Frequency and Factors Associated With Dental
Caries In Pregnant Female Visiting Antenatal Clinic of Public Sector Hospital
of Karachi, Pakistan
Marium
Azfar,1 Imran Khan,1 Amir Akbar Shiek,2 Syed
Ali Raza,3 Noureen
Iqbal,4 Muhammad Hanif,5 Khadijah Abid,6
1.
Department
of Community & Preventive Dentistry, Sindh Institute of Health Sciences,
JSMU Karachi, Pakistan.
2-3.
Department
of Community & Preventive Dentistry2/ Department of Community Dentistry3 Sir Syed College of Medical Sciences
for Girls Karachi, Pakistan.
4-5.
Department
of Examination5, Jinnah Sindh Medical University Karachi, Pakistan.
6.
Registration
& Research Cell, College of Physician & Surgeons Pakistan.
Correspondence to:
Ms. KhadijahAbid,
Email:
khadijahabid@gmail.com, ORCiD: 0000-0002-1329-4808
https://doi.org/10.36570/jduhs.2019.3.690
ABSTRACT
Objective: To
assess the frequency and factors associated with dental caries in pregnant
women attending antenatal clinic of a public sector hospital of Karachi,
Pakistan.
Methods: A
descriptive cross-sectional study was conducted at the Sindh Institute of Oral
Health Sciences, Jinnah Sindh Medical University, Karachi from July 2019-March
2020. Pregnant women of age 18-45 years visiting antenatal clinic were
included. The dental examination was carried out to assess the dental cariesin
accordance with the WHO diagnosis criteria. Frequency of dental caries along
with factors like age, socioeconomic status, educational status, occupation,
BMI, residence, family structure, gestational hypertension, and gestational
diabetes were noted. SPSS version 23 was used to analyze data. Binary logistic regression was
applied in order to identify the most significant
predictors of dental caries after adjustment. P<0.05 was taken as
statistically significant.
Results: Of 375
pregnant women, mean age was 30.32+-4.37years. Most of the women were from low
socio-economic class 237 (63.2%), uneducated 231 (61.6%) and belonged from
rural areas 196 (52.3%). Frequency of dental caries was found to be 108
(28.8%). In multivariate logistic regression model, uneducated females (aOR=9.53,
95% CI=3.93-23.10), rural area residents (aOR=19.73, 95% CI= 7.50-51.88), presence of gestational
diabetes (aOR=8.86, 95% CI=3.78-20.73) and presence of gestational hypertension
(aOR=4.33, 95% CI=2.01-8.92) remained statistically significant (p<0.05).
Conclusion: A higher frequency of dental
caries was observed in pregnant women attending antenatal clinics. The
significant factors that remained associated with dental caries in final
multivariate model were education, residence, gestational hypertension and
gestational diabetes mellitus.
Keywords: Dental
caries, PregnantWomen, Socio-Demographic factors, Medical history
INTRODUCTION
Females experience a variety
of psychological and physical disruptions and changes in specific parts of
their bodies during the gestation period. In several areas of the body,
including the oral cavity, significant levels of hormonal changes encountered
by pregnant women cause alterations and risks. The oral cavity is prone to many
adjustments and difficulties during pregnancy, most frequent problems
encountered are gingivitis and periodontitis.1,2
The tooth
decay is a growing infectious disease that is traditionally associated with the
interplay of genetic, behavioral and socio-demographic factors. In
industrialized countries, it affects up to 50 percent of adults.3,4 It was hypothesized that childbirth
could increase the risk of initiation or development of caries by changes in
saliva composition, persistent gastric reflux or less successful oral reaction.5 The changes in salivary composition can
caused by higher progesterone levels, which together
weaken the immune system contained in saliva which lead to mucosal inflammation
and tooth decay.6 The
increased progesterone level may also produce a decline in plasma bicarbonate
level, which decreases salivary PH. Increased acid production in the oral
cavity accompanied by a lack of attention paid by pregnant women to oral cavity
hygiene will accelerate the onset of caries.7 Estrogen regulates the proliferation, differentiation and
keratinization of cells leading to desquamation of the oral mucosa. Desquamated
cells may expand the microbial environment by providing nutrients and ideal
conditions for bacterial growth.6
However, due to the relatively short time frame of pregnancy and the kinetics
of dental caries progression, it is unlikely that dental caries will develop
initially to extensive tooth loss within this period.8
Studies
conducted in Pakistan, Brazil and Hungary reported frequency of dental caries
between 47% and 69% among pregnant women. 8-10
In a study conducted at Karachi showed the prevalence of dental caries among
pregnant women was high (57%) in rural areas as compared to urban population
and 29% of them had complain of bleeding gums.11 Further studies have been conducted to identify
periodontal diseases and its complications, gingivitis, oral hygiene practices
and knowledge of periodontal diseases among pregnant women of Pakistan11-13, but there is scarcity of data
particularly regarding dental caries and its associated factors. Hence, the aim
of present study was to assess the frequency of dental caries at current
magnitude and factors associated with it in pregnant women of Karachi,
Pakistan.
