|Year : 2015 | Volume
| Issue : 2 | Page : 138-143
Oral health status and adverse pregnancy outcomes among pregnant women in Haryana, India: A prospective study
Puneet Singh Talwar1, Ramandeep Singh Gambhir2, Deepti Talwar3, Ramandeep Kaur Sohi4, Ashish Vashist4, Vaibhav Munjal5
1 Department of Public Health Dentistry, Bhojia Dental College and Hospital, Baddi, Himachal Pradesh, India
2 Department of Public Health Dentistry, Gian Sagar Dental College and Hospital, Rajpura, Punjab, India
3 Department of Oral Surgery, MM University, Mullana, Ambala, Haryana, India
4 Department of Public Health Dentistry, Sri Sukhmani Dental College and Hospital, Dera Bassi, Punjab, India
5 Department of Pedodontics and Preventive Dentistry, National Dental College and Hospital, Dera Bassi, Punjab, India
|Date of Web Publication||18-Jun-2015|
Ramandeep Singh Gambhir
Department of Public Health Dentistry, Gian Sagar Dental College, Rajpura - 140 601, Punjab
Source of Support: None, Conflict of Interest: None
Background: Women's oral health is affected by certain conditions such as pregnancy, puberty, menstrual cycle, menopause and nonphysiological conditions such as hormonal contraception and hormonal therapy. This study was conducted to assess the oral health status and treatment needs of pregnant women and to correlate periodontal health with adverse pregnancy outcomes like preterm birth (PTB) and low birth weight (LBW). Materials and Methods: A prospective study was undertaken at a Government Hospital in Haryana. Pregnant women who were in their third trimester of pregnancy and visited the hospital for routine ante-natal check-up constituted the final sample size (223). Dental caries and periodontal status were assessed using a WHO Proforma-1997. None of the subjects were in the habit of taking alcohol, chewing and smoking tobacco. The main outcome measures were gestational age and weight of the newborn. Data were analyzed using SPSS package version 13. Results: Decayed, missing and filled teeth index of the subjects was 2.87. Extraction was indicated in younger subjects when compared to the older ones. Bleeding was the main finding, which was present in 47.5% of the study subjects, followed by calculus. 63 more than 60% of subjects of subjects with 4-5 mm attachment loss belonged to 20-24 years age-group. There was a statistically significant association of probing depths and attachment loss with adverse pregnancy outcomes (P < 0.05) (PTB and LBW). Conclusion: There is a significant association between maternal periodontitis and pregnancy outcomes in the present study. It is recommended that suitable measures be undertaken by various health organizations to prevent periodontal problems among this particular group.
Keywords: Low birth weight, oral health, periodontitis, pregnancy complications, preterm
|How to cite this article:|
Talwar PS, Gambhir RS, Talwar D, Sohi RK, Vashist A, Munjal V. Oral health status and adverse pregnancy outcomes among pregnant women in Haryana, India: A prospective study. J Indian Assoc Public Health Dent 2015;13:138-43
| Introduction|| |
Oral health is an integral part of general health. Physiological conditions such as pregnancy, puberty, menstrual cycle, menopause and nonphysiological conditions such as hormonal contraception and hormonal therapy all influence women's oral health.  Pregnant women have special oral health needs due to hormonal fluctuations, which have a strong influence on the oral cavity. W.H.O World Health Day Theme of 1998, "Safe motherhood pregnancy is precious-let's make It special" draws our special attention towards this priority group, which needs special care. 
The influence of hormone on oral health was not known until the 19 th Century. The prevalence of gingivitis in pregnant women was first reported and described in 1974.  Before the turn of the 20 th century a fairly precise description of the gingival change during pregnancy was available. This description suggests that gingival condition in pregnant women should be considered as separate problem from that of simple gingivitis. In addition to generalized gingival changes pregnancy may also increase the prevalence of gingivitis and may cause tumor-like growth called "pregnancy tumor" or "Epulis gravidatum," which may occur inter-proximally and usually regress itself after delivery. 
The severity of gingival disease is reduced after childbirth, but the gingiva does not necessarily come back to normal. There may be a residual effect, which may continue and ultimately lead to a severe condition and loss of tooth. The periodontal changes such as pocket formation, increased tooth mobility and loss of attachment may lead to deterioration of oral health and loss of teeth.  "Lose a tooth for every pregnancy" is a popular notion that suggests that pregnancy causes tooth loss. However there is no medical literature to support this statement.
