Knowledge and Experience of Women about Dental Services Utilization during Pregnancy: A Cross-Sectional Questionnaire Study.

AIM OF THE STUDY: The present study was aimed to assess the knowledge and experience of women about dental services utilization during pregnancy.
METHODOLOGY: A hospital-based, cross-sectional questionnaire-based study was conducted among 300 women of age between 18 and 45 years who attended Malla Reddy Dental Hospital during 3 months period from October 2019 to December 2019. A questionnaire was distributed to all the participants who had given consent to participate in the study.
RESULTS: Only 30.7% of the participants attended for dental checkup during their pregnancy. Among them, most of the people (52%) had visited dentist for toothache, followed by gum care (29.34%) and regular checkup (18.47%). Most of the subjects (69.3%) did not use dental services as they were unaware of dental checkup during pregnancy. A significant difference was found between the urban and rural participants regarding the visit to the dentist during pregnancy (P = 0.000, Chi-square value = 19.157).
CONCLUSION: Most of the women unaware of dental checkup during pregnancy. They were also not sure aware of dental treatments which can be done during pregnancy and consequences of poor oral hygiene on pregnancy outcome. Copyright:

INTRODUCTION

Mouth is the mirror of health. Oral health affects the overall health and vice versa, especially in case of pregnant women. Pregnancy is a very crucial and unique time in women's life. Pregnancy itself causes many transient physiological changes due to hormonal changes which influence their general as well as oral health.

Many changes could be noticed, during pregnancy, in the oral cavity due to high levels of estrogen and progesterone hormones that alter the oral vascular permeability and immunocompetence, which leads to inflammation; hence, pregnant women are more prone to dental diseases such as xerostomia and periodontitis.[1]

Studies had shown that there is a link between “increased plasma levels of pregnancy hormones and a decline in periodontal health status.”[1] The prevalence of periodontal disease during pregnancy ranges from 30% to 100%.[2] Pregnant women are more prone to gingivitis, periodontitis, dental caries, xerostomia, and teeth erosion. Dental caries and dental erosion during pregnancy are attributable because of continuous nausea and excess intake of citrus fruits, and thus, it is important for them to receive preventive oral health care services.

Studies[34] had shown that poor oral hygiene during pregnancy leads to premature delivery of low birth weight babies. The U.S. Surgeon General,[5] World Health Organization,[6] and American College of Obstetricians and Gynecologists[7] had recognized that oral health is also important as a part of preventive healthcare for pregnant women and their newborns. Women should have knowledge about their oral health during pregnancy.

Hence, the importance of the oral health of pregnant women has been focused. It is recommended that pregnant women should visit the dentist during their pregnancy period.[8]

However, most of the pregnant women do not utilize dental services during pregnancy,[9] especially in the Indian scenario, women have a common misconception that they should not have dental checkup and dental treatments during pregnancy and they should postpone all dental treatments till delivery as dental treatments are harmful to their future babies as well as for themselves, but it results in facing the consequences of oral diseases. Apart from unawareness about dental checkup during pregnancy, there are some barriers that limit them to utilize dental services. All women, especially childbearing age, should have awareness of oral health problems during the pregnancy period. These are the one who can motivate and inform their friends and family members about the oral health awareness during pregnancy period.

Hence, the study was conducted to assess the knowledge about oral health problems during pregnancy and their experience about dental services utilization during pregnancy among women.

METHODOLOGY

A hospital-based questionnaire study was conducted among women of childbearing age between 18 and 45 years who attended the Malla Reddy Dental Hospital during 3 months period from October 2019 to December 2019.

Ethical clearance was obtained from the Mall Reddy Institute of Dental Sciences, and written consent was taken from all the subjects who had participated in the study.

Based on convenient sampling technique, a total of 300 female subjects who gave birth to at least one child had involved in the study.

A closed-ended questionnaire was framed based on experts' opinion in that fraternity, and a pilot study was conducted to know the feasibility of conducting the study and understanding of the questions by the subjects to restructure the questionnaire. The final questionnaire consists of three parts, and the first part consists of questions related to demographic data such as age, education, occupation, and number of live births, whereas the second part consists of three questions related to their visit to the dentist during pregnancy, reason for visiting the dentist, and the subjects who did not visit dentist during their pregnancy, and the reason for not visiting the dentist. The third part consists of five questions related to knowledge of the subjects about dental services utilization during their pregnancy.

Content validity was checked and validity of the questionnaire was found to be acceptable with Cronbach's alpha value of 0.82. Test–retest reliability was evaluated using Kappa statistic and the level of agreement was found to be acceptable with score of 0.8. Questionnaire was distributed to all the participants who had given consent to participate in the study after explaining about the study.

