|Year : 2019 | Volume
| Issue : 1 | Page : 21-27
Oral and dental care during pregnancy: A survey of knowledge and practice in 380 Iranian gynaecologists
Mahin Bakhshi1, Maryam Tofangchiha2, Sedigheh Bakhtiari1, Tannaz Ahadiyan1
1 Department of Oral Medicine, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Oral and Maxillofacial Radiology, Dental School, Qazvin University of Medical Sciences, Qazvin, Iran
|Date of Web Publication||27-Feb-2019|
Dr. Sedigheh Bakhtiari
Department of Oral Medicine, Dental Faculty, Shahid Beheshti University of Medical Science, Velenjak Blv, 1983969411, Tehran
Source of Support: None, Conflict of Interest: None
Aim: Pregnancy as a special condition in women's lives requires an optimum level of oral and dental care. Therefore, gynecologists play a key role to persuade pregnant women to seek oral health-care services. The aim of this study was to evaluate the knowledge and practice of gynecologists with regard to oral and dental health during pregnancy. Subjects and Methods: The measuring tool was a questionnaire. The validity of the questions was assessed by 12 faculty members working in this field, and then the Content Validity Index was calculated for each question. Questionnaire containing 23 questions; with 18 questions relating to knowledge and 5 questions relating to practice. Four hundred and fifty gynecologists were randomly selected to fill in the questionnaire. Statistical Analysis: The Kolmogorov–Smirnov Spearman and Kruskal–Wallis tests were used. Results: Response rate was 84.4%. The mean knowledge of gynecologists about oral and dental healthcare during pregnancy was 12.35 ± 2.737 out of a total score of 18, which shows that their awareness was at an appropriate level. Average practice of gynecologists with regard to oral and dental healthcare during pregnancy was 3.31 ± 1.256 out of a total score of 5, which is also an appropriate level. There was no significant relationship of age with the knowledge and practice of gynecologists with regard to oral health during pregnancy. There was a significant positive relationship between the year of graduation and knowledge (P = 0.042), though there was no significant relationship between graduation year and practice. Conclusion: The knowledge and practice of Iranian gynecologists with regard to oral and dental healthcare during pregnancy were at an appropriate level.
Keywords: Gynecologist, knowledge, oral health, practice, pregnancy
|How to cite this article:|
Bakhshi M, Tofangchiha M, Bakhtiari S, Ahadiyan T. Oral and dental care during pregnancy: A survey of knowledge and practice in 380 Iranian gynaecologists. J Int Oral Health 2019;11:21-7
|How to cite this URL:|
Bakhshi M, Tofangchiha M, Bakhtiari S, Ahadiyan T. Oral and dental care during pregnancy: A survey of knowledge and practice in 380 Iranian gynaecologists. J Int Oral Health [serial online] 2019 [cited 2019 May 20];11:21-7. Available from: http://www.jioh.org/text.asp?2019/11/1/21/253144
| Introduction|| |
Pregnancy is a natural process that leads to physical and psychological changes in women, including oral and dental changes. Fundamental physiological changes include endocrine, cardiovascular, blood, respiratory, digestive, and urinary tract changes., One of the most important changes is an increase in the level of important hormones such as estrogen and progesterone. High levels of these hormones increase the vascular permeability and also lead to some changes in the blood vessels, resulting in the progression of periodontal disease. When dental plaque is present, the gingival inflammatory response is even more severe during this period. The prevalence of gingivitis during pregnancy has been reported to be 30–100 percent.,, In many studies, periodontal diseases have been regarded as a risk factor for low birth-weight or preterm birth, as well as an increased risk of preeclampsia.,,
In a prospective study, Horton et al. showed that the prevalence of preterm birth (28 weeks) in pregnant women with moderate-to-severe periodontitis is 10 times higher than other pregnant women. Inflamed gingival tissues release inflammatory mediators such as tumor necrosis factor-alpha and prostaglandin E2, which have a toxic effect on the fetus.
Pregnancy indirectly induces dental caries. Different factors such as diet, sugar, and acidic substances due to morning sickness (vomiting during pregnancy) provide a foundation for the progress of dental caries. Good oral hygiene, however, can help prevent this problem.,,
Infectious diseases can cause fever and thereby promote miscarriage. Therefore, the prompt treatment of odontogenic infections and periodontitis is recommended. Whenever necessary, supragingival scaling and polishing should be performed. The prevention of plaque formation during pregnancy, especially in the first trimester, is important for the mother and the fetus. Apart from dental plaque control, no selective dental procedure should be performed because of the potential vulnerability of the fetus during the first trimester. The second trimester is the safest period for routine dental procedures.
