Prenatal oral health literacy status: a survey on patient’s perception and awareness among health care professionals

INTRODUCTION

Good oral health and control of oral disease protects a woman’s health and quality of life before and during pregnancy.^1,2 In recent years, substantial interest has been developed to establish a relationship between maternal and oral health care professionals thus ensuring that pregnant women receive proper preventive education and appropriate oral health services.^3-5

Very few studies have been published that has addressed the extent of gynaecologists’ and oral care professionals’ knowledge regarding the associations between oral health and pregnancy outcomes.^6,7 Studies have shown that many women do not seek dental treatment and are not advised to seek dental care as part of their prenatal care. Thus the objective of this study was to determine knowledge, attitude and practice behaviors regarding anticipatory guidance for pregnant women and treatment rendered during pregnancy and to evaluate the self-assessed maternal barriers and dental care seeking behaviours during prenatal and postnatal period.

MATERIALS AND METHOD

The present observational study consisted of 300 participants selected randomly in three groups i.e. 100 gynaecologists (Group – A), 100 oral health professionals (Group – B) and 100 pregnant women (Group – C). The gynaecologists and oral health care professionals (with postgraduation qualification) were selected from the licensed database obtained from the state councils respectively; whereas the pregnant women aged 18 -35 years were selected from maternity care centres of Bangalore city. A written consent was obtained from all the participants in the study.

The survey included three self-administered questionnaires developed by the study team or drawn from previous studies based on Lickert’s scale. All the three groups were asked “whether women should receive routine preventive dental care during Pregnancy”, “whether untreated oral disease can compromise on nutritional intake of mother during pregnancy” and the ideal time to provide dental care during pregnancy.” The knowledge of Group A and Group B regarding periodontal disease and pregnancy outcomes was assessed with questions like “does the presence of active periodontitis during pregnancy increase the risk of experiencing low birth weight and preterm birth and may increase the risk of developing pre-eclampsia”. The knowledge of Group C was assessed using close ended questions like “is dental checkup important during pregnancy, do you have any dental problem during pregnancy.”We assessed Group A and B’s attitudes, beliefs and practices about preventive care, routine and emergency treatment, prescribing medications to pregnant women with questions regarding “the correct chair position of pregnant woman on dental chair”, radiation exposure and their interest in CDE programs on dental care during pregnancy.” The questionnaire for pregnant women was designed to investigate their attitudes and knowledge of oral hygiene practices and barriers that may prevent from seeking dental care. All the three groups were also asked about the various educational and social barriers for providing prenatal and postnatal oral care and opinions about possible treatment outcomes.

The data collected was analyzed using the statistical package for social science (SPSS version 10.5) software and descriptive statistics i.e. mean, standard deviation and frequency distribution were calculated and tabulated. ANOVA test was used to evaluate the difference between the groups and Pearson’s correlation Coefficient was used to examine the relationship between intergroup KAP score.

RESULTS

This study provides population based data that characterized KAP of health care providers and dental experiences and behaviors of pregnant women.The majority of mothers were of age group 26-30 years (58%), 20-25 years (19%) and 31-35 years (23%). The educational status of the pregnant women was primary education (32%), completed graduation (52%) and completed post-graduation (16%).

Knowledge of oral health status during pregnancy: Only 31 % of Group A and 53% in Group B had agreed that presence of active periodontitis during pregnancy may increase the risk of developing pre-eclampsia. 97% of Group B respondents knew that the fluctuating pregnancy hormonal levels increase susceptibility to gingivitis and periodontal diseases. 80% of Group A strongly agreed that prostaglandins and cytokines released by the endotoxins can stimulate the labour. Inspite of the knowledge of impact of prostaglandins, they lack the information that the periodontitis also results in release of immunoinflammatory chemical mediators. Group B were ignorant about the fact that irritation of smooth muscles of uterus will promote contraction and can rupture the chorioamniotic membrane leading to pre-eclamsia and increased risk of preterm birth and low birth weight infants. (Table – 1)

74% of Group A and 41% of Group B respondents agreed that Fusobacterium nucleatum and U. urealyticum present in the oral cavity can lead to bacterial vaginosis, a recognized risk factor for preterm birth. 96% and 98% of Group A and B respondents agreed that women should receive routine preventive dental care during pregnancy. 83% of Group A and 79% of Group B participants considered second trimester as an ideal time to provide dental care. When asked to Group B participants about ptyalism observed in pregnancy only 14% knew that it is due to “Expectant mother’s inability to swallow normal quantity of saliva”. (Table – 1)