A single investigator had conducted the entire study to avoid the interviewer's bias. After completion of the study, data were entered in MS Excel Sheet 2007 and subjected for the analysis by using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, version 20.0. Armonk, NY:IBM Corp. Descriptive statistics such as frequency and percentages were calculated, Chi-square test was used for comparison of groups, and P < 0.05 was considered as significant.

RESULTS

Table 1 shows the distribution of demographic data of the participants.

Table 1

Demographic data of the participants

	Frequency (%)
Age group
18-19	7 (2.3)
20-29	81 (27)
30-39	129 (43)
40-49	83 (27.6)
Parity
1	77 (25.7)
2	148 (49.3)
3	63 (21.0)
4	12 (4.0)
Education status
Higher education	65 (21.7)
Secondary	142 (47.3)
Primary	64 (21.3)
Illiterate	29 (9.7)
Occupation
Homemaker	175 (58.3)
Employee	125 (41.7)
Economic status
Upper middle	171 (57.0)
Lower middle	76 (25.3)
High class	3 (1.0)
Low class	50 (15.6)
Total	300 (100.0)

The age group of the participants was distributed between 18 and 45 years with a mean age of 32 ± 1.2. Most of the participants (49.3%) had 2 live births, 25% of the subjects had single live birth, 21% had 3 children, and 4% of the subjects had 4 live births also. Most of the participants (47.3%) were with secondary education, 21.7% were with higher education, 21.3% were with primary education, and 9.7% were illiterates. More than half of the participants (58.3%) were homemakers, and 41.7% of them were employees. Based on their socioeconomic status, most of the participants (57%) were from upper middle class, followed by lower middle (25%) and lower class (15%) [Table 1].

Only 30.7% of the total sample attended for dental checkup during their pregnancy [Table 2]. Among them, most of the people (52% of those who attended for dental checkup) had visited dentist for toothache, followed by gum care (29.34% of those who attended for dental checkup) and regular checkup (18.47% of those who attended for dental checkup) [Table 3].

Table 2

Question regarding dental checkup during pregnancy

Dental checkup during pregnancy	Frequency (%)
Yes	92 (30.7)
No	208 (69.3)
Total	300 (100.0)

Table 3

Question regarding the reason to visit dentist

Reason to visit dentist	Frequency (%)
Gum care	27 (29.34)
Toothache	48 (52.17)
Regular checkup	17 (18.47)
Total	92 (100.0)

Among all the subjects who visited dentist during their pregnancy, 27 participants had visited for gum care, and among them, 11 participants were from urban and 16 participants were from rural area. Out of 48 participants who had dental visit during their pregnancy for toothache, 34 participants were from urban and 14 participants were from rural area, whereas 17 participants had dental visit during their pregnancy for regular checkup, and 16 participants were from urban and only one participant was from rural area [Table 3].

A significant difference was found between the urban and rural participants regarding their dental visit during pregnancy. (P = 0.000, Chi-square value = 19.157).

Subjects who had not visited the dentist during pregnancy were around 70%, and most of them (40.3%) had not visited due to unawareness of visiting the dentist during pregnancy, around 15% of them thought that they do not require dental checkup at all, and 9% of them had a myth that they should not visit dentist during pregnancy period [Table 4].

Table 4

Question regarding the reason for not visiting the dentist during their pregnancy

Reason for not visiting the dentist	Frequency (%)
No knowledge	121 (40.3)
Should not visit	26 (8.7)
Not required	44 (14.7)
No time for dental checkup	2 (0.7)
Fear of dentist	15 (5.0)
Visited	92 (30.7)
Total	300 (100.0)

Only 26% of the subjects knew that pregnant women should have a dental checkup during the pregnancy period. Moreover, 32% of them aware that pregnancy causes gum diseases and other diseases in the mouth. Almost half of the subjects (47.3%) did not aware that dental treatments can be done during pregnancy under special care and very few subjects (12%) knew that poor oral health has adverse effects on overall health of pregnant women, and dental X-rays can be taken during pregnancy covering with lead apron (10%) [Table 5].

Table 5

Distribution of participants according to knowledge about pregnancy oral health

	Yes (%)	No (%)	Don’t know (%)	Total (%)
Pregnant women should visit dentist during the pregnancy period?	78 (26)	108 (36)	114 (38)	300 (100)
Pregnancy causes gum diseases and other diseases in the mouth?	96 (32)	127 (42.3)	76 (25.3)	300 (100)
Dental treatments can be done during pregnancy under special care	75 (25)	142 (47.3)	83 (27.6)	300 (100)
Poor oral health has adverse effects on pregnant women health?	36 (12)	134 (44.6)	130 (43.3)	300 (100)
Gum diseases during pregnancy have adverse effect on pregnancy outcomes?	39 (13)	104 (34.6)	157 (52.3)	300 (100)
Dental X-rays can be taken during pregnancy under special precautions?	30 (10)	200 (66.7)	70 (23.3)	300 (100)

DISCUSSION

Studies[10] have indicated that pregnancy leads to poor periodontal health due to increased hormones.

