|Year : 2019 | Volume
| Issue : 4 | Page : 337-340
Relationship between hemoglobin levels and oral hygiene status in different trimesters of pregnancy – A cross-sectional study
Venkat Baghirath Pacha, Madhuri Mukhe, Hari Vinay Balisetty, P Parameswar Naishadham, Vijay Kumar Jogishetty, Bhargavi Krishna Ayinampudi
Department of Oral and Maxillofacial Pathology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
|Date of Submission||25-Mar-2019|
|Date of Decision||24-Sep-2019|
|Date of Acceptance||24-Oct-2019|
|Date of Web Publication||12-Dec-2019|
Dr. Hari Vinay Balisetty
Department of Oral and Maxillofacial Pathology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Background: Pregnancy is a phase which has gained much attention due to the physiological changes taking place, of which the oral health is of utmost importance as it may pose difficulties in birth outcomes. Aim: This study aims to evaluate the oral hygiene status with hemoglobin (Hb) concentration in each trimester and in each age group and to correlate between them. Materials and Methods: A randomized cross-sectional study was conducted on 1008 pregnant women of the age group 18–40 years who attended at the Government Maternity Hospital in Hyderabad. The individuals were screened for the oral health status, which includes oral hygiene index-simplified (OHI-S) and periodontal index (PI) by Russell. The blood sample was collected to evaluate hematological profile. The correlation between Hb levels and oral health status was evaluated by Chi-square and one-way ANOVA test using SPSS version software. The P < 0.05 was considered statistically significant. Results: The mean of OHI-S was 2.11 ± 0.514, PI was 2.61 ± 0.818, and Hb levels were 1.49 ± 0.500. There was a statistical significance between OHI-S (P < 0.025), PI (P < 0.014), and Hb levels (P < 0.710), respectively with the trimesters but not with the age groups. Therefore, the values for OHI-S and PI were higher in 3rd trimester when compared to other trimesters. Conclusion: The study suggests that there was a significant correlation between OHI-S, PI, and Hb levels within the trimesters of pregnancy irrespective of the age groups and Hb levels. The oral hygiene of examined women was satisfactory but is more at risk of periodontal diseases.
Keywords: Anemia, hemoglobin, oral health status, periodontal disease, pregnancy
|How to cite this article:|
Pacha VB, Mukhe M, Balisetty HV, Naishadham P P, Jogishetty VK, Ayinampudi BK. Relationship between hemoglobin levels and oral hygiene status in different trimesters of pregnancy – A cross-sectional study. J Indian Assoc Public Health Dent 2019;17:337-40
|How to cite this URL:|
Pacha VB, Mukhe M, Balisetty HV, Naishadham P P, Jogishetty VK, Ayinampudi BK. Relationship between hemoglobin levels and oral hygiene status in different trimesters of pregnancy – A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2020 Feb 28];17:337-40. Available from: http://www.jiaphd.org/text.asp?2019/17/4/337/272791
| Introduction|| |
The current concept of satisfactory oral health is possessing a healthy teeth. According to the Federation Dentaire Internationale 2016, oral health is defined as a multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow, and convey a range of emotions through facial expressions with confidence and without pain, discomfort, and disease of the craniofacial complex or fundamental components of health and physical and mental well-being. It exists along a continuum influenced by the values and attitudes of individuals and communities.
Oral health plays a prime role in the well-being of women, mainly during pregnancy, which is related to maternal health and also the general health of the fetus. During pregnancy, many physical changes take place, which may be receptive to the oral infections, including periodontal diseases. Therefore, pregnancy does not provoke periodontal disease, but it does worsen an existing condition. Changes in the oral health may be one of the reasons related to hormonal fluctuations during pregnancy. Hence, any alterations in progesterone synthesis and estrogen metabolism affect the immune system as well as the rate and pattern of collagen production in gingiva. As a result, these conditions reduce the body's ability to repair and maintain gingival tissues., After the delivery, the gingival changes may resolve due to the absence of local irritants such as calculus, plaque, and food debris.,
Anemia is a major health problem that affects 25%–50% of the population of the world and approximately 50% of pregnant women, which is considered as a major issue. This most common hematological problem in pregnancy is caused by iron deficiency, seen in 90% of cases. According to the World Health Organization (WHO) estimation, the prevalence of anemia in pregnant women is 14% in developed countries, it is 51% in developing countries, and it is 65%–75% in India. During pregnancy, anemia increases four-fold from the 1st to 3rd trimester. It is a well-known fact that in the mid-trimester there is a biological fall in hemoglobin (Hb) levels. This drop is attributed to increases in plasma volume, and hence decrease of blood viscosity leads to better circulation in the placenta.,
As far, there were only a few studies on oral hygiene and Hb levels; hence, we aimed to assess the oral hygiene status and Hb levels in pregnant women and to compare each trimester and in each age group.