METHODS
This
descriptive cross-sectional study was conducted at the Sindh Institute of Oral
Health Sciences, Jinnah Sindh Medical University, Karachi from July 2019-March
2020. Ethical approval was sought from ethical review committeebefore
conductingthe study (Ref: SSCMS/2019/16). Written informed consent was taken
from all the willing participants. All the pregnant women of age 18-45 years
visiting antenatal clinic were included in the study. Pregnant women presenting
with history of ischemic heart disease, hypertension or diabetes (before
pregnancy assessed on medical record) or pregnant women having asthma or any
psychological issues were excluded.
A sample
size of 375 was estimated using OpenEpi sample size calculator taking
statistics for dental caries among pregnant as 63.3%, margin of error as 4.9%
and 95% confidence level.14
The dental examination was carried out to assess the dental cariesin accordance
with the World Health Organization (WHO) diagnosis criteria by a single
examiner.15 The data regarding
socio-demographic factors and medical history were obtained using pre-designed
questionnaire after dental assessment. Socio-demographic determinants included
age, nationality, educational status, socio-economic status, employment status,
antenatal care (number of antenatal visits), number of children, living status,
residence and body mass index whereas medical assessment included presence of
any comorbidity such as gestational diabetes (women presenting with FBS
>92mg/dl or PLBS >140mg/dl and further evaluation by oral glucose
tolerance test (OGTT) to confirmed the diagnosis of gestational diabetes. The
cut-offs for each glucose level were: FBS > 92 mg/dl, 1 Hour > 180 mg/dl
and 2 Hours > 153 mg/dl.16
If any of the above values came abnormal, the patients were labeled as
gestational diabetes.Gestational hypertension was defined as pregnant women
with blood pressure>140/90 mmHg with no history of hypertension or taking
anti-hypertensive drugs prior to the pregnancy confirmed on medical history and
clinical examination.17
SPSS
version 23 was used to analyze data. Mean and standard deviation (SD) was
computed for quantitative variables whereas frequency and percentage were
computed for qualitative variables. In bivariate analysis, chi-square was used
to assess the association between dental caries and qualitative variables
whereas independent t-test/Mann Whitney U test was applied to see the
statistical difference between dental caries and quantitative variables. The
univariate logistic regression was applied to identify the significant
predictors of dental caries at p<0.10, the unadjusted odd ratios (ORs) along
with 95% CI were estimated. The factors which were significant in univariate
logistic regression model were added in final single multivariate logistic
regression model and adjusted ORs were computed along with 95% CI, in order to
identify the most significant predictors of dental caries after adjustment.
P<0.05 was taken as statistically significant for bivariate and multivariate
analysis.
RESULTS
Of 375 pregnant women, mean age was 30.32+-4.37 years. Majority of them were from low socio-economic
class 237 (63.2%), were uneducated 231 (61.6%) and belonged from rural areas
196 (52.3%). Only 19
(5.1%) women were employed and 32 (8.5%) were non-Pakistani. Most of them were
living in joint family system 294 (78.4%) and had 2 or more children74 (19.7%).The mean BMI of the patients was 32.94 +-5.20 kg/m2.Gestational
hypertension was observed in 124 (33.1%) and gestational diabetes mellitus in
89 (23.7%) women. Most of them had no antenatal visits 302 (80.5%).
