|Year : 2013 | Volume
| Issue : 1 | Page : 52-57
Evaluation of socio-demographic variables affecting the periodontal health of pregnant women in Chandigarh, India
Jagjit Singh Dhaliwal1, Gurvanit Lehl2, Sachinjeet K Sodhi3, Sonia Sachdeva1
1 Department of Periodontology and Implantology, National Dental College and Hospital, Dera Bassi, Mohali, Punjab, India
2 Department of Dentistry, Government Medical College and Hospital, Chandigarh, India
3 Department of Dentistry, The Apollo Clinic, Chandigarh, India
|Date of Submission||07-Apr-2011|
|Date of Acceptance||30-Aug-2012|
|Date of Web Publication||21-Feb-2013|
Jagjit Singh Dhaliwal
E 403, Rishi Apartments, Sector 70, Mohali, Punjab
| Abstract|| |
Background: The literature is replete with reports that pregnant women have an increased level of periodontal disease as compared with non-pregnant women of the same age. There are many studies correlating the effect of periodontal disease on the adverse pregnancy outcomes. The development of periodontal diseases during pregnancy can be influenced by factors such as preexisting oral conditions, general health, and socio-cultural background. There is very little data studying the effect of socio-demographic factors on the periodontal health of pregnant women. This study evaluated the periodontal status of a sample of pregnant women of Chandigarh and adjoining areas. The study also investigated the relationship between these variables and a series of demographic and clinical variables. Materials and Methods: The participants were 190 pregnant women attending Gynecology and Obstetrics outpatient department of Government Medical College and Hospital, Chandigarh. The participants were examined for their periodontal health and various socio-demographic variables were recorded on performas designed for the purpose of study. Statistical analysis was done. Results: The results revealed that the mean bleeding index scores and probing depth increased with statistical significance when the socio-economic status was lower ( P<0.05). No significant differences were found in bleeding index scores and mean probing depth among different categories of profession, education, place of residence, and trimester of pregnancy ( P>0.1). The plaque index was not significantly associated with the socio-economic status, profession, place of residence, and trimester of pregnancy ( P>0.1). Conclusion: In the population of pregnant women investigated under this study, the clinical and socio-demographic characteristics showed non-significant correlation except socio-economic status which showed statistically significant correlation with bleeding on probing and pocket depth. Further studies may be required in Indian population to determine the association of periodontal diseases in pregnant women with socio-demographic variables.
Keywords: Periodontal disease, pregnancy, socio-demographic
|How to cite this article:|
Dhaliwal JS, Lehl G, Sodhi SK, Sachdeva S. Evaluation of socio-demographic variables affecting the periodontal health of pregnant women in Chandigarh, India. J Indian Soc Periodontol 2013;17:52-7
|How to cite this URL:|
Dhaliwal JS, Lehl G, Sodhi SK, Sachdeva S. Evaluation of socio-demographic variables affecting the periodontal health of pregnant women in Chandigarh, India. J Indian Soc Periodontol [serial online] 2013 [cited 2015 Jan 25];17:52-7. Available from: http://www.jisponline.com/text.asp?2013/17/1/52/107475
| Introduction|| |
Many physiological and hormonal changes occur during pregnancy. It is a well known fact that these changes could alter the oral metabolism. These include alterations in hormonal levels, microbial strains present in the oral cavity, immune response, and cellular metabolism. , The increase in progesterone levels causes loss of keratinization of gingival epithelium, proliferation of fibroblasts, impaired chemotaxis, and phagocytic activity of neutrophils. ,, The prominent microorganism Prevotella intermedia increase in number because it uses progesterone as a nutrient which is available in GCF.  Therefore, pregnant women are considered at higher than normal risk of developing gingival and periodontal disease. Some periodontal conditions associated with pregnant women are pregnancy gingivitis and pyogenic granuloma.  The primary etiology for development of these conditions is the presence of local factors but hormonal changes contribute to predisposition of gingiva to these changes. 