| Materials and Methods|| |
A descriptive cross-sectional study was conducted on 1008 pregnant women of the age group 18–40 years who attended at the Government Maternity Hospital in Hyderabad. Ethical approval for the study was obtained from the Institute Ethical Committee (Reference No: ECR/267/Inst/AP/2016). The study period was from April 2017 to June 2017. The detailed instructions were given verbally to each participant of the study, and a written informed consent was obtained.
The study population was categorized into three groups based on the age groups at 18–23 years, 24–29 years, and 30 years and above and trimesters as 1st, 2nd, and 3rd. Full mouth examination was conducted, and detailed gingival and periodontal findings were recorded for each participant by a single independent dental professional. Each pregnant woman was examined for oral health status, which includes Greene and Vermillion's Oral Hygiene Index-Simplified (OHI-S) in 1964 and Russell's periodontal index (PI) in 1956.
After recording the complete gingival findings, the blood sample was collected to evaluate the Hb levels according to Sahli's method. Participant with a history of diabetes mellitus, smoking, and other infection disease were excluded.
Data were analyzed using SPSS software, version 20 (IBM, Chicago IL, USA). Descriptive statistics such as mean, standard deviation, and percentage were used. The association was evaluated using Chi-square and one-way ANOVA. The correlation between Hb levels and oral health status in each trimester was analyzed. Any P < 0.05 was considered statistically significant.
| Results|| |
Total 1008 participants were divided into 1st trimester, 2nd trimester, and 3rd trimester and aged 18–30+ years old.
The mean OHI-S of 1st trimester was 1.67 ± 0.57, 2nd trimester 1.47 ± 0.50, and 3rd trimester 1.49 ± 0.50. The mean PI varies in different trimester, and as follows, the mean of affected women in 1st trimester was 1.67 ± 0.57, 2nd trimester was 2.52 ± 0.81, and 3rd trimester was 2.64 ± 0.81. The mean of OHI-S was 2.11 ± 0.51, which shows satisfactory oral hygiene. The mean OHI-S in different trimester was 1.67 ± 0.57 in 1st trimester, 2.05 ± 0.51 in 2nd trimester, and 2.13 ± 0.51 in 3rd trimester [Table 1].
|Table 1: Distribution of pregnant women by trimester in relation to oral hygiene index-simplified, periodontal index and hemoglobin levels|
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There was a significant difference among the Hb levels and trimesters (P < 0.01) and among the bleeding on probing and age groups (P < 0.05) [Table 2].
OHI-S and PI showed statistically significant difference with the trimesters (P < 0.08; P < 0.47) and not with the age groups. In addition, OHI-S and PI were significantly associated (P < 0.47) [Table 3].
|Table 3: Correlation of Oral Hygiene index-Simplified and Periodontal index with each trimester and age groups|
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The results of the examination showed that 8.2% (n = 83) of the participants had good oral hygiene, 72.4% (n = 730) had fair oral hygiene, and 19.3% (n = 195) had poor oral hygiene.
Our results confirmed that in 1st trimester, the mean of OHI-S, PI along with mean age (in years) are 1.66, 1.66, and 23.33, respectively, in 2nd trimester, which indicates 2.05, 2.51, and 23.15 and in 3rd trimester indicates 2.13, 2.64, and 23.05. Hence, the mean age of the three trimesters remains the same without any variations in the age groups [Figure 1].
|Figure 1: Comparison of oral hygiene index-simplified and periodontal index with the age groups|
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| Discussion|| |
Anemia is a global health problem noticed in diverse countries. According to the WHO, anemia is a condition in which the number of red blood cells or their oxygen carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status. It is not a diagnosis; it is a symptom of some underlying condition, which occurs at any phase of the life, but is more prevailing in pregnant women and young children.
According to the classification of the WHO, the normal range of Hb in males and females is 13.8–17.2 g/dl and 12.1–15.1 g/dl, respectively. The pregnant women are considered anemic when the Hb levels are <11.0 g/dl in the 1st and 3rd trimesters and <10.5 g/dl in the 2nd trimester. However, the Hb cutoff value for pregnant women is 11.5 g/dl.