The
frequency of dental caries was observed in 108 (29%) pregnant women. (Figure 1)
A significant association of dental caries was observed with socio-economic
status (p-value <0.001), educational status (p-value <0.001), residence
(p-value <0.001), antenatal visits (p-value <0.001), living status
(p-value 0.004), gestational diabetes (p-value <0.001), and hypertension
(p-value <0.001). (Table 1)
The odds
of dental caries among low socioeconomic status was 2.24 times higher as
compared to odds of dental caries among high socioeconomic status (OR=2.24, 95% CI =
0.81-6.22). The odds of dental caries among middle socioeconomic status was 42%
lower as compared to high socioeconomic status (OR=0.576, 95% CI =
0.187-1.77). Uneducated females had 8.75 times higher odds of dental caries
(OR=8.75, 95% CI=4.48-17.1) as compared to educated
females and relationship was statistically significant (p=0.001). Rural area
residents had 31.28 times
higher odds of dental caries than urban residents (OR=31.28, 95%
CI=13.22-73.99). Females with no antenatal visit had 2.66 times higher odds of
dental caries as compared to females with at least 1 antenatal visits (OR=2.66,
95% CI=1.34-5.29) and relationship between dental caries and
antenatal visits was statistically significant (p=0.005). Females living in
joint family had 2.24 times higher odds of having dental caries as compared to
females living in nuclear family (OR=2.24, 95% CI=1.20-4.20) and family status
was significantly associated with dental caries (p=0.011). The odds of dental
caries among females with gestational hypertension was 5.66 times higher as
compared to odds of dental caries among females without gestational
hypertension (OR=5.66, 95% CI=3.49-9.18, p=0.001). Lastly, the odds of dental
caries among gestational diabetes was 8.83 times higher than females without
gestational diabetes (OR=8.83, 95% CI: 5.18-15.03) and showed statistically
significant association (p=0.001). (Table 2)
All the
factors which were significant in univariate analysis (p<0.10) were moved
into single multivariate logistic regression model to ascertain the effect of
predictors on the likelihood that pregnant females have dental caries. The
multivariate logistic regression model was statistically significant
(p<0.05). The model explained 66% (Nagelkerke R2) of the variation in the
dental caries and 88% of the cases were correctly classified. Uneducated
females were 9.53 times more likely to exhibit dental caries as compared to
educated females (aOR=9.53, 95% CI=3.93-23.10). Rural area residents were 19.73
times more likely to exhibit dental caries as compared to urban area residents
(aOR=19.73, 95% CI= 7.50-51.88). Women with gestational diabetes were at 8.86
higher risk of having dental caries as compared to women without gestational
diabetes (aOR=8.86, 95% CI=3.78-20.73). Women with gestational hypertension
were at 4.33 times higher risk of having dental caries as compared to women
without gestational hypertension (aOR=4.33, 95% CI=2.01-8.92). (Table 2)
Figure 1: Frequency of dental caries in pregnant females visiting
antenatal clinic (n=375)
TABLE
1: Comparison factors associated with dental caries (n=375) |
|||
VARIABLES |
Dental Caries |
p-value |
|
No |
Yes |
||
Age (Mean+-SD) |
30.33+-4.43 |
30.30+-4.23 |
0.953 |
Socio-economic status |
|||
Low |
149 (62.9) |
88 (37.1%) |
0.001* |
Middle |
99 (86.8) |
15 (13.2%) |
|
Upper
Middle |
19 (79.2) |
5 (20.8%) |
|
Education status |
|
|
|
Uneducated |
134 (58) |
97 (42%) |
0.001* |
Educated |
133 (92.4) |
11 (7.6) |
|
Residence |
|
|
|
Urban |
173 (96.6) |
6 (3.4) |
0.001* |
Rural |
94 (48) |
102 (52) |
|
Occupation |
|
|
|
Unemployed |
256 (71.9) |
100 (28.1) |
0.189 |
Employed |
11 (57.9) |
8 (42.1) |
|
Nationality |
|
|
|
Pakistani |
241 (70.3) |
102 (29.7) |
0.189 |
Non-Pakistani |
26 (81.3) |
6 (18.8) |
|
Antenatal visit |
|
|
|
No
visit |
205 (67.9) |
97 (32.1) |
0.004* |
Yes |
62 (84.9) |
11 (15.1) |
|
Living status |
|
|
|
Joint
family |
200 (68) |
94 (32) |