Preterm birth (PTB) and low birth weight (LBW) are the leading prenatal problems worldwide and have evident public health implications because they are closely related to perinatal mortality and to nearly one-half of all serious long-term neurological morbidity.  Various maternal factors have been associated with the delivery of PTB and LBW infants, which include age, height, weight, socioeconomic status, smoking, alcohol consumption, nutritional status and stress. In addition previous complications, maternal hypertension, infection, and cervical incompetence may also be important. , Periodontal infection can increase the level of inflammatory mediators, which shortens gestation age leading to LBW infants, PTBs, miscarriage and stillbirth. Hence, maternal periodontal infection is emerging as an independent risk factor for preterm delivery and LBW.  In contrast, several other studies question such an association and attribute it to a mere chance; the substantial proof is yet to arise. ,
Haryana is a state with a population density of 477 persons/km 2 with per capita income of Rupees 67,891. The literacy rate of Haryana state is 69.97%, infant mortality rate is 59% and the birth rate is 24.3% and growth rate is 28.43%.  Studies regarding oral health status (specially periodontal status) and treatment needs of pregnant women and their pregnancy outcomes are almost nonexistent in India. Hence, the current prospective study has been undertaken to report oral health status and treatment needs of pregnant women and to correlate periodontal health status with adverse pregnancy outcomes (PTB and LBW).
| Materials and methods|| |
Study population and sample size
This study was conducted after obtaining ethical clearance from the Institutional Review Board and with prior permission from the Director, Medical Health, Haryana. Written informed consent was obtained from each subject before commencing the study. The present study was conducted in Government Hospital, Sector-6, Panchkula, Haryana. The duration of the study was 12 months. The required sample size was determined using the formula for estimating sample size for single population proportion with 95% confidence level and 0.05 degree of accuracy required. With these assumptions, a sample size of 223 was obtained. Pregnant women who visited the hospital during their third trimester of pregnancy were included in the study on the basis of convenient sampling to reach the desired sample. Subjects were included for a period of 9 months so that subjects who were in their last trimester during the 9 th month of the study could deliver within in the study period. Subjects in the first and second trimester of the pregnancy were excluded from the study.
Examiner calibration and examination
A single trained examiner (PST) who was calibrated in the department conducted all the examinations. Intra examiner calibration was undertaken by examining 40 subjects followed by their re-examination a week later which resulted in 84% of diagnostic acceptability with a kappa value of 0.82.
The pregnant women were interviewed, and a Type III clinical examination was conducted. The "WHO Oral Health Proforma-1997" was used to record the clinical findings such as dental caries and periodontal status.  The information regarding alcohol consumption, tobacco smoking, history of previous delivery and postpartum obstetric history (pregnancy outcomes, birth weight and gender of child) were recorded on another structured format by another investigator. For the diagnosis of dental caries, examination was done using mouth mirrors and sharp probes. Clinical parameters recorded while performing periodontal assessment using community periodontal index probe were-clinical pocket probing depth (in mm), clinical loss of attachment from the base of periodontal pocket to the cement-enamel junction (in mm), bleeding on probing (presence or absence) and calculus (presence or absence). The dental examination was conducted using additional artificial light. A table to place the instruments was placed within easy reach of the examiner. The recording assistant was allowed to sit close to the examiner.
Pregnancy outcome data collection
Gestational age and birth weight of child were chosen as the two main pregnancy outcome characteristics. Estimation of gestational age was calculated on the basis of last menstrual period, ultrasound examinations and other physical parameters. In addition, adverse pregnancy outcome was categorized into outcome categories. Spontaneous birth at less than 37 weeks gestation was considered as PTB and LBW were defined as birth weight less than 2500 g. Both these categories were evaluated for their association with pocket depths and clinical attachment loss of the mothers.
The data were analyzed using SPSS package version 13.0. (SPSS, Chicago, IL, USA). A one-way analysis of variance (ANOVA) and Z-test was used to determine differences at the 5% significance level (P < 0.05), whereas proportions were compared by the use of Chi-square test. Linear Regression Analysis was also performed to compare the birth data with periodontal variables. P < 0.05 was selected to denote statistical significance.
| Results|| |
Among 223 subjects, majority 53.8% (120) were in the age group of 20-24 years followed by 33.2% (74) in the age group 25-29 years. 82.1% (183) of the subjects were unemployed and resided at homes only. Among a total of 223 subjects, only 44.8% (100) of the subjects were having their first pregnancy, and 39.9% (89) were having their second pregnancy. Deleterious habits like alcohol consumption, tobacco smoking and chewing were absent in the study subjects.
