Oral health status during pregnancy and evaluation of a maternal oral screening tool: A multicenter cross-sectional study

Abstract

BACKGROUND:

Pregnancy is associated with several transient hormonal changes that not only affect the patient’s health but also their relations with others in their surroundings. The alterations in the hormonal levels may affect the oral as well as systemic health of the individual during pregnancy. The present study aimed to evaluate oral health during pregnancy using a maternal oral screening (MOS) tool.

MATERIALS AND METHODS:

This multicenter, cross-sectional, prospective study was conducted in the Gynaecology outpatient department after obtaining Ethical clearance from the Institutional Ethics Committee. The total sample size was 100 pregnant women who were selected in a random manner. The oral health of pregnant female subjects was assessed using a “14-item” OHIP questionnaire along with clinical oral examination. The study data were analyzed using the statistical software SPSS version 20.0 (IBM, NY, US). Descriptive statistics data were observed as mean, standard deviation (SD), and percentages. Statistical association evaluation was done by the “Chi-square” statistical tool. ‘P’ values lower than 0.05 were statistically significant.

RESULTS:

On analyzing the MOS tool, 23.1% had dental problems, whereas 54% visited a dentist during the past year. 34% subjects were “at risk” of poor oral health. The analytical tools reported high sensitivity (75–90%) and low specificity (13–18%) of the MOS tool for the detection of pregnant women who are at risk of developing poor oral health. On comparing the MOS tool with OHIP-14, Item 1 of MOS demonstrated the highest sensitivity (84.3%), whereas Item 2 demonstrated only 52.2% specificity. On combining item numbers 1 and 2, sensitivity was found to increase up to 95.7% but a decrease in specificity was noted. On comparing the MOS tool and clinical oral/dental examination, combining items 1 and 2 resulted in the highest sensitivity (97.2%). On combining items 1 and 2 of the MOS tool, low specificity (12%) for dental assessment and OHIP-14 (17.1%) was obtained.

CONCLUSION:

The MOS tool can be used for evaluating the oral health status in pregnant females. The present study highlights the importance of conserving oral health during pregnancy.

Introduction

Oral health experts have emphasized the importance of screening programs for pregnant women.[1] Pregnancy has been found to increase the risk of developing oral and dental diseases, particularly periodontitis and dental caries, as a result of physiological alterations associated with pregnancy.[2,3]

The screening of pregnant women during the early trimester for oral and dental health increases the awareness among these women regarding preventive measures.[4] Hence, it is important that a valid and simple measurement tool for assessment of oral health with proven sensitivity and specificity is developed to identify individuals at risk of developing poor oral health during the course of pregnancy, so that adequate preventive measures can be timely put in place for prevention of oral disease.[5]

The major hormones that are involved in pregnancy are estrogens, progesterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), and human chorionic gonadotropin (HCG).[6] The level of these hormones rises due to uterine expansion, genital as well as breast enlargement, and induction of the pelvic ligament relaxation by increasing elasticity of sacroiliac joints as well as pubic symphysis for childbirth.[7]

Progesterone levels rise during pregnancy and help in maintaining the thickness of the uterine wall and prevent the chances of miscarriage during the course of pregnancy.[8] FSH and LH regulate the menstrual cycle; a decrease in levels of these hormones during pregnancy prevents ovulation.[9]

The changes in physiology as well as behavior during pregnancy have a negative effect on oral health. Alterations in hormones, vascularity, as well as the immunological system, result in a heightened inflammatory response within the gingiva in response to dental plaque or any overhanging restorations and prosthesis that can ultimately culminate in gingivitis, periodontitis, and pregnancy epulis.[10]

An optimal level of maternal oral health is crucial for the health of the fetus, which can adversely affect the outcome of pregnancy, for example, pre-term birth, as well as lower weight at birth. Therefore, an early intervention during pregnancy and customized dental care an important aspects of maternal-fetal health.[11,12,13]

Thus, in view of available scientific findings, this cross-sectional study was designed to evaluate the status of oral health in pregnant females and to analyze the implementation of the maternal oral screening (MOS) tool and referral process. This study is novel due to the follow-up of the MOS tool during pregnancy, as it underlines the importance of oral hygiene maintenance during pregnancy and routine dental visits.

Materials and Methods

Study design and setting

This was a multi-center, cross-sectional study conducted in Obstetrics and Gynecology set-ups, which included both private and Governmental centers (Anugrah Narayan Magadh College and Hospital, Gaya).

Study participants and sampling

This hospital-based study had a total sample size of 100 pregnant females aged between 20 and 35 years, calculated as per statistical estimation. The prior written informed consent was obtained from all the study participants before commencing the study. The subjects qualifying for inclusion in the study, as per predetermined criteria, were chosen.

Sample size estimation

A power analysis was established by G * power, version 3.1.1 (Franz Faul Universität, Kiel, Germany). A sample size of 100 was found to yield 95% power for the detection of statistically significant differences with a significance level of 0.05.