There has been increasing evidence in the past years that periodontal disease in pregnant women may be associated with complications such as pre-term low birth weight (PTLBW), growth retardation, and preeclampsia. ,,,,,,,
Our understanding of the etiology and pathogenesis of complications related to periodontal disease in pregnant women has increased considerably in the past few years. This may not be able to explain all cases, but it has provided a framework around which links with periodontal diseases may be considered. Thus, it is of prime clinical interest to assess individual woman's risk for periodontal disease during pregnancy so that the prevalence and incidence of periodontal disease during pregnancy be decreased in order to avoid these potential complications.
Some of the studies have reported that socio-demographic variables influence the periodontal disease outcomes in pregnant women by influencing the individuals' resources to pay for care, access to care, understanding of the importance of oral health, and effective self-care practices. ,,
In light of these studies, we conducted a study on Indian women to evaluate the relationship between various socio-demographic and clinical variables affecting periodontal disease outcomes in pregnant women.
The purpose of present study was
- to evaluate the periodontal status in a sample of pregnant Indian women (in Chandigarh and adjoining areas) by measuring the plaque index (PI), bleeding index (BOP), and probing depth (PD) and
- to investigate the relationship between these variables and a series of demographic and clinical variables to determine how these relationships may be modified to improve oral health in pregnant women.
| Materials and Methods|| |
The study included 190 pregnant women attending the Gynaecology and Obstetrics outpatient department (OPD) of Government Medical College and Hospital, Chandigarh. Since patients attending this OPD are from the Union territory Chandigarh, adjoining towns of Panchkula and Mohali, and surrounding villages, it has an equal distribution of urban and rural population. An informed consent was taken from all the subjects and study protocol was approved by the ethical committee of the hospital. A performa was designed for this study to record the patients' age, socio-economic status, profession, education level, and place of residence. Patients were also enquired about their frequency of dental checkups and brushing. Data were also collected about trimester of pregnancy, number of previous pregnancies, and health problems due to pregnancy and other than pregnancy. Patients living in Chandigarh, Mohali, and Panchkula were classified as urban and from adjoining villages as rural. Periodontal maintenance was grouped as frequent if patient had undergone multiple visits in the previous year and infrequent if no visit was made. Then, periodontal examination was carried out for each patient.
Periodontal examination and assessment
Periodontal examination was carried out by same examiner in all the patients in order to avoid interexaminer variability. Following measurements were recorded for each tooth: (1) Plaque index: Presence of dental plaque was recorded according to the Silness and Loe plaque index,  (2) Bleeding on probing: The presence or absence of bleeding was recorded as per the sulcus bleeding index given by Muhlemann and Son,  (3) probing depth was recorded using the True Pressure Sensitive (TPS) probe.
Mean and standard deviations were calculated for continuous variables and frequency distributions were studied for discrete variables. Analysis of variance (ANOVA) test was used to compare clinical indices between demographic and clinical characteristics and if results were significant, difference between categories was tested with the Chi-square test. A probability value of <0.05 was taken as statistically significant.
| Results|| |
The socio-demographic characteristics of population are listed in [Table 1]. The mean age was 25 ± 3.44 years, with majority of study population in the 17-25 (59.47%) and 26-30 (33.68%) years old categories. The predominant economic-professional level was "housewife" (78.4%), followed by "employee" (18.4%). Most of the women under study were educated, 42.6% being educated up to matric level, 27.3% were graduates, and 38% were postgraduates. More than half of the sample (52.1%) lived in urban areas.
[Table 2] depicts the clinical variables related to pregnancy in the study population. The great majority of participants were in the third trimester (65%). There was a very low proportion of pregnancy-related health problems (20.5%) in the study population. More than half of the sample was primigravidae (59.4%), others having one child (34.2%) or two children (5.8%). Only two women (1.1%) had other health problems.
[Table 3] shows a plaque index score in relation to various demographic variables and clinical variables related to pregnancy. No difference was observed in the plaque index scores among various groups of different socio-economic status (P=0.312), professional level (P=0.161), education level, living areas (P=0.5), frequency of dental visits (P=0.7), trimester (P=0.2), and number of previous pregnancies (P=0.06). Moreover, the PI score was very low in the sample (mean=1.17 ± 0.04) showing that the study population had good oral hygiene.