General looseness of teeth may be observed in the third trimester of pregnancy due to gingival inflammation, loss of attached gingiva, and changes in the lamina dura.
The most common oral complication of pregnancy is gingivitis, which mostly occurs in the second trimester. Localized gingival hyperplasia is also observed in pregnancy it is called the pregnancy tumor. If surgery is required, it should be postponed until after delivery.
Dental treatment during pregnancy is difficult for both the mother and the dentist. For instance, there are difficulties involved in the administration of medication and its interaction with the pregnancy, as well as the pain, fear, and anxiety due to the physical and psychological state of the mother.
Although radiography is performed in pregnant women in accordance with some considerations, there is still concern about the possible side effects on the fetus. Administration of local anesthesia with epinephrine is generally safe during pregnancy and is a part of Groups B and C of the Food and Drug Administration drugs classification. Although anesthetics containing vasoconstrictors cross the placenta, the applications of such drugs below the toxic threshold do not cause fetal malformations.
The sensitivity of pregnant women and their families leads to an unwarranted fear of dental treatments in these people. Lack of sufficient knowledge makes pregnant women concerned about any treatment or care for themselves and their fetal health. In this regard, the role of gynecologists as their doctors is very important because changing this inaccurate attitude is tightly correlated to the knowledge given by the specialist physician to the patients. This requires gynecologists to have enough knowledge of dental and oral changes during pregnancy., Therefore, this study aimed to assess the knowledge and practice of gynecologists in relation to dental and oral healthcare during pregnancy.
| Subjects and Methods|| |
Initially, a questionnaire was designed in cooperation with the Community Oral Health (COH) Department of Dental School. The validity of the questions regarding the simplicity, clarity, and relevance was assessed by 12 faculty members working in this field, and then the content validity index was calculated for each question. The questionnaire included 25 questions about knowledge and six questions about the practices, followed by gynecologists regarding oral hygiene and dental care during pregnancy.
There were three possible answers for each question – correct, incorrect, and no response.
The questionnaire was distributed among 20 gynecologists as a pilot. After 1 month, the questionnaire was given to the same people for the second time. After the questions were answered, the reliability was determined by calculating the Kappa coefficient for each question. Of the 25 questions relating to knowledge, seven questions were removed and of the six questions relating to the practice, one question was removed. Finally, a questionnaire containing 23 questions with 18 questions relating to knowledge (Questions 1–19) and five questions relating to practice (Questions 19–23) – was prepared. The questionnaire was divided into six sections. The first five sections were related to knowledge while the last section was related to the practice. Questions 1–5 were related to the necessity of dental care before and during pregnancy, Questions 6 and 7 were related to oral health during pregnancy, Questions 8–10 to the effects of pregnancy on oral and dental health, Questions 11–13 to the impact of oral diseases on pregnancy, Questions 14–18 to dental procedures during pregnancy, and Questions 19–23 To dental practice during pregnancy. The questionnaire was distributed among 450 gynecologists. These people were randomly selected from participants of the monthly meetings and Annual Congress of Gynecology, as well as from other places such as hospitals and private clinics. Correct and incorrect answers were extracted and reported as the level of knowledge and practice of gynecologists. Each correctly answered question was given; score #1, while the incorrectly answered or unanswered questions were given score #0. Therefore, knowledge scores ranged from zero to 18 and practice scores ranged from 0 to 5.
Knowledge scores were as follows: 0–4.5 = very poor, 4.5–9 = poor, 9–13.5 = good, and 13.5–18 = very good. Practice scores were considered as follows: 0–1 = very poor, 1.26–2.51 = poor, 2.52–3.77 = good, and 3.78–5 = very good.
Participants were assured of the confidentiality of the information at the beginning and were asked to anonymously fill in the questionnaire to their satisfaction.
This study was approved by the Ethics Committee of the Shahid Beheshti University of Medical Sciences, Dental School (code IR.SBMU 2016, B 310147).
To describe the variables, descriptive statistics (mean and standard deviation) and frequency percent were used. The Kolmogorov–Smirnov test was used to assess the normal distribution of data. Spearman correlation coefficient was used to determine the relationship between knowledge and practice scores with age and year of graduation. In addition, the Kruskal–Wallis test was used to determine the relationship between knowledge and practice with occupation. The rate of type I error (α) and confidence level was considered equal to 0.05 and 95%, respectively. When the type I error (α) was lower than 0.05 (P < 0.05), the difference was assumed to be statistically significant. Statistical analysis was done using SPSS 20 (IBM, Armonk, NY, USA).
| Results|| |
In this study, response rate was 84.4%. From the 450 gynecologists, 380 persons filled in the questionnaire.