Data collection tool and techniques

A trained dental professional observed the oral findings in selected subjects. Oral findings included gingivitis, periodontitis, dental caries, and the occurrence of pyogenic granuloma or pregnancy epulis. The treatment requirement was assessed on the basis of tooth decay and periodontal assessment.

The data obtained was recorded in study sheets by the trained dental professional within a period from January 2024 to June 2024. The oral examination of selected pregnant females was done for the oral health status, treatment needs, and oral hygiene status by the WHO. Oral Health Assessment Form (1997).[14] The oral hygiene status assessment was done by utilizing the Oral Hygiene Index-Simplified (OHI-S) as suggested by Greene and Vermillion (1964).[15]

The responses to the MOS tool, OHIP-14, and clinical oral/dental examination were evaluated. Figure 1 shows a conceptual diagram representing the theoretical framework.

Figure 1.

Showing a conceptual diagram representing the theoretical framework

Inclusion criteria for subject selection were as follows: 1) pregnant women from all trimesters who were willing to be enrolled in the study. Exclusion criteria were: 1) women with any systemic diseases such as cardiovascular disease, diabetes mellitus, and hypertension, 2) individuals on antibiotics for the past 3 months, and 3) subjects unwilling for the oral examination were excluded.

Ethical consideration

All recorded patient data was coded as per the Declaration of Helsinki, and the study observer was single-blinded to prevent bias during clinical observations. Institutional ethical committee clearance was obtained from the required Ethics Committee (IEC/NM34-56-24).

Statistical analysis

Data analysis was done by using the statistical software, SPSS version 20.0 (IBM, NY, US). Descriptive statistics data were observed as mean, standard deviation (SD), and percentages. Statistical association evaluation was done by employing the “Chi-square” statistical tool. “P” values less than 0.05 were considered to be statistically significant.

Results

Demographic characteristics

On analyzing the obtained data for socio-demographic profiling, it was noted that there were 48% females in the 18–25 years age group, 47% were in the 26–35 years age group, and 15% were in the above years age group. This was found to have a statistically significant difference (P = 0.05). On analysis of geographical location, 34% belonged to urban, 29% belonged to semi-urban, while 37% were from a rural background. Hence, no statistically significant difference (P = 0.06) in area of residence was found in females reporting to the OPD.

The oral health was examined by a single Dentist who made the following observations in the study sample:

1. Treatment Need in Studied Pregnant Females: Most of the study participants required preventive oral and dental care, pit and fissure sealants, restorative treatment, prosthesis, endodontic treatment, and tooth extractions [Table 1].

2. Assessment Using OHIP (Oral Health Impact Profile)-14: This is a subject-based measurement of oral health developed on the basis of the conceptual model proposed by Locker.[16] It is precise, has validity, and is a reliable tool (gold standard) for assessing other tools for oral health assessment.[16,17] Oral Health Impact Profile-14 (OHIP-14) consists of fourteen questions based upon a five-point “Likert” scale. The total score of OHIP-14 ranges between 0 and 56. Higher scores indicate poor oral health. This particular tool comprises 07 domains which are: i) limitation in function, ii) physical pain, iii) psychological discomfort, iv) physical disability, v) psychological disability, vi) social disability, and vii) handicap.[16]

3. Maternal Screening Tool (MOS) Analysis of Oral Health: On analyzing the MOS tool, 23.1% reported dental issues, while only 54% had a dental visit in the past 12 months. 34% subjects were found to be “at risk” of poor oral health [Table 2 and Figure 2].

Table 1.

Demonstrating treatment needs in pregnant females

Treatment Needed		Mean±SD Scores
a) Preventive measures		1.05±0.21
b) Pit and fissure sealants		0.29±0.02
c) Restorations		1.98±0.45
d) Crown prosthesis		0.03±0.12
e) Endodontic treatment		0.29±0.45
f) Extractions		0.34±0.12

Table 2.

Responses to MOS Tool, OHIP-14, and Clinical Oral/Dental Examination

Tool Assessed		Percentages
a) Maternal oral screening (MOS) tool
Item 1: Do you have any oral/dental problems?
Yes		23.1%
No		76.9%
Item 2: Did you have any dental visits in the past year?
Yes		54%
No		46%
Pregnant women “at risk” of poor oral health		34%
b) OHIP-14 tool
>4 score		46.1%
c) Oral/dental assessment
Presence of dental decay		17%
Pregnant females with poor oral health after examination		42%

Figure 2.

Responses to the MOS tool, OHIP-14, and clinical oral/dental examination

Oral health of pregnant female subjects was assessed using a “14-item” OHIP questionnaire along with clinical oral examination. Both of these analytical tools reported high sensitivity (75–90%) and low specificity (13–18%) of the MOS tool for the detection of pregnant women who are at risk of developing poor oral health. Analyzing the MOS tool against OHIP-14, Item 1 of MOS demonstrated the highest sensitivity (84.3%), whereas Item 2 demonstrated only 52.2% specificity. On combining item numbers 1 and 2, sensitivity was found to increase up to 95.7% but a decrease in specificity was noted [Table 3 and Figure 3].