A total of 36% of Group C participants agreed that bacteria in oral cavity and pregnancy hormonal changes can increase the risk of oral diseases but only 17% believed that oral diseases during pregnancy may increase the risk of developing hypertension and can indirectly harm the baby. (Table – 2)

Our results showed that Group A had a high degree of knowledge regarding the association of periodontal disease and possible pregnancy outcomes than Group B and C ( p value <0.001) (Table – 3)

Attitudes and beliefs towards oral health during pregnancy: A total of 92% in Group A and 98% in Group B felt that dental treatment should be a part of prenatal care. 82% in Group A and 99% in Group B agreed for prenatal counselling regarding caries prevention and routine preventive care. 75% in Group A and 97% in Group B agreed for a periodic periodontal evaluation of pregnant women every trimester carried out by dental professional. 53% in Group A and 35% in Group Bfelt lack of time to counsel pregnant women as it is time consuming. 57% in Group A and 91% in Group B thought prenatal oral health programs based on community approach will change the pregnancy oral health behavior. (Table – 4)

In Group - C, only 28% reported to have dental problems during pregnancy. Out of these, 67.8% had mentioned their problem to their gynaecologists. Of these only 26.3% were referred to a dentist by their doctors. Among women reporting dental problems, 68% reported having sensitivity in teeth and bleeding gums, 25% reported having only sensitivity in teeth. 55% of pregnant women agreed that untreated oral disease can compromise on nutritional intake of mother. 90% of Group C participants felt that dental treatment is not safe during pregnancy. A total of 40% felt that going for dental treatment is costly. The results revealed that education level of pregnant women was a significant predictor for utilization of dental services during antenatal period ( p value<0.05) (Table – 3)

The attitude of Group B regarding prenatal counselling and dental care during pregnancy was significantly more than Group A and C (p value<0.001). (Table -5)

Practice behaviors of providing routine dental care to pregnant patients: Table-3 shows the comparison of practice behaviors of Group A (56.2%) and Group B (64.9%) towards providing care to pregnant women. 40% of participants in Group-A reported counselling pregnant women and only 35% referred pregnant women to the sources of oral health care for screening. Only 26% periodically examined the oral cavity of pregnant women on a regular basis.(p value < 0.05).

A total of 65% in Group-B reported counseling pregnant women. 61% of them knew the correct position of pregnant women on dental chair. About 75% of them performed scaling, periodontal examination and restoration procedures for pregnant patients in all three trimesters. When it comes to taking IOPAR, 60% never did so in their practice. For performing emergency procedures like extraction, emergency access openings and drainage of abscess, 35% of them administered local anesthesia in 2nd trimester while 14% administered in 1st and 3rd trimester also. When asked about single tooth extraction for pregnant patient, more than 60% never did in their practice. Before prescribing any medication to pregnant women, 86% agreed for consulting a gynecologist. (Table-6)

Intragroup correlation of knowledge, attitude and practice behaviors towards prenatal and post natal oral health is shown in Table-7 Though the knowledge of oral health professionals is adequate, they face limitations in the providing dental services to the pregnant women during prenatal period.

Barriers cited by Group A and B in providing dental care during pregnancy: A total of 46.5% in Group A and 60% in Group B cited lack of information regarding outcome of poor oral health as a barrier to providing care for pregnant women. Almost half of them identified lack of time (49.5%), and poor connectivity (46.2%)as a barrier, while 37% Group B participants identified legal risks associated with negative birth outcomes as a barrier.

None of the participants in Group C reported having counselling regarding prenatal and postnatal oral health by gynecologists. Most of the pregnant women reported having a dental visit only if they had a dental problem. The majority of the participants in Group A (65%) and Group B (60%) were advising patients to delay treatment until after pregnancy.

DISCUSSION

Most women do not access oral health care during pregnancy, despite evidence that poor oral health can have an adverse impact on the health of pregnant women and her child.^8,9 The oral health professionals and gynaecologists were aware of the association of periodontitis with pregnancy, but they lack the knowledge about periodontitis leading to elevated level of inflammatory markers which relatively initiates labour due to early uterine contraction leading to preterm birth. This explains the limited knowledge of interrelationship between systemic and oral health during pregnancy among gynaecologists and oral health professionals.

