Title: Periodontal status of women receiving antenatal care and its association with their oral health-related behavior and quality of life: A Cross-sectional
study
Sarmad Saif 1,2, Siti Lailatul Akmar Zainuddin1,2 *, Fauziah Jummaat 2
1SchoolofDentalSciences,Universiti Sains Malaysia,HealthCampus,16150,Kelantan, Malaysia.
2Hospital Universiti Sains Malaysia, USM Health Campus, 16150, Kelantan, Malaysia.
Corresponding and reprint:
Dr. Siti Lailatul Akmar Zainuddin School of Dental Sciences,
Universiti Sains Malaysia, Health Campus, 16150, Kelantan, Malaysia
E-mail:[email protected]
Tel: +609-7675846; Fax: +609-7675505 Abstract
The inflammation of the periodontal tissue is positively correlated with the increased levels of primary hormones during pregnancy. Since the levels of these hormones increase substantially during pregnancy, therefore, these extensive hormonal changes may alter periodontal tissue's inflammatory profile, adversely affecting the periodontal status with deleterious effects. Current study was aimed to determineandevaluatethe levels of periodontal parameters and the oral health- related quality of life impact during 2nd and 3rd trimester of pregnant women attending the Obstetrics & Gynaecology (O&G) Clinic at Hospital Universiti Sains Malaysia (USM). Seventy fivepregnant women with the mean age of 30.5 (±4.5) years participated in this study. A questionnaire representing different domains of Oral Health Impact Profile (OHIP)–14 items was devised andadministered amongst the participants, followed by theexamination of periodontal status.The presence of initial signs of periodontal diseases, such as bleeding on probing and increased periodontal pockets, were found amongst almost all of the participants. The mean and standard deviation (SD) of plaque score(PS) and gingival bleeding index (GBI) were recorded to be 49.25% (16.92) and 31.34% (18.04) respectively.Themean periodontal pocket depth(PPD) was found to be 4.1(0.15) mmand the mean percentage of sites of PPD ≥ 4 mm was 23.5% (13.03). The
prevalence of women who reported any oral health problem impact measured by the OHIP-14 was higher in the 3rd-trimester group. However, there was no significant difference observed between the participant from different trimesters, for both dental examination and the OHIP-14 questionnaire. The essential outcomes from this study may help in crafting programs to educate pregnant women about the significance of oral health and promote the importance to visit oral health care providers during pregnancy.
Keywords: periodontal disease, pregnancy, OHIP-14 1. Introduction
Periodontium, which is a set of specialized tissues containing; periodontal ligaments, gingiva, cementum, and alveolar bone, helps keepthe tooth in its alveolar socket.Any change in theperiodontiummay lead tothe pocket formation, recession, or in certain cases both. Either way, these changes (also known as periodontal disease) have destructive effects on the alveolar bone which leads to loss of dentition[1]. Periodontal disease is broadly classified into gingivitis and periodontitis.Initial mild periodontal disease in which only gingival soft tissue is involved is referred to as gingivitis, which is very prevalent and easily treatable with the help ofmodest and effective oral hygiene maintaining procedures. Worldwide, Gingivitis has impacts on 50-90 percent of the adult population[2]. If the initial signs of this mildest form of periodontal inflammation remain untreated, then, in susceptible individuals,it may extendfurther deep into the sulcusand it leads to loss of periodontal connective tissue and alveolar bone, hence causingaggressive periodontal disease like periodontitis[3].
The American College of Obstetricians and Gynaecologists (ACOG) defined pregnancy as starting with the embryo implantation in the uterine wall [4].Pregnancy is a delicate time, where a female‟s body experiences massive changes of change to create the feto-maternal balance between the growing fetus requirements and the maternal immune system. During this time, the placenta works as a physiological barrier and buffer between the mother and the fetus for the exchange of nutrients and waste products. This exchange is required for fetal growth and simultaneously for healthy growth any maternal immune surveillance which could harm the fetus is suppressed[5].Along with the physiological changes, pregnancy greatly affects the hormonal profile of an individual.Hormone production such as progesterone levels increases tenfold during pregnancy whereasestrogen levels increase upto 30 times their regular number during the normal
menstrual cycle[6].The increase in progesterone leads to increased vascular permeability, crevicular fluid, and prostaglandin production, which may resultin inflammation of the Gingiva [7].
It may also affect the development of local inflammation and inflammatory factors. Such as reduction in the regulation of the production of interleukin-6 and reduction in the resistance of gingival tissues to bacterial challenge[8].Therefore, there exists a strong relationship between pregnancy and the periodontal status of the person, thus pregnancy is considered to have a widespread oral impact [9, 10].
