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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2017  |  Volume : 35  |  Issue : 1  |  Page : 47-50

Opinion of dentists and gynecologists on the link between oral health and preterm low birth weight: “Preconception care - treat beyond the box”

1 Department of Periodontology, JSS Dental College and Hospital, Mysore, Karnataka, India
2 Department of Implantology, JSS Dental College and Hospital, Mysore, Karnataka, India

Date of Web Publication31-Jan-2017

Correspondence Address:
Aruna Ganganna
Department of Periodontology, JSS Dental College and Hospital, Room No. 9, Mysore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.199231

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Background: Periodontal diseases are known to set an inflammatory response at the systemic level which can adversely affect the pregnancy outcomes, and many patients are unaware of this association. Health-care providers play a vital role in educating patients toward maintaining good oral health; hence, our study was planned to evaluate the knowledge, attitude, and practices of dentists' and gynecologists' concerning this link. In addition, referral to the dentists' during the preconception period was also emphasized. Materials and Methods: This was a cross-sectional questionnaire survey conducted among dentists and gynecologists' in the city of Mysore. The participants were divided into two groups and were asked specific questions about the association between oral health and preterm low birth weight (PTLB). Group I constituted the dentists possessing both graduate and postgraduate degree and Group II were the gynecologists'. Results: Seventy-nine percent of the total participants agreed about the link between periodontal health and PTLB. Dentists were more aware of the periodontal changes during pregnancy and stressed on frequent dental checkup during pregnancy. Preconception care was a neglected part of the protocol by the gynecologists', and only 12% of them referred patients to a dentist in the preconception period. Factors significantly associated with knowledge in logistic regression analyses were older age, dentists and the years of experience (>5 years). Conclusion: Knowledge about oral health is important, to maintain good general health; hence, health workers should not miss opportunities to contribute to this health promotion. An integrated work by the dentists and gynecologists may reduce the adverse pregnancy outcomes associated with periodontal diseases.

Keywords: Periodontitis, preconception care, pregnancy, preterm low birth weight

How to cite this article:
Ganganna A, Devishree G. Opinion of dentists and gynecologists on the link between oral health and preterm low birth weight: “Preconception care - treat beyond the box”. J Indian Soc Pedod Prev Dent 2017;35:47-50

How to cite this URL:
Ganganna A, Devishree G. Opinion of dentists and gynecologists on the link between oral health and preterm low birth weight: “Preconception care - treat beyond the box”. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2022 Aug 8];35:47-50. Available from: http://www.jisppd.com/text.asp?2017/35/1/47/199231

   Introduction Top

Periodontal diseases are a group of oral inflammatory diseases caused by bacterial plaque and influenced by host factors. They remain as a low-grade chronic infection at the systemic level causing transient bacteremia. Numerous studies have addressed this phenomenon on a wide range of organ systems and hypothesized many interactive mechanisms linking oral and systemic health. In this regard, studies linking oral infections and maternal health are increasing, supporting the current scientific evidence of treating periodontal infections which can be influential in reducing adverse pregnancy outcomes.[1]

Preterm low birth weight (PTLB) accounts for about two-thirds of neonatal deaths and is more prevalent in developing countries than developed countries. Factors such as premature rupture of membranes, vaginal infections, smoking, race, maternal age, and diabetes increase the risk of PTLB, but these factors are not present in approximately one-fourth of the patients leading to a continued search for other causes.[2] The World Health Organization stated that oral diseases, including periodontal diseases, are a serious health problem and increasing awareness of oral health should be considered as an important component of general health. Awareness regarding pregnancy and its effect on periodontium is considerable but knowledge on the inverse relationship is sparse. Hence, the health workers hold a major role in sculpting the attitude of the patients toward good oral hygiene which can subsequently improve the birth outcomes by reducing the maternal and the neonatal mortality. These can be achieved by timely referral to a dentist by the concerned gynecologist, imparting knowledge on preventive dental measures in the form of plaque control, caries control, nutritional counseling both in the dental office and at home. In addition, the timing of anti-infective interventions should also be emphasized as periodontal treatment after conception might not successfully eliminate the microbial/cytokine load which has already set in.

Several studies across the world have associated maternal periodontitis with adverse pregnancy outcomes. A landmark study by Offenbacher et al.,[3] after controlling for the obstetric risk factors showed that periodontitis was a significant risk factor for PTLB. However, many data have even failed to prove this linear causal relationship. Hence, there is a need for larger clinical trial which can throw light on this far-debated topic.

There is a dearth in the data available about the knowledge, attitude, and practice patterns of gynecologists and dentists on this much controversial issue; hence, our study aimed at these cluster of doctors as they primarily influence patients who experience profound physiologic and psychologic changes during their pregnancy.

