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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 4  |  Page : 396-402

Oral health, nutritional knowledge, and practices among pregnant women and their awareness relating to adverse pregnancy outcomes


1 Department of Oral Medicine and Radiology, New Horizon Dental College and Research Institute, Bilaspur, Chhattisgarh, India
2 Burn and Trauma Centre, Bilaspur, Chhattisgarh, India
3 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Mathikere Sampige Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India

Date of Submission03-Dec-2015
Date of Acceptance20-Jan-2017
Date of Web Publication21-Feb-2017

Correspondence Address:
Dr. Ravleen Nagi
Department of Oral Medicine and Radiology, New Horizon Dental College and Research Institute, Sakri, Bilaspur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_246_15

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   Abstract 

Introduction: Oral health is often neglected by pregnant females, and physicians should evaluate and educate pregnant women regarding the routine dental checkups to prevent complications. Periodontitis is associated with preterm birth and low birth weight babies, and high levels of cariogenic bacteria in the oral cavity of the mother leads to dental caries in infants. Most of the pregnant women are unaware of periodontal diseases during pregnancy because of lack of knowledge. Aims and Objectives: The aim of the study was to assess the oral health-related awareness and practice among pregnant women in Bilaspur city. In addition, we assessed the knowledge of mothers towards nutrition during pregnancy because adequate prenatal nutrition is one of the most important environmental factors affecting the health of pregnant women and their babies. Materials and Methods: The study was a cross-sectional study. A total of 446 samples were selected by convenience sampling technique. A questionnaire containing 12 questions related to knowledge and practices pertaining to oral health and 12 questions related to diet and nutrition along with sociodemographic data were used for collecting information. Analysis were conducted using the Statistical Package for the Social Sciences (SPSS) for Windows (version 20.0, SPSS Inc., Chicago IL, USA). Results: Majority of women (74%) were not aware about periodontal diseases, which is common during pregnancy. Only 44.9% were aware which period was safe for dental treatment, and 33.4% were aware that exposure to high dose radiation is dangerous to the baby. A total of 50.1% experienced bleeding from gums during pregnancy; 99.8% maintained their oral hygiene by brushing twice daily and 96.8% visited dentist twice yearly. Concerning nutritional awareness, pregnant patients were aware of the meaning of food (40.1%) and the importance of food (45.5%), balanced (47%), and healthy diet (43.9%). They had adequate knowledge regarding requirement of food for proper functioning of the body (59.9%) as well as for fighting infections (67.2%). Knowledge regarding sources of carbohydrates/proteins, iron, zinc, vitamin A and iodine was low in our patients. Conclusion: The results suggest that knowledge and practices of pregnant women should be improved for better pregnancy outcomes. It requires proper coordinated effort between oral health and prenatal communities for maternal and child's oral health outcomes. Nutritional education programs should be carried out by medical centres, which should be directed towards women in rural areas.

Keywords: Awareness, maternal nutrition, oral health, practice, pregnancy


How to cite this article:
Nagi R, Sahu S, Nagaraju R. Oral health, nutritional knowledge, and practices among pregnant women and their awareness relating to adverse pregnancy outcomes. J Indian Acad Oral Med Radiol 2016;28:396-402

How to cite this URL:
Nagi R, Sahu S, Nagaraju R. Oral health, nutritional knowledge, and practices among pregnant women and their awareness relating to adverse pregnancy outcomes. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2021 Jan 28];28:396-402. Available from: https://www.jiaomr.in/text.asp?2016/28/4/396/200635