[Table 4] shows bleeding on probing (BOP) score in relation to various demographic variables and clinical variables related to pregnancy. Significant differences were seen in bleeding on probing among groups of different socio-economic status. Bleeding on probing was higher among lower class category (P<0.004). No significant difference was detected between categories of age (P>0.1), profession (P>0.05), education (P>0.1), residence (P>0.1), frequency of dental visits (P>0.7), presence or absence of pregnancy health problems, and other health problems related to pregnancy.
[Table 5] shows probing depth in relation to various demographic variables and clinical variables related to pregnancy. Significant differences were observed in probing depth among groups of different socio-economic status. Probing depth was higher in lower class category (P=0.006). No significant differences were seen in other categories in relation with probing depth (P>0.1). Moreover, periodontal pockets were present in very few individuals depicting good periodontal health of sample.
| Discussion|| |
The incidence of gingival inflammation in pregnant women has been reported to range from 36% to 100%.  Silness and Lφe determined that the correlation between the amount of dental plaque and the severity of gingivitis was higher post-partum than during pregnancy, and concluded that "some other factor" was involved in the etiology of pregnancy gingivitis.  Hormonal and vascular changes associated with pregnancy can exaggerate the response of the gingiva to bacterial plaque.  It has been reported that healthy gingiva stays usually unaffected, and thus pregnancy itself does not cause gingivitis, but dental plaque or calculus is required for initiation of gingival changes during pregnancy.  Good oral hygiene practices, however, can minimize gingival disease during pregnancy. , Therefore, good oral hygiene of patients in study population which is obvious from the low plaque index score could be attributable for low prevalence of periodontal disease in this population.
It is difficult to make comparison of study results with the previous studies because of the differences in study populations and study designs. Our study results are somewhat in accordance with study of Miyazaki et al.  They conducted a survey concerning periodontal disease prevalence and treatment needs in pregnant women ranging from 16 to 43 years of age in Kumamoto and Kitakyushu cities, Japan. They used CPITN values for the assessment of periodontal condition, which is quicker, simpler, and very useful for the field of public oral health. In our study, a pressure-sensitive probe was used, which is more reliable, as it avoids over- or underestimation of the pocket depth. In their study, signs of periodontal disease were observed in 95% of the pregnant women and 96% of the non-pregnant women. More sextants showing healthy periodontal conditions were observed in the pregnant than in the non-pregnant women. In our study also most of the pregnant women had good periodontal health except some women belonging to low socio-economic status.
Our study results vary from the study of Machuca et al.;  they evaluated the periodontal status of pregnant women and its relationship to demographic variables in the province of Seville, Spain, and periodontal condition in their study population was related to different socio-demographic variables such as professional level, level of education, and previous periodontal maintenance. It might be accredited to differences in study populations.
Tilakaratne et al.  studied the effects of pregnancy on the periodontium, in a rural population of Sri Lankan women and their study results showed that pregnancy had an effect only on the gingiva and not on periodontal attachment levels. In our study, significant results were obtained in relation to bleeding on probing and probing depth in women of lower socio-economic status. It might be an attributed negligence of oral hygiene in women of lower socio-economic status leading to increased gingival inflammation during pregnancy. The levels of oestrogens are elevated in pregnancy leading to changes in keratinization of the gingival epithelium and alteration in the connective tissue ground substance. This results in decreased effectiveness of the epithelial barrier. These effects combined with vascular changes caused by elevated hormone levels give rise to aggravated response to the irritant effects of plaque, resulting in overt gingivitis.
Yalcin et al.  studied the effect of socio-cultural status on periodontal condition in pregnancy in Turkish women by recording clinical measurements including the plaque index, gingival index, and probing depth. They evaluated interaction between these parameters and their socio-cultural background. They reported the correlation of clinical index scores with educational level and periodontal care.