   Materials and Methods Top

This was a cross-sectional study conducted among 300 doctors (Dentists and Gynecologist) in the city of Mysore, Karnataka. A questionnaire method was employed which constituted 12 questions. This was divided into three different sections intending to clearly focus on the objectives of the study. The survey was executed from June 2013 to December 2013 and was approved by the Institute's Review Board. The participants were divided into two groups as follows:

  • Group I: Dentists' involved in a private practice or associated with a dental college
  • Group II: Gynecologists'.

The dentists possessing both undergraduate and postgraduate degree were involved but, periodontists and postgraduate students of periodontology were excluded vowing to the fact that their awareness in the concerned topic being higher, which could give imprecise data.

The questionnaire was divided into the following sections:

  • Section 1: Demographic details of the participants such as age, sex, field of specialization (for postgraduate students in dentistry), years of practicing experience
  • Section 2: Pathogenic correlation between oral health and PTLB
  • Section 3: Knowledge about changes in the oral health during pregnancy
  • Section 4: Individual practices followed
  • Section 5: Consequences of PTLB.

One question in the last part of the questionnaire specially targeted the gynecologists concerning the protocol of referring patients to dentists in the “preconception period.”

The validity of the survey was measured by handing the final questionnaire to a sample of thirty respondents. Potential problems were evaluated by encouraging questions from the respondents; questions raised by the respondents indicated a defective item which was fixed later. In addition, an expert (other than the two principal investigators) who understood the topic read through the questions to check whether they captured the topic under investigation and ruled out confusing, double barreled, and leading questions. Finally, the internal consistency of the questions was measured by calculating the Cronbach's alpha (CA).

The questionnaire was distributed to all the study participants and was collected 3–4 days after the first visit. Discussions on the concerned topic were not entertained which could probably influence the answers. However, the need of the study and the objectives were clearly mentioned.

Statistical analysis

The data collected was evaluated using SPSS (SPSS version 10.5, SPSS, Chicago, IL, USA). The CA value for the first five questions was 0.67 and for the remaining questions the value was 0.85. The Chi-square test was performed to detect significant associations among categorical variables and Student's t-test for continuous variables.

The regression model used the dependent variable knowledge score and was calculated in the following manner: A score of 1 was given if participants correctly responded to all periodontal findings and if they reported their awareness about the link between periodontal health and PTLB; a score of 0 was given if these variables were not correctly answered. Independent variables in the model were age, sex, field of specialization, graduation or postgraduation, and years of experience. P = 0.05 was considered statistically significant for all statistical analysis.

   Results Top

A total of 300 doctors responded to the questionnaire with a mean age of 33.9 years. Since the doctors were approached individually to collect the forms, response rate was 100% without any dropouts. Among the total respondents, 67% were females and 33% were males with an average experience of 8.3 years in Group I and 10.4 years in Group II.

[Table 1] showed their responses to various questions addressing the link between periodontal health and PTLB where only 79% of the total doctors were aware of this association.100% of the participants agreed that mouth served as a “mirror to general health” but only 70% of the participants were aware of the Hunter's theory of focal infection. 63% of the doctors knew about the translocation of periodontal pathogens into the fetoplacental unit, and only 56% of the participants were aware of categorizing a newborn as preterm low birth infant and were mostly gynecologists.
Table 1: Responses to various questions on the link between periodontal health and preterm low birth weight

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Majority of the participants (78%) were aware of the specific periodontal changes associated with pregnancy. Dentists were significantly more aware than the gynecologists of gingival bleeding, halitosis, abscesses, mobility, and tooth loss. 86% of the participants educated their patients on oral health and emphasized on routine dental checkups during pregnancy.

However, only 53% of the participants were aware of the potential consequences of PTLB, and the gynecologists showed higher level of knowledge in this aspect. Only 12% of the gynecologists referred patients to the dentists in the preconception period [Table 2].
Table 2: Response of gynecologists toward patients referral to a dentist during preconception period

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Binary logistic regression analysis with the knowledge score as the dependent variable showed that age (odds ratio [OR] = 1.055), field of specialization (OR = 1.635), and years of practicing experience (OR = 2.254) were only significant variables associated with knowledge levels. Older aged participants may have more exposure to patients, therefore, are more likely to have knowledge about the link between oral health and PTLB. Although sex and graduation level of the participants were not a significant predictor of knowledge levels [Table 3].
Table 3: Logistic regression analysis of factors associated with knowledge level of effects of periodontal health on preterm low birth weight

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   Discussion Top

PTLB (<37 weeks gestation and <2500 g weight) represents a major cause of neonatal morbidity having a tremendous impact both financially and emotionally on the affected families. There is growing evidence that identifies a strong association between oral health and PTLB. Hence, there is a need to improve knowledge about this link among the health workers. Increasing the knowledge of health-care providers will positively improve their attitudes and behavior toward the management of patients. To the best of our knowledge, this is the first study that documents and contrasts the knowledge of dentists and gynecologists regarding the link between oral health and PTLB. The difference in knowledge levels among the dental graduates and the postgraduates has also been evaluated.