During pregnancy, the growth of the fetus requires iron supplements and alter in the maternal blood volume, lead to decrease in Hb concentration in the first trimester, which further reduce during the second trimester and rise again during the third trimester. Currently, the WHO has not recommended Hb cutoff points for anemia in any trimester. In our study, Hb level cutoff value is Hb < 9.7 g/dL, which can predict iron deficiency anemia in the 2nd and 3rd trimester.
Maternal anemia is a risk factor for poor outcome of pregnancy. In India, the pregnant women were screened for early detection of anemia and for its beneficial management with iron therapy, which was considered as a vital role for antenatal care  because India contributes to about 80% of the maternal deaths caused by anemia in South Asia. Our study confirmed that there was no significance difference in OHI-S and PI compared to Hb levels. However, Hari et al. stated that there was a correlation within hematologic levels with gingivitis and not with periodontitis at first-trimester pregnancy.
In addition to the assessment of health status through clinical measures, patient-based assessment of health status is essential to evaluate health. PI is used to determine the degree of destruction of periodontal tissue, due to the elevated levels of circulating estrogen, which leads to the prevalence of gingivitis and gingival hyperplasia during pregnancy. Results of this study showed that the prevalence of periodontitis was high in all the trimesters, and the majority showed the beginning destructive of periodontal disease [Figure 2].
Periodontal disease increases with the trimesters rather than the age groups in our study. The examined women who were beginning destructive of periodontal disease needs periodontal treatment includes scaling and root planning, which is considered safe during pregnancy and improves both maternal and neonatal health, and simple gingivitis needs oral hygiene instructions and professional prophylaxis.
As bleeding on probing is the most common dental problem and few studies reported to around 60%–70% of pregnant women, due to decreased immune response, hormonal fluctuations and changes in normal oral flora. Our study showed that the majority were affected in 3rd trimester, but in previous literature, it was mentioned that the possibility of bleeding on probing increased between the 1st and 2nd trimester.
The other oral changes which are seen in pregnancy include pyogenic granuloma, wherein our study, only one woman of all the examined had pregnancy growth. Pyogenic granulomas (pregnancy tumors) occur in about 1%–5% of the pregnant women. The pyogenic granuloma is caused by the dual action of local factors such as plaque leads to gingival irritation and sex hormones which increases angiogenesis. It usually appears in first pregnancies during first and second trimester and may relapse after the child's birth.
Increased facial pigmentation begins during the first trimester. Kandan et al. reported that in 73% of pregnant women showed bilateral brown patches in the mid-face. The etiology is unknown but believed that this may be due to increase in the serum levels of estrogen and progesterone. In our study, pigmentation was significant only with age groups but not with the trimesters, but in contrast, according to Dabette et al., there was a greater facial pigmentation in 2nd trimester followed by 3rd trimester.
Socioeconomic status is one of the possible factors for poor health and oral health outcomes. The results of the present study revealed an association between socioeconomic factors such as occupation, education, and dental hygiene. Due to the lack of accessibility to dental clinics and awareness to maintain proper oral health may indicate low socioeconomic status. Smoking, presence of local factors, obesity prior to pregnancy are other risk factors associated with periodontitis during pregnancy, which may be of greater risk when the disease is active because of alter exacerbation and remission of periodontal disease, reported in previous studies. Despite their association, studies have demonstrated that pregnancy does not cause periodontitis but rather exacerbates preexisting periodontal conditions. Hence, the present study also showed there was a marked increase in the association between pregnancy and periodontal condition.
| Conclusion|| |
The study suggests that there was a significant correlation between OHI-S, PI, and Hb levels within the trimesters of pregnancy irrespective of the age groups and Hb levels. The oral hygiene of examined women was satisfactory but is more at risk of periodontal diseases. They need more dental care in maintaining the oral hygiene during their pregnancy. Despite, every pregnant woman should be given instructions to keep up the oral hygiene and encourage their visit to the dentist, thus establishing a personal sense of responsibility to attain and maintain optimum dental health.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Glick M, Williams DM, Kleinman DV, Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World dental federation opens the door to a universal definition of oral health. J Am Dent Assoc 2016;147:915-7.
Lu HX, Xu W, Wong MC, Wei TY, Feng XP. Impact of periodontal conditions on the quality of life of pregnant women: A cross-sectional study. Health Qual Life Outcomes 2015;13:67.
Amin R, Shetty P. Oral health status during pregnancy in Mangalore. Nitte Univ J Health Sci 2014;4:114-7.