Ehlers et al. had conducted a study[11] in 2013 to compare the periodontal status of pregnant and nonpregnant women. They found that gingival inflammation was highly seen in pregnant women when compared to control group. Recent study[12] had shown that there was a relation between periodontitis and low birth weight during pregnancy.

Mangskau and Arrindell[13] conducted a study in North Dakota during 1996, and it was reported that almost half of the participants (43%) received oral care during pregnancy. It also found that the educated women with high income had received dental care than others. The main reasons for not seeking dental care were financial barriers and not having dental health problems.

In the present study, women who live in urban area had received more dental care during their pregnancy than the rural area, and the reason might be because the availability of dental services is more in urban than rural areas.

Seeking oral care was reported to be associated with many factors such as age and income level, lack of education,[14] sociodemographic differences,[14] and lack of perceived need.[15]

Azofeifa et al.[14] conducted a study to assess and compare the oral health status such as dental caries and periodontal disease among pregnant and nonpregnant women of age between 15 and 44 years by using the data from National Health and Nutrition Examination Survey of 1999–2004 and concluded that significant sociodemographic differences were seen among pregnant women in usage of dental services and also showed that having a dental visit within the year was significantly increased as the pregnant woman's age, education, and income increased.

Another study conducted by Cigna Corporation[16] in 2015 in the U.S. reported that though many pregnant women (76%) had dental problems; very few of them (57%) reported to have dental visit.

In the present study, only 30.7% of the subjects had dental visits during their pregnancy period due to various reasons such as 9% of them for gum problems, 16% of them due for toothache, and 5.7% of them for regular checkup.

Le et al.[17] in 2009 conducted a telephonic interview to find out the reason for not seeking dental care during pregnancy and they reported that personal matters such as economic, domestic, and employment issues and also dental care issues such as time, cost, understanding the importance of oral care, and attitude of oral care provider were the reasons that made the pregnant women to avoid the dental care.

In the present study, almost 70% of subjects did not seek dental care during their pregnancy period due to various reasons such as 40.3% had not visited due to unawareness of using dental services during pregnancy, around 9% of them had a myth that they should not use the dental services during pregnancy, 14.7% of them thought that dental checkup during pregnancy is not required, 5% of them due to fear of dental checkup, and around 1% of them said no time for dental checkup.

Marchi et al.[15] in 2010 conducted a study to know the reasons for not seeking dental care during pregnancy and they found that the main reason was lack of felt need, and the other reason was economic barriers.

In the present study, only 26% of participants aware that pregnant women should visit the dentist, and 32% of them knew about the adverse effects of pregnancy on oral health. Only 25% of the subjects were aware that dental treatments can be done during pregnancy under special care and very few people (13%) knew that about gum diseases during pregnancy have adverse effects on pregnancy outcomes.

Every woman should know that seeking dental care during pregnancy is not harmful, and there are certain guidelines for the treatment of pregnant women. Dental care services can take place during any trimester and, if urgent, should not be delayed.[18]

Lead aprons should be used during dental X-ray imaging to avoid the risk of radiation exposure during pregnancy.[19] In the present study, very few subjects (10%) knew that dental X-rays can be taken during the pregnancy period.

Women can seek both preventive and therapeutic dental care during pregnancy, but they should have appointments in such a way that they should be comfortable on the dental chair-like posture and duration of dental services for overall maintenance of health.[15]

A complete general and oral healthcare should be planned at the first visit of pregnant women which include health education and oral hygiene instructions such as brushing two times a day, flossing, gargle with water after every meals, and referral for oral health problems.

Would be mothers should know that Streptococcus mutans bacteria are associated with dental caries, and it can be transmitted from mother to child and infect the child's teeth at early age that leads to risk of early childhood caries.[20] Hence, healthcare providers should suggest their patients for dental checkup also at initial days of pregnancy period.

Limitations

As it is a questionnaire study based on interviewing the study subjects, there is a chance of memory bias as the participants were not current pregnant women and they could not remember what had happened during their pregnancy times.

CONCLUSION

In the present study, very few participants had knowledge about dental checkup during pregnancy time. Few of them have a myth that they should not have dental checkup and seeking dental care during the pregnancy period. Women should have knowledge about oral healthcare, dental checkups, and safety of dental treatments during pregnancy to avoid adverse effects of poor oral health on pregnancy outcomes. Awareness programs should be conducted by dental professionals for all women to know the importance of dental checkup during pregnancy period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.