History of previous delivery
Ninety-two percent of the subjects delivered normally and most of the study subjects in all the age groups also had normal previous deliveries of their children. About 5% (6) of the pregnant women in the age-group of 20-24 years had their first child born through caesarean section as compared to 4.1% (3) of subjects in the age-group of 25-29 years who underwent caesarean section. Only 1.7% (4) of the study subjects gave a history of preterm and LBW associated with their previous children. Previous history of miscarriage was reported by 2.2% (2) of the study subjects.
[Figure 1] depicts the decayed, missing and filled teeth (DMFT) according to the age of the study population. Mean DMFT of the study population was 2.87. DMFT of the study subjects increased with increasing age. Mean number of decayed and missing teeth due to caries were 2.73 ± 1.03 and 0.628 ± 1.75, respectively and their relation with age was found to be statistically significant (P < 0.01, ANOVA). Maximum number of subjects having caries (34.16%) belonged to 25-29 years age-group. Mean number of subjects requiring one surface filling, pulp care and extraction were 1.48 ± 2.85, 0.07 ± 0.51 and 0.04 ± 0.28 respectively. Proportionally more younger subjects needed extraction as compared to older ones and treatment needs of the subjects were nonsignificant in relation to the age (P = 0.07).
|Figure 1: Mean decayed, missing and filled teeth of the study population according to various age‑groups|
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[Figure 2] illustrates the periodontal health status of the study sample. Shallow pockets were present in 4.5% of the subjects. Bleeding was the main finding, which was present in the majority (47.5%) of the study subjects, followed by calculus present in 24.2% of the study subjects. About 63.6% of the subjects with an attachment loss of 4-5 mm and 66.7% of subjects with an attachment loss of 9-11 mm belonged to 20-24 years age-group [Table 1]. Loss of attachment was nonsignificant in relation to the age of study subjects (P > 0.05).
|Figure 2: Age‑wise distribution of periodontal status of study population on the basis of community periodontal index score|
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|Table 1: Age‑wise distribution of subjects according to loss of attachment in 3rd trimester of pregnancy|
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Pregnancy outcomes and periodontal health
There were statistically significant differences in the periodontal variables with the normal birth and LBW group (P < 0.05). Normal-term group demonstrated a statistically significant difference in periodontal parameters when compared with the preterm group (P < 0.05). However, there was a higher percentage of subjects with bleeding and with a pocket depth of 4-5 mm in the normal-term group as compared to the preterm group [Table 2].
|Table 2: CPI index of subjects according to birth weight and gestational age of their children|
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Loss of attachment was more significant in the case of LBW group as compared to normal-weight group (P < 0.05). Normal-term group also experienced significant losses in the attachment level when compared with the preterm group (P < 0.05). There were a comparatively higher percentage of subjects with attachment loss of 4-5 mm who experienced a LBW [Table 3].
|Table 3: Attachment loss of subjects according to birth weight and gestational age of their children|
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[Table 4] summarizes the results of linear regression analysis. The final model demonstrated that PTB and LBW were associated with mean probing depths, mean loss of attachment, bleeding on probing and calculus. The adjusted R2 value was 0.032.
|Table 4: Linear regression analysis with P to compare birth data with periodontal variables with adjusted R2 value|
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| Discussion|| |
The present study assessed the oral health status and pregnancy outcomes of 223 pregnant women in their third trimester who visited Government Hospital, Panchkula.
Eighty-seven percent of the subjects belong to 20-29 years of age. In the study, 82.1% of women were found to be unemployed, which is similar to study conducted in Hyderabad.  This can be attributed to the fact that in a country like India, women still are thought to be the caretaker and responsible for children, whereas men are considered to be the bread earner of the family. Low sociodemographic characteristics can have a detrimental effect on the periodontal health of the individuals. 
Fifteen percent of the pregnant women were in 3 rd and 4 th gravida. This reflects on the failure of the family welfare programs, and the other reason could be infant and child mortality.  Health care programs should concentrate more on educating young people, providing financial support, creating awareness and counseling households with married adolescent women. Almost 66% of the study subjects had normal previous deliveries. This can be explained on the basis of a recent survey in Haryana; more than 80% of the pregnant women were regularly visiting health center for their ante-natal check which significantly reduces chances of any complication and consequently cesarean section. 