Gajendra S, Kumar JV. Oral health and pregnancy: A review. N Y State Dent J 2004;70:40-4.
Bobetsis YA, Barros SP, Offenbacher S. Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc 2006;137 suppl 10:7S-13S.
Shah AF, Batra M, Qureshi A. Evaluation of impact of pregnancy on oral health status and oral health related quality of life among women of Kashmir Valley. J Clin Diagn Res 2017;11:ZC01-4.
Raber-Durlacher JE, van Steenbergen TJ, Van der Velden U, de Graaff J, Abraham-Inpijn L. Experimental gingivitis during pregnancy and post-partum: Clinical, endocrinological, and microbiological aspects. J Clin Periodontol 1994;21:549-58.
Ahankari A, Leonardi-Bee J. Maternal hemoglobin and birth weight: Systematic review and meta-analysis. Int J Med Sci Public Health 2015;4:435-45.
Amel Ivan E, Mangaiarkkarasi A. Evaluation of anaemia in booked antenatal mothers during the last trimester. J Clin Diagn Res 2013;7:2487-90.
Chang SC, O'Brien KO, Nathanson MS, Mancini J, Witter FR. Hemoglobin concentrations influence birth outcomes in pregnant African-American adolescents. J Nutr 2003;133:2348-55.
Kalaivani K. Prevalence and consequences of anaemia in pregnancy. Indian J Med Res 2009;130:627-33.
] [Full text]
Carlin A, Alfirevic Z. Physiological changes of pregnancy and monitoring. Best Pract Res Clin Obstet Gynaecol 2008;22:801-23.
Tan EK, Tan EL. Alterations in physiology and anatomy during pregnancy. Best Pract Res Clin Obstet Gynaecol 2013;27:791-802.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.
Russell AL. The periodontal index. J Periodontol 1967;38:585-91.
Goyal G. Iron deficiency anemia and oral health prospective – A review. Int J Biol Biol Sci 2015;4:32-6.
WHO/UNICEF/UNO. IDA – Prevention, Assessment and Control. Report of A WHO/UNICEF/UNO Consultation. Geneva: World Health Organization; 1998.
Obeagu EI, Ezimah AC, Obeagu GU. Erythropoietin in the anemias of pregnancy: A review. Int J Curr Res Chem Pharm Sci 2016;3:10-8.
Laflamme EM. Maternal hemoglobin concentration and pregnancy outcome: A study of the effects of elevation in El Alto, Bolivia. Mcgill J Med 2011;13:47.
Kumar S, Dubey N, Khare R. Study of changes in red blood cell indices and iron status during three trimesters of pregnancy. Int J Med Sci Public Health 2016;5:2062-6.
Tiwari M, Kotwal J, Kotwal A, Mishra P, Dutta V, Chopra S. Correlation of haemoglobin and red cell indices with serum ferritin in Indian women in second and third trimester of pregnancy. Med J Armed Forces India 2013;69:31-6.
Sharma A, Patnaik R, Garg S, Prema Ramachandran. Detection & management of anaemia in pregnancy in an urban primary health care institution. Indian J Med Res 2008;128:45-51.
] [Full text]
Hari S, Benso S, Santana K, Nasution NH, Masulili LC. Hemoglobin and erythrocyte levels in correlation to periodontal status in first trimester pregnancy. J Int Dent Med Res 2016;9:207-10.
Naseem M, Khurshid Z, Khan HA, Niazi F, Zohaib S, Zafar MS. Oral health challenges in pregnant women: Recommendations for dental care professionals. Saudi J Dent Res 2016;7:138-46.
Gürsoy M, Pajukanta R, Sorsa T, Könönen E. Clinical changes in periodontium during pregnancy and post-partum. J Clin Periodontol 2008;35:576-83.
Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones. J Periodontol 2002;73:701-8.
Kandan PM, Menaga V, Kumar RR. Oral health in pregnancy (guidelines to gynaecologists, general physicians and oral health care providers). J Pak Med Assoc 2011;61:1009-14.
Dabette KL, Bijayanti DT, Hafi BN, Singh RL. Skin changes during pregnancy: A study from Northeast India. Indian Dermatol Online J 2018;9:455-7.
] [Full text]
Claas BM, Ellison-Loschmann L, Jeffreys M. Self-reported oral health care and access to oral health information among pregnant women in Wellington, New Zealand. N Z Med J 2011;124:37-50.
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[Table 1], [Table 2], [Table 3]