth after meals
Yes	121 (53.7)
No	69 (30.6)
Sometimes	35 (15.5)

To assess the prevalent myths and importance of oral hygiene during pregnancy, few questions were asked with true, false, and do not know as choices. The correct responses were assessed for their significance [Table 4]. For all the seven items assessed, the number of participants giving the correct responses was significantly less than the incorrect responses (P < 0.001).

Table 4

Correct participant responses on individual survey item about common myths and importance of oral health

Item content	Correct response (%)	t value	P value
Pain in gums and bleeding normal during pregnancy (false)	36	4.375	<0.001
Pregnancy causes loosening of the teeth (false)	19.55	11.517	<0.001
Visit to a dentist is safe during pregnancy (true)	30.66	6.292	<0.001
Pregnant females should avoid dental treatment unless it is an emergency (false)	10.2	19.726	<0.001
Oral health and pregnancy are related (true)	8.88	21.684	<0.001
Not maintaining oral health can affect the children (true)	25.33	8.509	<0.001
Not maintaining oral hygiene during pregnancy can lead to early delivery (true)	5.33	29.829	<0.001

P<0.05 significant, P<0.001 highly significant. tvalue and P value derived from t- test for percentages

DISCUSSION

The aim of this survey was to assess the oral hygiene habits and awareness of oral health among pregnant females visiting the outpatient department of our hospital. The survey also assessed the influence of common Indian myths about oral hygiene during pregnancy on participants. Finally, the survey was aimed to assess the awareness of pregnant females about effect of oral hygiene on pregnancy outcomes.

The hormonal variations during pregnancy put pregnant females at a higher risk for developing various dental problems.[10] Another factor contributing to this is the fact that lesser number of females seek dental treatment during pregnancy even when there is an existing dental problem.[1112] In our observation, 43.5% of participants never visited a dentist even though 72.44% of participants self-reported one or more oral health problem. One-third of participants reported effect of oral health problems on their eating habits. Inadequate diet as well as lower reporting and visit to dentist can affect the well-being of the developing fetus.[13]

It is well established that routine dental procedures during pregnancy are completely safe and do not adversely affect the pregnancy outcomes.[14] However, the most common barrier in seeking oral care during pregnancy in our observation was safety concern for the developing baby. The participants even after motivation were not willing to undergo any treatment, even though ESIC is a social security initiative, and the dental treatment provided at our hospital is completely free of cost. The other major reason for not taking treatment was that the participants were advised by others not to take treatment. This is a prevalent myth in Indian society, and the participants and their family members were counseled against it after the completion of survey.

A large number of the participants had a good knowledge about oral hygiene habits. The same was reflected in their practices where around two-thirds of participants used toothpaste and brush as oral hygiene aid and 79.5% of them brushed at least once daily. Most of the participants changed their brush either at 3 months or 6 months, and nearly, half of them rinsed their mouth after meals. This awareness about oral hygiene could be because of the fact that none of the participants of survey were illiterate. The awareness could be increased further by organizing counseling sessions for the expectant families on a regular basis.

The questionnaire to assess the understanding of pregnant females regarding a link between oral and systemic health was based on the common Indian myths and prevalent beliefs in Indian society. In all the questions, the percentage of correct responses was significantly lower than incorrect responses.

Many of the respondents of our study believed that bleeding gums were normal in pregnancy. However, it is because of the increased vascularity of oral tissues due to pregnancy hormones. The myth can be easily thwarted by explaining the individuals about the primary etiological agent which still remains dental plaque. With proper oral hygiene maintenance, gingival health can be maintained throughout pregnancy.[15] In our survey, one of the essential beliefs was that pregnancy causes loosening of the teeth. This perception could be curbed if proper information is provided that if oral hygiene is maintained well, pregnancy per se does not cause periodontal disease.[16] It is the already existing local factors which under the influence of increased circulating hormones lead to exaggerated periodontal disease progression.[17]

Substantial number of the females did not find visit to a dentist safe during pregnancy and avoided dental treatment unless it was an emergency. These beliefs are unfounded, and routine dental care is considered safe during pregnancy. The safest period for dental treatment remains the second trimester where complex procedures such as minor surgeries can also be carried out.[18] The pregnant females participating in our survey were unaware that oral health and pregnancy are related and not maintaining oral health could cause adverse pregnancy outcomes. Although the research is still trying to establish a concrete relationship between poor oral health and adverse pregnancy outcomes, several studies have pointed toward the same.[192021] The common oral periopathogens have been found in the amniotic fluid surrounding preterm babies.[2223] A link between the circulating endotoxins from oral bacteria and early delivery has also been suggested.[24] The results of our study point toward prevalent wrong information regarding oral health in pregnant females.

Several studies of similar designs have been conducted within the country and abroad.[25262728] Among these studies conducted in various parts of India had similar conclusions that awareness regarding oral health was poor in pregnant females irrespective of their age or educational qualifications.[2930] In a study conducted in Poland, to assess the level of oral health knowledge in pregnant females, as high as 70% prevalence of gingivitis and periodontitis was found with low health awareness.[28]

Although the pattern of results in these different studies remains similar, the finding of one population cannot be applied to the other population directly. Our study was designed for patients covered under a government-run social security scheme and belonged essentially to lower socioeconomic strata. Since a prevention program was being developed for this particular population, an assessment of their awareness was eminent. Since similar studies have been performed over the years in India, the results remain similar which show the lack of implementation of these data into policymaking. We tried to overcome this barrier too by making a prevention program based on our findings and bringing it to implementation level.

In collaboration with the Department of Obstetrics and Gynecology, a five-point program has been designed for prenatal and antenatal oral health care of pregnant females as follows:

A monthly awareness talk for females in reproductive age in cooperation with public health nurses, ASHA, and Anganwadi workers posted at our rural health and urban health centers

An oral health checkup as soon as the pregnancy is detected

A one-on-one session with pregnant females and their family members to break their myths and promote oral hygiene

Preventive oral health care provided within the course of pregnancy

A postpregnancy session for awareness of mother regarding oral health of self and child.

The limitation of our study remains its observational nature. Direct counseling and emergency treatment were provided to the participants. Although routine dental care was offered to the patient, most of the participants refused to undergo any routine dental procedure. This indicates that a complete overhaul of the mindset of the population is required, not only the pregnant females.

CONCLUSION

A definitive roadmap for comprehensive oral health care of existing mothers has been developed from our observations which will prevent not only adverse pregnancy outcomes but also will help in early maintenance of oral hygiene in children of these mothers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.