About 8.1% of study subjects delivered preterm. The possible reason behind this may be because of the fact that 44.8% of subjects were in their 1 st gravidity and all the subjects who were free of alcohol, smoking tobacco and chewing tobacco habits, which are major risk factors for pregnancy failure. Similar findings were reported in another study. 
Dental caries was present in 53.8% of the study subjects. The mean DMFT of the study population was 2.87, which is less as compared to another study conducted among rural pregnant women in India.  There was a nonsignificant association between number of teeth needing treatment with age in this study. An Australian study reported similar findings. 
The role of periodontal infections in relation to PTB and LBW has always been in debate. Many studies show an association while a lot other do not agree on such associations. ,, The percentage of subjects having calculus and shallow pockets in the present study is less as compared to findings of Vergnes et al.  Loss of attachment level greater than 6-8 mm was low in the all the age-groups in the present study population, which is congruence with findings of a study,  but less percentage of subjects had an attachment loss of 4-5 mm in the present study as compared to study results of Gursoy et al. 
The incidence of LBW in the present study is much higher as compared to the results of a study conducted on Spanish population.  This could be due to various social, economic and biological variables, which are the main contributing factors toward LBW in India.  However, the periodontal status of pregnant women in the Spanish study did not show any association with adverse pregnancy outcomes; which is not in agreement with the present study.
About 92% of pregnant women had normal term delivery in the present study, which is found to be similar to that reported by Gursoy et al.  and Moore et al.  There were a significant association of periodontal infection with PTB and LBW in the present study. This finding is similar to another study conducted in Madagascar in which there was a strong association between periodontitis and PTB and LBW (P < 0.01).  About 30% of subjects having severe attachment loss delivered preterm as compared to 11% of the health subjects. This association came out to be statistically significant (P < 0.05). Bleeding on probing was significantly greater in women with LBW in the present study and another study conducted on Caucasian pregnant women.  Reports of a study conducted in Taiwan revealed that bleeding on probing was significantly more in subjects with periodontitis and there was a significant co-relation between maternal periodontal disease and LBW which is in agreement with the results of present study. 
This study had some limitations. Some of the data gathered (smoking, alcohol intake, history regarding previous deliveries) were self-reported from the subjects, which may have biased the results to some extent. Moreover, the present study did partial mouth recording of periodontal variables despite the evidence that the use of partial methods can result in underestimation of the disease.  However, it was necessary to reduce the potential discomfort to a minimum to increase the power of the study.
| Conclusion|| |
The present study highlights the oral health status and relation of various periodontal variables with adverse pregnancy outcomes. There is a gradual increase in DMFT as the age increases. There is a significant association between maternal periodontal disease in the third trimester and adverse pregnancy outcomes like PTB and LBW. Suitable measures can be implemented by the Government, Professional Organizations, and Dental Institution to screen and identify pregnant women with periodontal problems, and suitable interceptive measures can be taken up.
| References|| |
Patil SN, Kalburgi NB, Koregol AC, Warad SB, Patil S, Ugale MS. Female sex hormones and periodontal health-awareness among gynecologists - A questionnaire survey. Saudi Dent J 2012;24:99-104.
Fathalla M. Women have a right to safe motherhood. Plan Parent Chall 1998;1:1-2.
Kolodzinsky E, Malatesta E, De Caldelas NM. Gingival changes in pregnant women. Rev Asoc Odontol Argent 1974;62:116-9.
Durairaj J, Balasubramanian K, Rani PR, Sagili H, Pramya N. Giant lingual granuloma gravidarum. J Obstet Gynaecol 2011;31:769-70.
Christensen LB, Jeppe-Jensen D, Petersen PE. Self-reported gingival conditions and self-care in the oral health of Danish women during pregnancy. J Clin Periodontol 2003;30:949-53.
Boggess KA, Beck JD, Murtha AP, Moss K, Offenbacher S. Maternal periodontal disease in early pregnancy and risk for a small-for-gestational-age infant. Am J Obstet Gynecol 2006;194:1316-22.
Heaman M, Kingston D, Chalmers B, Sauve R, Lee L, Young D. Risk factors for preterm birth and small-for-gestational-age births among Canadian women. Paediatr Perinat Epidemiol 2013;27:54-61.