A total of 380 gynecologists with an average age of 45.69 were included in the final analysis.
More than half of them had 16–33 years of work experience and nonacademic occupation. Out of a total score of 18, the average gynecologist's knowledge about oral healthcare during pregnancy was 12.35 ± 2.737 (with a minimum score of 3 and a maximum score of 18), which indicates that their knowledge was at an appropriate level. Out of a total score of 5, the average practice score of gynecologists with regard to oral healthcare during pregnancy was 3.31 ± 1.256 (with a minimum score of 0 and a maximum score of 5), which indicates a proper level of practice.
Demographic data of participants are summarized in [Table 1].
|Table 1: Sociodemographic characteristics of the study participants (n=380)|
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There was a significant correlation between graduation year and the knowledge of the gynecologists (P = 0.42); however, no significant association between the year of graduation and practice (P = 0.534).
There was no significant relationship of age with knowledge and practice of gynecologists in relation to oral health care during pregnancy.
The distribution of the scores of knowledge (P = 0.09) and practice (P = 0.96) among different occupational groups (academic and nonacademic) did not show a significant difference.
Out of a total score of 5, the average gynecologist's knowledge about the need of oral and dental care before and during pregnancy was 3.67 ± 1.035 [Figure 1].
|Figure 1: Knowledge of gynecologists regarding need to oral and dental care before and during pregnancy|
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Out of a total score of 2, the average gynecologist's knowledge about oral and dental hygiene during pregnancy was 1.61 ± 0.596 [Figure 2].
|Figure 2: Knowledge of gynecologists regarding oral and dental hygiene during pregnancy|
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Out of a total score of 3, the average gynecologist's knowledge about the impact of pregnancy on dental health was 2.11 ± 0.941 [Figure 3].
|Figure 3: Knowledge of gynecologists regarding the effects of pregnancy on dental health|
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Out of a total score of 3, the average gynecologist's knowledge about the impact of oral diseases on pregnancy was 2.07 ± 1.044 [Figure 4].
|Figure 4: Knowledge of gynecologists regarding the effects of oral diseases on pregnancy|
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Out of a total score of 5, the average gynecologist's knowledge in relation to dental procedures during pregnancy was 2.90 ± 1.152 [Figure 5].
|Figure 5: Knowledge of gynecologists regarding dental practices during pregnancy|
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Out of a total score of 5, the average practice of gynecologists with regard to oral health care during pregnancy was 3.31 ± 1.256 [Figure 6].
|Figure 6: Practice of gynecologists regarding oral health care during pregnancy|
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The levels of knowledge and practice of gynecologists about oral health during pregnancy are summarized in [Table 2] and [Table 3].
| Discussion|| |
A total of 380 gynecologists with an average age of 45.69 participated in this study. The average score of knowledge about dental and oral health care during pregnancy was 12.35 ± 2.737 out of 18, while the average practice score was 3.31 ± 1.256 out of 5, which indicates that their knowledge and practice were at an appropriate level. The mean age of the participants was similar to the mean age of gynecologists participating in the studies by Cohen et al. (2015) and Wilder et al.,
Of the 380 gynecologists participating in the study, more than half had nonacademic occupations. In a study by Cohen et al. (2015), 47.9% of obstetricians and gynecologists were working in private clinics, 35.3% in the hospital, and 16.8% in both hospital and clinics.
In the present study, more than half of the participants had 15–33 years of work experience. In a study by Golkari et al., the average work experience of participating gynecologists was 23 years, and in a study by Cohen et al. (2014), 60.5% of the participants had over 10 years of work experience.
In contrast to our results, in the study by Golkari et al., a significant inverse correlation was found between work experience and performing the dental examination at the first visit or periodically for the pregnant patient; the probability of dental examinations decreased with increasing work experience.
In accordance with the present study, Shah et al. also found no significant correlation between the knowledge of gynecologists and their age.
For more consistency, knowledge and practice are discussed in separate and distinct paragraphs.
In terms of the necessity of oral and dental health care before and during pregnancy, the results of this study show that the average knowledge of gynecologists was 3.67 out of 5. Most of the participants believed that it is necessary for pregnant women to consult a dentist before and during pregnancy to control their oral health. This result is in line with the results of studies by Shenoy et al. and Cohen et al., which reported that about 90% of gynecologists believed that regular dental checkup and dental care are mandatory for pregnant women.,
In terms of oral and dental hygiene during pregnancy, in this study, more than 80% of the participants believed that plaque control and scaling before pregnancy reduces gingivitis during pregnancy.