   Introduction Top


Pregnancy is a unique period in women's life and is characterized by complex physiological changes, which may adversely affect oral health. Even a healthy pregnancy causes major changes in the maternal anatomy, physiology and metabolism. These include changes in the cardiovascular, respiratory and gastrointestinal systems as well as changes in the oral cavity, with increased susceptibility to oral infection.[1] Educating pregnant women regarding preventing dental caries is critical as evidence exists that most infants and young children acquire caries causing bacteria from their mothers.[2] In addition, pregnant women are more susceptible to gingival and periodontal diseases. Studies have reported that the frequency of periodontal disease among pregnant women ranges from 35% to 100%.[3],[4] It has been suggested that periodontal diseases during pregnancy have a causal relationship with premature birth and low birth weight babies (<2500 g).[5] Other adverse pregnancy outcomes are pre-eclampsia, ulcerations of gingival tissue, pregnancy granuloma and tooth erosion.[6] Another concern is the prescription and administration of drugs during pregnancy as these may cross the placental barrier and cause teratogenic effects to the fetus.[7]

Attempts should be made to focus on pregnant women's dental health, as studies have shown that women attend health care centers more often during their pregnancy; therefore, the primary goal of a dentist should be to evaluate the mother's oral health during this crucial period in order to improve the wellbeing of the infant.[8] To improve supportive function, primary focus should be on the mother and the child, rather than the child alone, and intervention should be undertaken before the child is born.[9] Studies have also shown that educating women could prevent nursing bottle caries in infants and children.[10],[11] In addition, healthy diet during pregnancy is important because it provides improvement in maternal health and child outcomes. Iron deficiency anemia is the most common (80%) micronutrient deficiency in pregnant females accounting for 19% for all maternal deaths.[12] Zinc deficiency is also common during pregnancy.[13] These nutritional deficiencies not only have impact on the quality of life of women but also effect the newborn, including the birth weight of the newborn. Furthermore, socioeconomic status of women plays a major role. Women living in urban slums have poor access to health care and proper nutrition as compared to rural areas.[14] Therefore, it is important to assess the nutritional status of pregnant females and to increase the nutritional knowledge of patients for better wellbeing. The aim of the present study was to assess the knowledge, attitude and oral health practices of pregnant women of Bilaspur city, as well as to assess the nutritional awareness of pregnant mothers.


   Materials and Methods Top


The present study was a cross-sectional survey conducted among the pregnant women of Bilaspur city. Ethical clearance was obtained from the institutional ethical committee, a Medical and Health Research Ethics committee at the Ministry of Health. Informed written consent was obtained from all the patients. The participants were selected from three tertiary care centers, three primary health centers and ten private nursing homes of Bilaspur city over a period of 1 year. The demographic data, socioeconomic status and oral hygiene practice were recorded from each patient using the following questionnaire:

  1. Do you think there is any correlation between oral health and pregnancy outcome? (Yes/No/Never heard of this)
  2. How often are you brushing or flossing your teeth during pregnancy? (Twice or more a day/once a day/not everyday)
  3. Are you using any mouth rinse products at least once a week during this pregnancy? (Yes/No)
  4. Have you experienced any dental problem during pregnancy? (Yes/No)
  5. Are you aware that periodontal disease is common during pregnancy? (Yes/No)
  6. Have you consulted dentist for bleeding gums? (Yes/No)
  7. Do you think pregnancy is the cause for loosing of teeth? (Yes/No)
  8. Have you taken any treatment during pregnancy? (Yes/No/Don't know)
  9. Are you aware about the period of pregnancy which is safe for dental treatment? (Yes/No)
  10. Have you taken any medication without prescription by a doctor during pregnancy? (Yes/No/Don't know)
  11. Are you aware that certain drugs during pregnancy can affect growth of the child? (Yes/No)
  12. Are you aware that exposure to radiation during pregnancy is dangerous? (Yes/No).


Sample size was estimated based on the results of the pilot study. Hence, sample size was estimated to be 446 participants at a power of 80% and confidence interval of 95%. Women who were unwilling to participate in the study, having less than 20 teeth in their oral cavity, <18 years or >45 years of age were excluded from the study. Cross-sectional data were collected from direct interviewing of the participants through a questionnaire. Oral health-related questionnaire had 12 items, and for each correct answer, score 1 was given; score 0 was given for wrong answer [Table 1]. Nutritional knowledge questionnaire consisted of 12 questions which assessed respondents their knowledge regarding the definition of food, good balanced diet, importance of diet during pregnancy, sources of carbohydrate, protein, iodine, iron, and vitamin A, and negative effects of malnutrition on the mother and fetus [Table 2]. Respondents were allowed to choose correct answers by indicating whether a given statement as yes or no. The knowledge of respondents was scored, 1 point was allocated to a correct response for all questions on nutrition knowledge; all the correct answers were then summed up and converted to 100.
Table 1: Demographic details and oral hygiene practices (OHP) of patients