Baig SA, Khan N, Baqai T, Fatima A, Karim SA, Aziz S. Preterm birth and its associated risk factors. A study at tertiary care hospitals of Karachi, Pakistan. J Pak Med Assoc 2013;63:414-8.
Ali TB, Abidin KZ. Relationship of periodontal disease to pre-term low birth weight infants in a selected population - A prospective study. Community Dent Health 2012;29:100-5.
Mitchell-Lewis D, Engebretson SP, Chen J, Lamster IB, Papapanou PN. Periodontal infections and pre-term birth: Early findings from a cohort of young minority women in New York. Eur J Oral Sci 2001;109:34-9.
Moore S, Ide M, Coward PY, Randhawa M, Borkowska E, Baylis R, et al.
A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J 2004;197:251-8.
Provisional Population Totals at a Glance Figure: 2011. Haryana: Government of India, New Delhi; 2012. Available from: http://www.censusindia.gov.in/2011-provresults/prov_data_products_haryana.html. [Last accessed on 2013 Oct 10].
World Health Organization. Oral Health Assessment Form. Oral Health Surveys, Basic Methods. 4 th
ed. Geneva: WHO Press; 1997. p. 26-9.
Avula H, Mishra A, Arora N, Avula J. KAP assessment of oral health and adverse pregnancy outcomes among pregnant women in Hyderabad, India. Oral Health Prev Dent 2013;11:261-70.
Bonfim Mde L, Mattos FF, Ferreira e Ferreira E, Campos AC, Vargas AM. Social determinants of health and periodontal disease in Brazilian adults: A cross-sectional study. BMC Oral Health 2013;13:22.
Singh L, Rai RK, Singh PK. Assessing the utilization of maternal and child health care among married adolescent women: Evidence from India. J Biosoc Sci 2012;44:1-26.
District Level Household and Facility Survey-Fact Sheet Haryana. International Institute for Population Sciences, Mumbai; 2008. Available from: http://www.jsk.gov.in/dlhs3/Haryana.pdf. [Last accessed on 2013 Oct 12].
Rajapakse PS, Nagarathne M, Chandrasekra KB, Dasanayake AP. Periodontal disease and prematurity among non-smoking Sri Lankan women. J Dent Res 2005;84:274-7.
Pentapati KC, Acharya S, Bhat M, Rao SK, Singh S. Knowledge of dental decay and associated factors among pregnant women: A study from rural India. Oral Health Prev Dent 2013;11:161-8.
Jago JD, Chapman PJ, Aitken JF, McEniery TM. Dental status of pregnant women attending a Brisbane maternity hospital. Community Dent Oral Epidemiol 1984;12:398-401.
Vergnes JN, Kaminski M, Lelong N, Musset AM, Sixou M, Nabet C, et al.
Maternal dental caries and pre-term birth: Results from the EPIPAP study. Acta Odontol Scand 2011;69:248-56.
Noack B, Klingenberg J, Weigelt J, Hoffmann T. Periodontal status and preterm low birth weight: A case control study. J Periodontal Res 2005;40:339-45.
Gürsoy M, Pajukanta R, Sorsa T, Könönen E. Clinical changes in periodontium during pregnancy and post-partum. J Clin Periodontol 2008;35:576-83.
Santa Cruz I, Herrera D, Martin C, Herrero A, Sanz M. Association between periodontal status and pre-term and/or low-birth weight in Spain: Clinical and microbiological parameters. J Periodontal Res 2013;48:443-51.
Bharati P, Pal M, Bandyopadhyay M, Bhakta A, Chakraborty S, Bharati P. Prevalence and causes of low birth weight in India. Malays J Nutr 2011;17:301-13.
Rakoto-Alson S, Tenenbaum H, Davideau JL. Periodontal diseases, preterm births, and low birth weight: Findings from a homogeneous cohort of women in Madagascar. J Periodontol 2010;81:205-13.
Marin C, Segura-Egea JJ, Martínez-Sahuquillo A, Bullón P. Correlation between infant birth weight and mother's periodontal status. J Clin Periodontol 2005;32:299-304.
Wang YL, Liou JD, Pan WL. Association between maternal periodontal disease and preterm delivery and low birth weight. Taiwan J Obstet Gynecol 2013;52:71-6.
Agerholm DM, Ashley FP. Clinical assessment of periodontitis in young adults - Evaluation of probing depth and partial recording methods. Community Dent Oral Epidemiol 1996;24:56-61.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]