Survey conducted by Shenoy et al.[4] among the gynecologists reported that the respondent's knowledge was high regarding oral manifestations of periodontal disease but low regarding the same as a risk factor in PTLB. In addition, a survey by Suri et al.[5] concluded that gynecologists' in spite of being aware about dental practices during pregnancy failed to translate into appropriate practice.

In this study, although majority of the dentists and gynecologists believed that periodontal health may affect the birth outcomes, gynecologists were significantly less aware of the specific changes in periodontium during pregnancy such as gingival bleeding, tooth loss, halitosis, and tooth decay. After adjusting the other predictors in the model, the estimated odds that dental practitioner's knowledge were 1.6 times the odds for gynecologists. The low awareness of periodontal changes by gynecologists could be explained by their interests in practice and the curriculum which focuses on a systemic level, unlike the dentists who focus on oral health. In addition, dentists and the gynecologists fail to communicate regarding the periodontal status and pregnancy outcomes; hence; our study supports the importance of collaboration between medical and dental professionals. Practitioners with more than 5 years of experience had 2-fold increased odds of more favorable attitudes because of the increased exposure and the frequency of cases seen during their experience.

In our study, postgraduation did not affect the attitude of the practitioners, and they showed no better knowledge level compared to the graduates; this can be attributed to the dental curriculum which does not contain adequate topics related to oral–systemic link. In addition, the exclusion of periodontists and postgraduate students of periodontology who normally study “periodontal medicine” in their formal educative program could have led to the insignificance. Hence, our findings support the need for elaborate coverage in medical education on oral health care during pregnancy.

Dentists' awareness on the consequences of PTLB was poor and majority of them gave their consensus toward educative programs for the knowledge upgradation.

To our surprise, only 12% of the gynecologists' referred patients to dentists' in the preconception period and the rest agreed that it was important to refer but, routinely did not follow the protocol. At this level, health-care practitioners often fail to implement the available research data in their clinical practice.

The term preconception period generally refers to the 3 months leading up to pregnancy and can impact 136 million women who give birth each year. In developing countries, pregnancies are assisted, complications are few, and outcomes are generally favorable but not all are planned, and these women do not get an opportunity to address their preconception health.

Preconception care provides simple interventions before pregnancy which can prevent a significant proportion of maternal and neonatal mortality and morbidity. For example, initiation of folic acid supplementation at least 1 month before pregnancy reduces the incidence of neural tube defects such as spina bifida and anencephaly.[6] Wide range of interventions has been included under this umbrella of preconception care which includes nutritional care, weight management, immunization, addressing chronic infections, substance abuse, etc. Unfortunately, periodontal interventions have a low strength of recommendation probably due to the lack of sufficient evidence supporting the causal link between PTLB and oral infections.

   Conclusion Top

This survey showed that the dentists showed more favorable attitudes toward oral health in pregnancy but had limited knowledge about its impact on PTLB and its further consequences. However, gynecologists were aware but failed to execute the same at a clinical level. Preconception care also remains as an example of how “think population” is never translated into action at the “treat individual level.”

It is extremely important in medical education and practice that maintenance of health and well-being should assume its rightful position alongside the study of pathogenesis, disease diagnosis, and treatment.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Lamster IB, Smith QT, Celenti RS, Singer RE, Grbic JT. Development of a risk profile for periodontal disease: Microbial and host response factors. J Periodontol 1994;65 5 Suppl:511-20.  Back to cited text no. 1
Offenbacher S, Jared HL, O'Reilly PG, Wells SR, Salvi GE, Lawrence HP, et al. Potential pathogenic mechanisms of periodontitis associated pregnancy complications. Ann Periodontol 1998;3:233-50.  Back to cited text no. 2
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 10 Suppl:1103-13.  Back to cited text no. 3
Shenoy RP, Nayak DG, Sequeira PS. Periodontal disease as a risk factor in pre-term low birth weight-an assessment of gynecologists' knowledge: A pilot study. Indian J Dent Res 2009;20:13-6.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
Suri V, Rao NC, Aggarwal N. A study of obstetricians' knowledge, attitudes and practices in oral health and pregnancy. Educ Health (Abingdon) 2014;27:51-4.  Back to cited text no. 5
Al-Gailani S. Making birth defects 'preventable': Pre-conceptional vitamin supplements and the politics of risk reduction. Stud Hist Philos Biol Biomed Sci 2014;47:278-89.  Back to cited text no. 6


  [Table 1], [Table 2], [Table 3]


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