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Table 2: Nutritional knowledge of pregnant patients

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Questionnaires were pretested and validated by three experts from the field of Gynecology and Periodontology prior to the commencement of the study. They were distributed to pregnant women who were asked to complete the questionnaire in front of the investigator. The questionnaires were verbally explained in the local language to illiterate women and those facing any problem. The questions were based on knowledge and practices related to pregnancy and oral health, habits, nutrition, diet and use of medications. Discrete categorical data were presented as n (%). The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for windows (version 20; SPSS Inc; Chicago IL, USA).


   Results Top


Demographic analysis

Majority of participants (245, 54.5%) were in the age group of 31–45 years; 45% were aged 18–30 years. Most of the sample population belonged to urban area (235, 52.7%) and was mostly from middle class (137, 30.8%) and lower middle class (128, 28.7%). Most of the pregnant patients were not working (269, 60.3%), and maintained their oral hygiene by brushing at least daily (188, 42.1%). [Table 1] illustrates the demographic and oral hygiene practices of patients.

Oral and dental health practices

Majority of the patients (73%) had dental problems during pregnancy. A total of 50.1% had experienced bleeding from gums, and only 25% had taken dental treatment during pregnancy; approximately 22.9% took analgesics and antibiotics without a dentist's prescription [Figure 1]. Most pregnant patients were able to maintain their oral hygiene by brushing twice daily (99.8), after breakfast and dinner (50.2%), and using floss (35%) and mouthwash (22%); 52.5% visited a dentist twice yearly [Figure 2]. [Figure 3] shows the reason for not practicing the oral hygiene with the best available tooth cleaning aid.
Figure 1: Proportion of respondents to oral health awareness questions

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Figure 2: Oral hygiene measures followed by patients for prevention of development of oral diseases

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Figure 3: Reasons for limiting the use of best method of cleaning the teeth in pregnant females

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Response to oral health awareness questions

A total of 59.8% of the study population was aware of correlation between oral and systemic health. Twenty-six percent of the participants had knowledge regarding periodontal problems and only 50% had consulted the dentist for bleeding gums. Only 44.9% of the patients were aware that first and third trimesters of pregnancy were not safe for dental treatment. A total of 66.4% participants were not aware of radiation protection measures to be taken during pregnancy. Approximately 32.8% of the patients were aware regarding the drugs which could affect the child's growth, and 22.9% of pregnant females were taking medications without prescription by a doctor [Figure 1].

Periodontal problems experienced during pregnancy

Higher levels of circulating hormones during pregnancy, especially progesterone, combined with maintenance of poor oral hygiene leads to pregnancy gingivitis, which is characterized by inflamed, swollen gingiva, and increased tendency of the gingiva to bleed, periodontitis, and other adverse pregnancy outcomes such as low birth weight babies and premature birth. In the present study, majority of the pregnant females had signs and symptoms of gingival and periodontal diseases. Sixty-seven percent had swollen gingiva and 50.1% experienced bleeding gums. Twenty-five percent of the patients had mobility of teeth and 74% had no educational knowledge regarding the periodontal complications [Figure 4].
Figure 4: Signs and symptoms of gingival and periodontal disease among pregnant females

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Response of pregnant patients to nutrition related questions

[Table 2] depicts that most pregnant patients were aware that food was required for proper functioning of the body (59.9%) and to fight against infections during pregnancy (67.2%). Concerning the meaning of food, only 40.1% correctly knew the meaning of foods whereas 59.9% respondents did not know the meaning of foods. Out of the 446 respondents, 45.5%, 47%, and 43.9% of the respondents had the knowledge regarding importance of food during pregnancy, benefits of balanced diet, and healthy and unhealthy food, respectively, whereas 54.5%, 32.7%, and 56% of the respondents did not have any knowledge, as shown in [Table 2].