Many women do not seek dental care during their pregnancy and those often confront the unwillingness of dentist to provide care. And many expectant mothers are unaware of the implications of their oral health for themselves, their pregnancy and their unborn child. In this study, knowledge and awareness for pregnant women about their teeth and gingival condition was generally poor as seen in a survey by Alwaeli HA et al¹⁰ where it was observed that only 5.1% believed there might be a relationship between gum diseases and premature labour. There was a lower proportion (28%) of reported dental problem in comparison with other previous studies.^10-15 Among them, the highest percentage was of sensitivity and bleeding from gingiva(68%). Christensen LB et al¹⁵ reported that one-third of the pregnant women perceived signs of gingival inflammation. However, a greater degree of knowledge of “association of periodontal disease with pregnancy outcomes” in educated and working women was observed. This revealed that education level is a significant predictor for utilization of dental services during pregnancy as stated in previous studies by Hamissi J et al¹⁶ and Thomas NJ et al¹⁷. These findings suggest that better knowledge and awareness play an important role in understanding the benefits of utilizing dental services during pregnancy.

Though the knowledge and attitude of the gynaecologists and the oral health professionals were quite adequate, still providing proper prenatal oral health service was an issue of concern. There was no association between the knowledge and practice behaviours of Group A and B. This further showed no significant increase in advising dental visit during pregnancy.

Very few gynaecologists believed that prenatal dental counselling is necessary and oral treatment can be carried out safely during pregnancy. The present study reflected that though, majority of gynaecologists believe that they are the first health professionals to be seen by pregnant women, only few of them considered it necessary to include dental care as a part of comprehensive prenatal care. Even though patients mention the dental problem, 65% of Group A participants did not refer them to the sources of oral health care for screening.

Zanata RL et al¹⁸ in 2008 observed that 65.8% gynaecologists reported that they were aware of this subject but only 36.7% routinely refer the pregnant women to dental care. Results of our study and previous studies have showed that gynaecologists do not routinely advise their patient to seek dental care during pregnancy and reason cited was lack of time.^19-22

Our study showed that half of oral care professionals were interested in information on continuing dental education program and educational material on pregnant women, also seen in a survey by Huebner CE et al²³ where 71% were interested in these education material.

Majority of oral health professionals were aware of seating the pregnant women in semi reclined left lateral position on dental chair. This is to avoid the increased tendency of aspirating the acidic stomach contents and delayed gastric emptying because of hormonal changes and incompetent oesophageal valve in pregnant women.

There was a weak association between the knowledge and attitude of Group- B and this uncertainty appears to affect practices. Only 35% percent provided comprehensive care. These findings were similar to survey conducted by Da Costa et al²⁴. This indicated that oral health care professionals are more confident and feel safe to provide oral prophylaxis, than other treatment. There is increased percentage of oral health care professionals providing emergency care but there is lack of comprehensive care to pregnant women.

Comparisons of self-reported knowledge and practice with the aforementioned guidelines revealed several points of difference; the greatest regarded obtaining full-mouth radiographs, administering long-acting anaesthetics injections and self-medications. Safety concerns were revealed in our study by oral health care professionals. Most of them were concerned about legal issues related to pregnancy when the patient is undergoing dental procedure. Many were insecure to prescribe medications and seemed gynaecologist’s opinion for the same.

Our survey revealed that almost half (50%) of pregnant women cited lack of information regarding outcome of poor oral health as a barrier to dental care. The large majority of pregnant women did not have a dental visit during pregnancy. The main reason women reported for not receiving dental care during pregnancy was lack of perceived need.The other difficulties cited by pregnant ladies were the high cost and difficult access to dental treatment. These findings were similar to the study by Gaffield, et al²⁵. This can be attributed to lack of information about prenatal oral health among pregnant women.

Better education of the importance of dental care before and during pregnancy is needed, ultimately, the resulting improvement in understanding of oral health during pregnancy should be included as part of the women oral health agenda.^26,27

CONCLUSION

Both groups recognised that they receive inadequate information about prenatal oral care during training. The gynaecologists and other physicians are far more likely to see expectant mothers than are the oral health care professionals. Therefore it is essential that these health care providers be aware of the infectious aetiology and associated risk factors of periodontal diseases, make appropriate decision regarding timely and effective intervention for pregnant women and establish a collaborative prenatal health care unit including counselling and referral for comprehensive oral health treatment.

Why this paper is important to paediatric dentists

•  The findings of this study may increase the level of knowledge and interest amongst paediatric dentists towards the appropriate management strategies regarding the oral care of pregnant women. 
• We being Paediatric Dentists can make efforts to widely promote the importance of dental care during pregnancy to all women and relevant providers especially since pregnancy provides a “teachable” moment in self-care and future child care. 

Conflict of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.