Besides oral hygiene, Periodontal disease serves as reservoirs of bacteria and these bacteria can approach the foetus through the placental barrier. Preterm birth [11], low birth weight new-borns [12], increased time to conception [13] and premature rupture of membranes [14] have been attributed to the presence of periodontal disease in pregnant women.
Hence it is necessary to evaluate the periodontal conditions during pregnancy and if required, treatment modalities should be used to encounter the harmful effects of periodontal disease in pregnancy. With respect to health status evaluationthrough clinical measures, patient centred health status evaluation is equallynecessary for health. Moreover, the influence of diseases on a person's functional or psychosocial well-being is commonly assessed and demarcated as health-related quality of life. It is a holistic approach towards knowing the complete manner disease affects the individual. The evaluation of the health-related quality of life is perceived as an crucial part of evaluation programs for public health, health careresearch, and clinical purposes [15].
Clinical screening programs and a harmonizing perspective on the social, functional and psychological implications of diseases related to oral cavity (such as periodontal disease) during pregnancy is imperative for the planning and evaluation of pregnant women's dental care; this perspective is also crucial in the identification of the issues and concerns of pregnant women [16].
2.Materials and Methods 2.1 Study aims and population
The current study was aimed to evaluate and determine the difference and presenceof signs related to periodontal disease at different stages of pregnancy and also to assess oral health impact profile in pregnant women attending Hospital USM, Kelantan, Malaysia. A cross-sectional study was conducted at O&G Clinic, Hospital Universiti Sains Malaysia (USM) in Kota Bharu, Kelantan, Malaysia. The participants were recruited by convenience sampling and the exclusion criteria were
set as, pregnant women with any uncontrolled medical conditions such as blood disorders,hypertension, diabetes mellitus, drug history, and having less than six teeth, could not take part in the study. All participants were recruited voluntarily and informed written consent was taken. Age, ethnicity, and stage of pregnancy were recorded. The assessment of OHRQoL was made by means of the Malaysian version of the Oral Health Impact Profile (OHIP)-14 which has 14 items[17]. The Malaysian OHIP-14 is specifically customized according to the Malaysian population [18]. Participants were instructed to grade the impact of their oral health on 14 key areas of OHRQoL which were collected under seven diverse domains; Functional Limitation, Physical Pain, Psychological Discomfort, Physical disability, Psychological disability, Social disability, and Handicap. These participants were requestedto answered that how frequently they experienced difficulties and problems with their teeth, mouth, or dentures (related to 14 items) since the onset of their pregnancy. The approval for protocol used in this study were approved from Human Research and Ethics Committee USM (USM/JEPeM/18010020).
2.2 Oral assessment
All participantswere subjected toa full-mouth periodontal examination to determine periodontal status. The parameters used were plaquescore (PS)[19], Gingival bleedingindex (GBI)[20], periodontal pocket depth (PPD). All measurements were recorded by using the UNC-15 periodontal probe which is 15mm in length with coding at 5th, 10th, and 15th markings.
To observe the presence of PS and GBI, four surfaces of the tooth; Mesial, Distal, Buccal / Labial, and Lingual were observed for the presence of plaque and bleeding on probing (BOP). The total number of dental surfaces with plaque and BOP were calculated and the percentage value for both PS and GBI was devised. Moreover, PPD was measured on six different sites of each tooth namely mesiobuccal, mid buccal, distobuccal, mesiolingual, mid-lingual, and distolingual. Lastly, the diagnosis of periodontal diseases was made clinically as per the American Academy of Periodontology [21].
2.3 Research tool
In this recent literature Malaysian version of the Oral Health Impact Profile (OHIP(M)) questionnaire was quite widelyused and adopted accordingly to assess oral health-related quality of life of participants [22]. In current study we used this validated Malaysian version OHIP (M).The questionnaire was first developed bySlade and Spencer for the evaluation of different domains related to the quality of life of patients [23]. OHIP (M) containsfourteen items and seven domains
which are functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. A two-point Likert scale format that ranges from „0‟ for „never‟, „hardly ever‟, „occasionally‟ and „2‟ for „fairly often‟ and „very often‟
was incorporatedin current study to assessthe frequency of impact triggered by oral conditions during pregnancy. After evaluation and assessment of responses by the participants the prevalence of impact was determined which is the percentage of respondents reporting one or more impacts
„fairly often‟ or „very often‟ the method used in this study coincide with previous literature[22].
This variable is used because it identifies those domains which more severe and chronic rather than brief or temporary oral health impacts during pregnancy.