Micronutrients are essential for healthy pregnancy, especially iron, whose deficiency leads to iron deficiency anemia, which is the most common cause of maternal deaths (19%); [Table 2] shows that most of respondents were not aware of the beneficial effects of nutrients and vitamins and their intake was decreased during pregnancy. In our study, out of the 446 patients, nutritional knowledge of sources of carbohydrates and proteins, iron, zinc, vitamin A, and iodine was 27.1%, 19.9%, 15.2%, 22.4%, and 20.6%, respectively. This inadequate nutrition could lead to various complications such as miscarriages, low birth weight babies, and preterm birth. Only 30.5% of the patients were aware of such nutrition-related consequences. Regarding consumption of type of food, [Figure 5] depicts that more than two-third of pregnant women from rural and urban areas consumed green leafy vegetables, pulses, milk and milk products, and fruits, however, consumption of eggs was less in pregnant women in rural areas (37%) as compared to urban areas (66.3%).
Figure 5: Comparison of dietary consumption of foodstuffs during pregnancy between urban and rural women

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   Discussion Top


During pregnancy, a woman's body undergoes complex physiological changes that can adversely affect oral health. Therefore, dental professionals need to ensure the oral health care of pregnant women.[1] In the present study, majority of patients were unaware of periodontal/gingival diseases (74%) during pregnancy. They were not educated regarding the impact of oral health on pregnancy outcomes by the treating doctor (gynecologist). These findings coincide with Alwaeli et al. who concluded that knowledge and awareness of pregnant women about their teeth and gingival condition was poor.[15] Similar results were reported by Rogers et al. who concluded that only 25% of the patients had received advice concerning their gingival and periodontal health.[16]

In our study, most of the pregnant women were in the age group of 31–45 years and were educated, however, they had poor knowledge about the association of oral health and adverse pregnancy outcomes as well as the periodontal diseases that are common during pregnancy. This poor knowledge was independent of socioeconomic class and place of residence. Results were comparable to study by Bamanikar et al.[17] Further, more clinical trials should be conducted to assess the impact of knowledge on socioeconomic class and place of residence.

In the present study, majority of pregnant women were unaware of the safe period of dental treatment, i.e., which trimester of pregnancy is safe for dental treatment. Second trimester is safe for pregnant women to carry out dental procedure, as most of the tissues are in the formative period in the first trimester, and there is risk of postural hypotension in the third trimester. Seventy-three percent of the patients had experienced dental problems and only 25% had taken dental treatment. For dental pain, 22.9% patients took medication without prescription. This could be attributed to poor knowledge and low level of awareness of patient and education by the treating doctor (gynecologist).[18] Patil et al. in their study concluded that, in India, 85.7% of the gynecologists never examine the oral cavity of the patient during routine checkup. Lack of knowledge, lack of time, and limited access to oral health professionals have been identified as barriers among gynecologists for poor oral health of patients.[19] In addition, pregnant mothers should be educated regarding the association of periodontal diseases and adverse pregnancy outcomes, and should be motivated for regular dental checkup. Another crucial finding in our study was that there are still myths related to dentistry prevalent in India. Twenty-five percent of the women believed that pregnancy was causing loss of teeth.[6]

Despite the dental problems, 99.8% of the women brushed their teeth twice daily and 96.8% visited dentist regularly. Our results were comparable to the study conducted by Thomas et al., in which dental floss prevented gum disease and use of fluoridated tooth paste reduced tooth decay.[20] In the present study, 50.2% patients brushed after breakfast and dinner, 35% used dental floss, and 22% used mouthwash.