Wandera et al.  had examined periodontal status and tooth loss in pregnant Ugandan women and assessed the relationship with socio-demographic factors, parity (number of children), dental care, and oral hygiene. The oral condition of pregnant women was characterized by low prevalence of bleeding, high prevalence of calculus deposits, low prevalence of 4-5 mm pockets, and by a moderate prevalence of tooth loss. They concluded that age, social status, oral hygiene, and parity might be the potential risk factors for chronic periodontal disease in their study population. In our study, only the socio-economic status was a potential risk factor in the development of periodontal disease.
The comparison between studies is also complicated because of a different ethnic composition of study populations. Machuca et al.  study population was White Europeans, Wandera et al.  study report included Africans, Yalcin et al.  study included Caucasian women, and our study was conducted on Asians. Moreover, study populations of Miyazaki,  Machuca,  and Tilakaratne  were primarily from rural areas whereas in our study, majority of the population was from urban areas. Moss et al.  emphasized that race is a significant factor governing the incidence and progression of periodontal disease and African Americans were more likely to experience incidence/progression of periodontitis as compared to other races. Jeffcoat et al. published interim results from an ongoing study in Alabama and reported that their population was made up of 83% African Americans, and that these subjects had significantly more periodontal disease: Unfortunately they did not report how much more. 
Trimester of pregnancy also influences the periodontal condition. Early cross-sectional studies  implied that gingivitis steadily worsens through pregnancy and does not diminish until after delivery, but later longitudinal studies imply that there is a peak in inflammation during the second trimester and then a decrease in the third term. ,, A small cross-sectional study of Turkish women  supported these findings and reported that they were reflected in an increase in the mean probing pocket depth between the first and third trimesters. In our study, majority of patients were in the third trimester, when decrease in gingival inflammation occurs; so it could have also accounted for the variation in study results.
Other factors such as socio-economic status and profession are also important. Very few patients (6.8%) belonged to category of lower socio-economic status. Although most of the patients were housewives (78.4%), majority of the sample was educated at least up to matric level (81%). In the study of Machuca et al.,  most of the patients were housewives but majority of them were educated up to primary level.
So, factors such as living area, ethnicity, socio-economic status, education, and oral hygiene of patients may be responsible for the differences in study results of various studies taking into consideration influence of various socio-demographic factors on periodontal health of pregnant women.
| Conclusion|| |
In the sample of pregnant women investigated in this study, very few women presented with periodontal disease, which may be attributed to their good oral hygiene maintenance. Moreover, the clinical and socio-demographic characteristics showed non-significant correlation except socio-economic status, which showed statistically significant correlation with bleeding on probing and probing depth. Further studies may be required in the Indian population to substantiate association of periodontal disease in pregnant women with the socio-demographic variables.
| References|| |
|1.||Amar S, Chung KM. Influence of hormonal variation on the periodontium in women. Periodontol 2000 1994;6:79-87. |
|2.||Jonsson R, Howland BE, Bowden GH. Relationships between periodontal health, salivary steroids, and Bacteroides intermedius in males, pregnant and non-pregnant women. J Dent Res 1988;67:1062-9. |
|3.||Miyagi M, Aoyama H, Morishita M, Iwamoto Y. Effects of sex hormones on chemotaxis of human peripheral polymorphonuclear leukocytes and monocytes. J Periodontol 1992;63:28-32. |