In terms of the impact of pregnancy on dental and oral health, in this study, about 75% of the participants were aware that pregnancy could cause gingivitis and bleeding. This is consistent with Shenoy's study results, which reported 77% awareness. In addition, Golkari et al. reported that a high percentage of gynecologists were aware that gingivitis (85%) and bleeding (95%) may occur during pregnancy. In terms of tooth loss, 52% believed that pregnant women would probably or certainly lose a tooth during pregnancy. Furthermore, 80% believed that pregnancy can be probably or definitely related to tooth decay. In the present study, 66% of participants believed that pregnancy increases tooth decay.
Regarding the effect of oral diseases on pregnancy, in this study, about 75% of the participants were aware that gingival diseases could cause preterm delivery and low birth weight. In line with the results of this study, Zanata et al. (Brazil, 2008) showed that periodontal infection was considered a serious risk factor for low birth weight by 66% gynecologists. Furthermore, Shenoy et al. showed that periodontal diseases were considered by 61.9% of the participants as a risk factor for preterm low birth weight (PLBW). Besides, Golkari et al. indicated that the majority of obstetricians and gynecologists (91.7%) consider periodontal disease to be a risk factor for PLBW.
In terms of dental procedures during pregnancy, the average of knowledge was 2.90 ± 1.152 out of 5. More than 60% of the participants were aware that scaling, tooth extraction, and taking dental radiography with a lead apron are permitted in the second trimester and are harmless. Moreover, 56.9% were aware that the use of dental anesthetics containing lidocaine and adrenaline is permitted in pregnancy and 41% were aware that all dental procedures cannot be performed in the second trimester. Cohen et al. (2014) reported that 97.4% of obstetricians and gynecologists believed that dental treatment is possible during pregnancy.
In terms of practice, the study findings showed that the average practice score of gynecologists with regard to oral health care during pregnancy was 3.31 ± 1.256 out of 5, which indicates the appropriate level of practice. In more than 60% of the cases, the specialists recommended fluoride therapy, regular checkups, and scaling to their patients. They also referred their patients to a dentist at the start of pregnancy. Furthermore, 62% evaluated their patients' oral health at the beginning of the pregnancy. In line with the present study, Shah et al. revealed that the level of practice in gynecologists in India with regard to the oral health of pregnant women was good – 42% of gynecologists recommended using fluoride toothpaste and 62.6% recommended brushing twice per day to pregnant patients. Furthermore, 47.7% referred their patients to a dentist and 62.6% recommended oral examination to their patients.
However, Cohen et al. (2014) reported that most obstetricians and gynecologists (75.1%) had never performed the oral examination. Only 10.5% of obstetricians and gynecologists mentioned giving routine oral health advice to their pregnant patients, while 55.8% mentioned that oral health advice was only given when the patient was at risk. About 66.7% of specialists mentioned referring their pregnant patients to a dentist for oral and dental checkups.
Wilder et al., in a study conducted in North Carolina, showed that 51% of specialists recommended regular dental checkups to their patients, 22% of specialists checked the oral health status of their patients on the first visit, while 48% mentioned that they examine patients' oral status only when they express a problem. Besides, Patil et al. (2013) found that 85.7% of the obstetricians and gynecologists never examine the oral status of their patients during a regular checkup. According to the systematic review of Rocha study, there are many barriers to dental management during pregnancy, such as phobia to dental treatment, ignorance of dental hygiene, and suspect to the safety of dental work during pregnancy, and this study can support that gynecologists can effect in decreasing of this barriers and motivation of pregnant women.
Golkari et al. reported that 80% of obstetricians and gynecologists ask their patients to get oral health checkup during pregnancy. In the same study, 41.7% of obstetricians and gynecologists stated that they examine the oral health status of pregnant patients in the first visit, 16.7% in the course of pregnancy, and 20.8% when the patient mentions a problem, while 20.8% stated that the examination of oral health is the responsibility of the dentist, not the obstetrician and gynecologist.
| Conclusion|| |
The knowledge of gynecologists regarding oral and dental care during pregnancy is at an appropriate level. Women who are planning to get pregnant should obtain necessary knowledge from obstetricians, gynecologists, and dentists to decrease the complications and impact of pregnancy on oral and dental health on the one hand and prevent the side effects of oral and dental diseases on pregnancy on the other hand.
The authors would like to thank the gynecologists who participated in this study and Dr. Borghani for suggesting the subject of the research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]