2.4 Statistical analysis
In this current study all data have been analyzed in SPSS version 24.0 and all participant characteristics were evaluated and the descriptive statistics such as mean and standard deviation (SD) for continuous variables, and frequency and percentage for categorical variables were determined. Baseline comparisons of periodontal parameters and impact prevalence of OHIP-14 between the two groups were determined using the independent t-test. Frequency distribution was used for the determination of socio-demographic attributes like lifestyle habits, last dental visit, frequency of tooth brushing for different trimesters. Statistical significance was set at a P-value
<0.05 at a 95% confidence interval (CI).
3.Results and Discussions
Pregnancy is a special physiological state characterized by a series of temporary adaptive changes in the body structure as a result of increased reproductive hormone (i.e. estrogen and progesterone) production. Such endocrine actions also affect the oral cavity and may result in transient and irreversible changes, which may be considered pathological [24]. In this study, we assessed the periodontal status in two phases (second and third trimester) of pregnancy and evaluated the perception of pregnant females towards the oral health-related quality of life
3.1 Subjects characteristics
Table 1 summarizes the demographic characteristics, dental service utilization, frequency of brushing daily, and education level of the participants. The mean age (SD)of the participants of this study was 30.5(4.5) years old while the mean age of 2nd-trimester participants was 28.21(5.03) and of the 3rd trimester was 29.70(4.22). The majority of participants were Malays (96%) and among all
the participants, 52%hadtertiary or above educational background and 42% had higher secondary or below educational level.About 73% did not visit any of the dental health care providers during the term of their pregnancy and 76% of the participants brush once a day and only 24% of the participants brushed twice daily.
This study further highlights that education doesn‟t always correlate with good oral hygiene. Despite more than 50% of the sample population having a good educational background only slightly more than 9% have regular appointments with dental health care providers. This could be due to the lack of knowledge about the importance and significance of good oral hygiene practices. As has been reported in the previous studies that due to pregnancy-related reasons there is an impaired capacity for proper brushing and lack of maintenance of good oral hygiene [25].
Furthermore, most pregnant women reported that tooth brushing was nearly impossible because of pregnancy-related nausea [26].
Table 1: Socioeconomic demographic characteristics, educational levels, dental service utilization and frequency of brushing exhibited by the participants.
Subjects Demographic
characteristics
2nd Trimester
n=21
3rd Trimester
n=54
Total participants
n=75 Age
[mean(SD)]
28.21(5.03) 29.70 (4.22) 30.5(4.5) Race
Malay,n (%) Non-Malay, n (%)
20(95.2) 01 (4.8)
52 (96.3) 02 (3.7)
72(96) 03(04) Educational level
Higher secondary or below, n(%)
Matriculation or bachelor degree or above,
n(%)
10(47.6) 11(52.4)
26(48.1) 28(51.9)
36(48) 39(52)
Brushing Once a day n(%) Twice a day n(%)
16(76.1) 05(23.8)
41(75.9) 13(24.1)
56(76) 18(24) Dental treatment
Received n (%) Syptomatic n(%) Not utilized n(%)
0(0) 4(19) 17(81)
8(114.8) 10(18.5) 36(66.7)
8(9.9) 14(17.3) 53(72.8)
3.2 Periodontal parameters
The result from table 2 showed that all participants exhibited explicit signs of some forms of periodontal disease (100%). Further identification showed that participants in their second trimester had mean values of 4.1mm (SD0.14), 26.0% (SD18.02), and 47.2% (SD16.58) for PPD, GBI, and PS respectively. The mean total incidence of sites with probing depth ≥ 4mm was 22.2%
(SD13.16) to be present in the second trimester of the participants. The mean values of PPD, GBI, and PS for the participants in their third trimester were calculated to be 4.1mm (SD0.15), 36.7%
(SD19.69), and 50.1% (SD17.13) respectively. Whereas, themean of total sites with probing depth
≥ 4mmwas 24.0%(12.87) for the participants in their third trimester.The analysis reveals that PPD, GBI and PS mean have no statistically significant difference between the two trimesters (p>0.05).
All the participants of this study were found to suffer from periodontal disease. A study in Amman, Jordan, demonstrated similar results, whereby 100% of the pregnant women had signs of periodontal disease [27]. Whereas, a study in the Raichur district of India also reported 95% of the sample population of primigravidae women to have some signs of periodontal disease [28]. The literature further supports the findings of this study, because work carried out by Jago et al. in Brisbane Australia and Miyazaki et al. in Japan show similar trends, where the majority of the sample population showed signs of one or the other form of periodontal disease. The increased prevalence of periodontal disease could be due to the poor oral hygiene status of the pregnant women that may have aggravated the influence of hormones on the periodontium [29][30][31].