|4.||Willershausen B, Lemmen C, Hamm G. Modulation of glycosaminoglycan-and collagen synthesis by human gingival fibroblasts by progesterone. Dtsch Zahnarztl Z 1991;46:668-71. |
|5.||Zachariasen RD. The effect of elevated ovarian hormones on periodontal health: Oral contraceptives and pregnancy. Women Health 1993;20:21-30. |
|6.||Kornman KS, Loesche WJ. The subgingival microflora during pregnancy. J Periodontal Res 1980;15:111-22. |
|7.||Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60:257-64. |
|8.||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. |
|9.||Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103-13. |
|10.||Dasanayake AP, Russell S, Boyd D, Madianos PN, Forster T, Hill E. Preterm low birth weight and periodontal disease among African Americans. Dent Clin North Am 2003;47:115-25. |
|11.||Agueda A, Ramon JM, Manau C, Guerrero A, Echeverría JJ. Periodontal disease as a risk factor for adverse pregnancy outcomes: A prospective cohort study. J Clin Periodontol 2008;35:16-22. |
|12.||Siqueira FM, Cota LO, Costa JE, Haddad JP, Lana AM, Costa FO. Maternal periodontitis as a potential risk variable for preeclampsia: A case-control study. J Periodontol 2008;79:207-15. |
|13.||Marakoglu I, Gursoy UK, Marakoglu K, Cakmak H, Ataoglu T. Periodontitis as a risk factor for preterm low birth weight. Yonsei Med J 2008;49:200-3. |
|14.||Lopez NJ, Smith PC, Gutierrez J. Periodontal therapy may reduce the risk of preterm low birth weight in women with periodontal disease: A randomized controlled trial. J Periodontol 2002;73:911-24. |
|15.||Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003;101:227-31. |
|16.||Canakci V, Canakci CF, Canakci H, Canakci E, Cicek Y, Ingec M, et al. Periodontal disease as a risk factor for pre-eclampsia: A case control study. Aust N Z J Obstet Gynaecol 2004;44:568-73. |
|17.||Machuca G, Khoshfeiz O, Lacalle JR, Machuca C, Bullón P. The influence of general health and socio-cultural variables on the periodontal condition of pregnant women. J Periodontol 1999;70:779-85. |
|18.||Alwaeli HA, Al-Jundi SH. Periodontal disease awareness among pregnant women and its relationship with socio-demographic variables. Int J Dent Hyg 2005;3:74-82. |
|19.||Wandera M, Engebretsen IM, Okullo I, Tumwine JK, Astrøm AN; PROMISE-EBF Study Group. Socio-demographic factors related to periodontal status and tooth loss of pregnant women in Mbale district, Uganda. BMC Oral Health 2009;9:18-29. |
|20.||Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-35. |
|21.||Benamghar L, Penaud J, Kaminsky P, Abt F, Martin J. Comparison of gingival index and sulcus bleeding index as indicators of periodontal status. Bull World Health Organ 1982;60:147-51. |
|22.||Al Habashneh R, Guthmiller JM, Levy S, Johnson GK, Squier C, Dawson DV, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32:815-21. |
|23.||Gursoy M, Pajukanta R, Sorsa T, Könönen E. Clinical changes in periodontium during pregnancy and post-partum. J Clin Periodontol 2008;35:576-83. |
|24.||Silness J, Loe H. Periodontal disease in pregnancy. 3. Response to local treatment. Acta Odontol Scand 1966;24:747-59. |
|25.||Miyazaki H, Yamashita Y, Shirahama R, Goto-Kimura K, Shimada N, Sogame A, et al. Periodontal condition of pregnant women assessed by CPITN. J Clin Periodontol 1991;18:751-4. |
|26.||Tilakaratne A, Soory M, Ranasinghe AW, Corea SM, Ekanayake SL, de Silva M. Periodontal disease status during pregnancy and 3 months post-partum, in a rural population of Sri-Lankan women. J Clin Periodontol 2000;27:787-92. |
|27.||Yalcin F, Eskinazi E, Soydinc M, Basegmez C, Issever H, Isik G, et al. The effect of sociocultural status on periodontal conditions in pregnancy. J Periodontol 2002;73:178-82. |
|28.||Moss KL, Beck JD, Offenbacher S. Clinical risk factors associated with incidence and progression of periodontal conditions in pregnant women. J Clin Periodontol 2005;32:492-8. |
|29.||Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldberg RL, Hauth JC. Periodontal infection and preterm birth: Results of a prospective study. J Am Dent Assoc 2001;132:875-880. |
|30.||Hugoson A. Gingival inflammation and female sex hormones. A clinical investigation of pregnant women and experimental studies in dogs. J Periodontal Res Suppl 1970;5:1-18. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]