Our patients were unaware regarding the drugs to be taken during pregnancy as some drugs could affect child development. Radiographic imaging of oral tissues is not contraindicated with proper radiation protection measures, however, exposure to high dose radiation is dangerous to the fetus.[21] Dental treatment should be done with short appointments, judicious use of drugs, and avoidance of flat supine positioning. Expecting mothers should be taught that periodontal treatment is safe for both mother and child.[22] Gynecologists are better than dentists to counsel the patients regarding oral health care during the prenatal and postnatal period. Educating and motivating women to maintain good oral hygiene is fundamental in preventing dental disease.[18],[23]

In our study, we also assessed the nutritional knowledge of mothers during pregnancy on nutrition because it is known that good knowledge about basic nutrients and a well-balanced diet usually results in positive dietary practices, which are important determinants of optimum health from conception until death.[23] Evidences have shown that inadequate dietary intake during pregnancy results in an increased risk of short-term consequences such as low birth weight, preterm birth, and infant mortality and morbidity, and could have pathophysiologic or metabolic problems that appear to be the disorders of child growth and development.[24] Our study revealed that most of the pregnant patient were aware of the meaning of food (40.1%), importance of food (45.5%), and a balanced (47%) and healthy diet (43.9%). They had adequate knowledge regarding requirement of food for proper functioning of the body (59.9%) as well as for fighting infections (67.2%). The results were comparable to the study by Latifa et al.[25] Although the respondents had good knowledge of the importance of food, their knowledge related to micronutrients and vitamins was low; 27.1%, 19.9%, 15.2%, 22.6%, and 20.6% for carbohydrates/proteins, iron, zinc, vitamin A, and iodine, respectively. However, in another study it was found that 61.3% pregnant females had good knowledge regarding the benefits of the sources of iron and 71.8% knew the sources of calcium.[25] This low level of knowledge may be due to their lack of information and low socioeconomic status of most patients. Educational qualification is also a key determinant to nutritional status in women. In our study, it was found urban women were having good nutritional knowledge than pregnant women living in rural areas. Patients in urban areas were consuming more pulses, fruits, milk and milk products, eggs than those in the rural areas, and there was significant difference in the consumption of eggs; on the contrary, in a study by Wojtyla et al.,[26] 10% of the pregnant women from rural areas consumed milk and eggs everyday compared to urban inhabitants. It was also observed that pregnant women from rural areas rarely consumed raw and cooked salad and fruits but they drank tea more frequently than urban women. Therefore, in their study, among the respondents living in urban areas, higher amount of negative changes were observed concerning the amount and frequency of consumption of fruits and vegetables than rural areas. Bojar et al.[27] suggested that during pregnancy, apart from an increase in the amount of products consumed, there was a change in their proportions. In their study, a decrease was noted in the amount of fruits, whereas an increase was noted for meat, vegetables, and cereal products in the diet during pregnancy. Hence, previous studies have suggested that there was frequent consumption of fruits, pulses, green leafy vegetables, milk and dairy products, white meat, and eggs during pregnancy by both rural and urban women. However, rural women need more nutritional education about basic nutrients and balanced diet.[26],[27]

In a country like India, mothers play a vital role in transferring oral habits to their children. Fifty percent of pregnant women do not visit a dentist even when they need dental treatment despite the presence of pain. For better promotion of oral health, patients' gynecologist should recommend periodic dental checkups of expecting mothers. It is important for dental professionals to motivate and educate the pregnant females regarding oral hygiene measures throughout pregnancy as well as to seek dental treatment at the appropriate time. Apart from stressing oral hygiene care, dentists should also make them aware regarding periodontal problems and nutritional requirements during pregnancy.


   Conclusion Top


Good oral health and controlling oral diseases protects a woman's health and quality of life before and during pregnancy; and this has the potential to reduce the transmission of pathogenic bacteria from the mother to children. This study observed a lack of knowledge of oral health care among the pregnant women. Moreover, health behavior of pregnant women including nutritional behaviors affects the woman's health and development of fetus. In future, dental education programs should be conducted to motivate pregnant patients about their oral health as well as for better pregnancy outcomes. In addition, nutritional educational programs for women who plan pregnancy should be conducted by medical and health centres and should mainly involve women from rural areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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