According to our findings, PS, GBI, and mean probing pocket depth have no statistically significant difference between the two trimesters observed. Periodontal disease during pregnancy seemed to be dependent on, but unrelated to, the amount of dental plaque accumulation [32]. As pregnancy is a complicated state both physiologically and psychologically, periodontal disease during pregnancy may also be triggered by stress and anxiety [33].
Table 2: Periodontal parameters of pregnant women.
Parameter
2nd Trimester
Mean (SD) (n=21)
3rd Trimester
Mean (SD) (n=54)
Total Mean (SD) (n=75)
Mean difference (Confidence
Interval)
p-value
Mean Probing Pocket Depth (PPD)(mm)
4.1 (0.14)
4.1 (0.15)
4.1 (0.15)
0.0 (-0.04,0.08)*
0.6
Total sites with probing pocket depth ≥4 mm (%)
22.2 (13.61)
24.0 (12.87)
23.5 (13.03)
-1.8 (-8.18, 4.50)
0.6
Gingival bleeding index (%)
26.0 (18.02)
36.7 (19.69)
31.3 (18.04)
-7.6 (-16.23,1.02)
0.1
Plaque score (%) 47.2 (16.58)
50.1 (17.13)
49.3 (16.92)
-2.9 (-11.17,5.27)
0.5
3.3 OHIP-14
Table 3 represents the prevalence of negative impact on the quality of life of the participants during pregnancy due to oral health conditions in different domains of OHIP-14.
Impact prevalence means the total number of participants showing 'fairly often', or 'very often', responsesin domains of the OHIP-14 questioner. The total percentage of subjects showing negative impact through OHIP-14 questioners in the 2ndwas 14.3% and in the 3rd-trimester participant, it was 25.9% respectively. The most commonly reported negative impacts during pregnancy were within the domains of “physical pain” (20%) and “psychological discomfort” (10.7%).
As oral hygiene plays a vital role in defining the occurrence of periodontal disease, it is very important to determine how well pregnant women perceive their oral health. According to this study totalof 22.7% of pregnant women reporteda negative impact on their quality of life due to their oral health. In this recent study, it has been witnessed that the pregnant women who are participating frequently reported:“physical pain” (20%) and “psychological discomfort” (10.7%), these two domains of OHIP-14 were previously also reported by Lu et al in his study in 2015. In this previous study it was established that the pregnant participant mostly reported issues related to the domains of “physical pain” (5.6%) and “psychological discomfort” (4.5%) as compared to other domains of OHIP-14[34].
Table 3: Impact prevalence of each OHIP-14 domain during pregnancy
OHIP-14
2nd Trimester
21(%)
3rd Trimester
54(%)
Total participants
75(%)
p-value
Function limitation 0(0) 0(0) 0(0) 0
Physical pain 2(9.5) 13(24) 15(20) 0.2
Psychological discomfort
3(14.3) 5(9.3) 8(10.7) 0.7
Physical disability 2(9.5) 4(7.4) 6(8) 1.0
Psychological disability
2(9.5) 4(7.4) 6(8) 1.0
Social disability 0(0) 3(5.6) 3(4) 0.6
Handicap 0(0) 3(5.6) 3(4) 0.6
Impact prevalence 3(14.3) 14(25.9) 17(22.7) 0.2
A study concerning oral health-related quality of life was done in Hong Kong, discussed that the prevalence of negative impact on the psychological domains (discomfort and disability) ranges between 4.0% and 6.3%. There were less prevalent results found in the domains of social disability and handicap when compared with the domains of physical pain, psychological discomfort, and psychological disability these results coincide with our current study[35].Another similar study was done by Sari EY et al., 2011 show 36% of pregnant women reported the impact of at least one item of oral health impact profile-14 [36].The results of previous studies may vary with comparison to our study with regards to the racial or ethnic differences in the environmental and cultural changes, but the consensus is there and there is a dire need for different oral health awareness programs to encourage pregnant women to attend dental health care facilities regularly during their gestational period.
4.Conclusion
The prevalence ofperiodontal disease among the 2nd and 3rd trimesters of pregnancy was 100%. Among them, 22.7% have the impact of at least one OHIP-14 item, with the most commonly reported impacts were within the domains of “physical pain” and “psychological
discomfort”. The findings of the study may help in designing programs to educate pregnant women on the necessity of maintaining a healthy periodontal status during pregnancy.
Acknowledgments
The authors would like to express their gratitude to all staff in Gynaecology &
Obstetrics Clinic and Dental Clinic, Hospital Universiti Sains Malaysia who were involved during the study. We are indebted to all patients for their kind participation. This study was supported by Research University Grant, Universiti Sains Malaysia (304/PPSG/6316158).
Declaration of Interest
All authors declared no conflict of interest in any form.
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