Table 3.

Table Demonstrating Sensitivity and Specificity of Maternal Oral Screening (MOS) Tool with OHIP-14 and Clinical Oral Examination

		Item 1 (MOS)		Item 2 (MOS)		Combined Items 1 and 2
OHIP-14 tool
a) Sensitivity		84.3%		65.9%		95.7%
b) Specificity		78.1%		52.2%		23.2%
Oral health assessment
a) Sensitivity		12%		45.2%		97.2%
b) Specificity		87.1%		17.1%		45.1%

Figure 3.

Demonstrating the specificity and sensitivity of the maternal oral screening (MOS) tool with OHIP-14 and clinical oral examination

On comparison between the MOS tool with clinical oral/dental examination, combining items 1 and 2 resulted in the highest sensitivity (97.2%). On combining items 1 and 2 of the MOS tool, low specificity values for dental assessment (12%) and OHIP-14 (17.1%) were obtained.

Discussion

The hormonal changes in pregnancy, along with nutritional and hygienic habits, can cause gingival, periodontal disease, and dental caries, and are the major risk factors causing premature birth and low birth weight in babies. On the other hand, oral health in pregnant women has an established relationship with the mothers’ quality of life.[18]

Oral health is an indicator of overall health, imperceptibly affecting the nutritional status and quality of life of pregnant women. It is noteworthy that, to be maximally effective, prevention should start earlier in life to capture the whole spectrum of the disease. An unfortunate delay in seeking dental treatment has a multifactorial negative impact on the maternal well-being downstream of the infant.[19]

In the present study, gingivitis was found to be the most common oral condition (56%), followed by periodontitis in 34% pregnant women. Only 7% of the studied population was suffering from dental caries, while 3% were diagnosed with pyogenic granuloma.

VenkataLakshmi et al.[19] assess the oral health status and treatment needs of pregnant women and emphasize the deterioration of periodontal health with the progression of pregnancy from the first to the third trimester.

The present study demonstrated that approximately 54% of pregnant females used oral hygiene aids such as a toothbrush and toothpaste for teeth cleaning. Our findings are contrasted with Gürsoy et al.[20] and Christensen et al.[21] where the pregnant females examined were using a toothbrush and toothpaste. In the present study, the prevalence of pregnancy epulis, a type of pyogenic granuloma, was found to be 3%.

A valid, yet simple tool with good sensitivity as well as specificity for measuring the status of oral health must be chosen to facilitate the identification of pregnant women who are “at risk” of developing oral diseases. Early preventive measures to avoid dental or oral problems by referral during the first trimester are important to reduce morbidity in both mother and child.[22]

Oral health in pregnancy has implications that are other than dental caries. Systematic reviews by George et al.[15] and Newnham et al.[16] have demonstrated positive associations between adverse outcomes in pregnancy, like pre-term delivery and periodontal disease; however, no cause-and-effect relationship has been established. The MOS tool was developed after reviewing items surrounding oral health in pregnancy. The MOS tool consists of 2 items: a) Item 1 refers to common dental problems observed during pregnancy as well as oral diseases, whereas item 2 refers frequency of dental visits within the past year.

Total ≥1 score indicates the population of pregnant women who are the risk of developing oral/dental disease and hence, requires dental referral. Clinical oral examination is done for detecting dental problems and assessing sensitivity and specificity, which is considered the “gold standard” for diagnosis.

Hence, it can be inferred from the present study that the MOS tool is a useful measurement tool for assessment of treatment requirement as well as for creating awareness in pregnant women regarding seeking dental appointments for optimal oral health maintenance. George et al.[23] in their policy defining research paper underlined the role of midwives in the assessment of oral health and treatment during the first trimester of pregnancy. Thus, this article supports the use of the MOS tool in our study for evaluating the oral health status.

Payal et al.[24] evaluated the oral health status of pregnant females in Central India and highlighted the need for interaction between dental practitioners and gynecologists, including routine dental checkups during antenatal visits of pregnant females.

Asadi et al.[25] emphasized the importance of the health of the mother during pregnancy due to the effect on the health of the fetus and recommended monitoring the weight of mothers more sensitively from before pregnancy to the end of pregnancy.

A limitation of the present study was a small sample size. In addition, most of the participants were from the higher education group, which does not reflect the general population, where most women are uneducated. Hence, it is recommended to conduct further studies with a larger sample size to better understand the spectrum of factors affecting dental care utilization during pregnancy.

Conclusion

It is important for both maternal as well as fetal health to have good oral health, as it can impact systemic health as well. 2-itemed MOS is a sensitive tool for screening that can be easily used by midwives, antenatal care providers, and general practitioners. It can be used to increase awareness in women regarding the effects of oral health on general health and fetal health. However, more studies are required to determine the relevance of OHIP-14 in pregnant females.

Abbreviations

MOS (Maternal Oral screening), OHIP-14 (Oral Health Impact Profile-14), HCG (Human Chorionic Gonadotrophin), LH (Luteinizing Hormone).

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.