0.010* |
Nuclear
family |
67 (82.7) |
14 (17.3) |
|
No. of children (Median(IQR)) |
2 (1-2) |
0 (0-1) |
0.575 |
Gestational hypertension |
|||
Yes |
58 (46.8) |
66 (53.2) |
0.001* |
No |
209 (83.3) |
42(16.7) |
|
Gestational diabetes mellitus |
|||
Yes |
31 (34.8) |
58 (65.2) |
0.001* |
No |
236 (82.5) |
50 (17.5) |
|
BMI (Mean+-SD) |
33.12+-5.32 |
32.48+-4.88 |
0.279 |
*significant, All data
presented as number (%)
Table 2: Regression analysis for
the variables associated with dental caries (n=375) |
||||
Variables |
OR (95% CI) |
p-value |
aOR (95% CI) |
p-value |
Age |
0.998 (0.95-1.05) |
0.953 |
- |
|
No of children |
0.924 (0.75-1.13) |
0.445 |
- |
|
Socio economic status |
||||
Low |
2.244 (0.81-6.22) |
0.120 |
- |
|
Middle |
0.576 (0.19-1.77) |
0.336 |
||
High |
Ref |
|||
Education |
|
|
||
Uneducated |
8.752 (4.49-17.07) |
0.001* |
9.538 (3.94-23.10) |
<0.001* |
Educated |
Ref |
Ref |
||
BMI |
0.976 (0.94-1.02) |
0.278 |
- |
|
Residence |
|
|
||
Rural |
31.28 (13.23-73.99) |
<0.001* |
19.736 (7.51-51.88) |
<0.001* |
Urban |
Ref |
|
||
Occupation |
|
|
||
Employed |
1.862 (0.73-4.77) |
0.195 |
- |
|
Unemployed |
Ref |
|||
Nationality |
|
|
||
Non-Pakistani |
0.545 (0.22-1.37) |
0.198 |
- |
|
Pakistani |
Ref |
|||
Antenatal visit |
||||
No |
2.667 (1.34-5.29) |
0.005* |
2.182 (0.79-6.01) |
0.132 |
Yes |
Ref |
Ref |
||
Living status |
|
|
||
Joint family |
2.249 (1.20-4.21) |
0.011* |
1.782 (0.73-4.37) |
0.206 |
Nuclear Family |
Ref |
Ref |
||
Gestational hypertension |
|
|
||
Yes |
5.663 (3.49-9.18) |
<0.001* |
8.861 (3.79-20.74) |
<0.001* |
No |
Ref |
Ref |
||
Gestational diabetes mellitus |
||||
Yes |
8.831 (5.19-15.04) |
<0.001* |
4.34 (2.11-8.92) |
<0.001* |
No |
Ref |
|
|
|
*significant,
OR: Odds Ratio, aOR: Adjusted Odds Ratio |
DISCUSSION
Pregnant
women are more vulnerable to tooth decay due to an increase in oral cavitys
acidic environment, decreased sugar intake consumption, and oral health
carelessness. Recurrent vomiting is normal during pregnancy, enhancing acidic
environment that leads to development of carious pathogens and increased
demineralization that makes teeth caries-prone. Untreated carious lesions
increase the occurrence of cellulitis and abscess.18
A
handful amount of studies has been conducted regarding socio-demographic status
and dental caries among school children and rural communities 19-22. However, different factors related
with dental caries among pregnant women remains negligent. Therefore, the
present study determines the frequency and risk factors of dental caries among
pregnant women. Present study showed that 29% of the pregnant females had
dental caries. There are several studies conducted in this context. An
Australian author observed 54% of the pregnant females had oral problems 23 and other authors have proclaimed dental
problems as a challenge among pregnant women 24, 25.
The oral
health status is essential entity to be examined among pregnant women in order
to facilitate pregnant women with higher oral hygiene and lesser oral problems
during their pregnancy. As Pakistan is comprised of mostly low socio-economic
class and the study was conducted at government sector, majority females belong
to low socioeconomic status and were uneducated. In the present study about
63.2% belonged from low socio-economic class and 62% were uneducated. In one
study, pregnant women were found to be more likely to develop dental caries as
compare to non-pregnant women who were uneducated 14. The study conducted
in Multan 26 showed that
education, income and age does not play any role in developing caries or even
periodontal disease. In another study conducted at KulsoomBaiValika Hospital
Karachi 27, 53.6% pregnant
women had acquired primary level of education and mean age of pregnant women
was 31.32 +- 4.318 years slightly analogous to current study findings. Hence,
in the present study we found dental caries was significantly associated with
socioeconomic status, education and residence in bivariate analysis
(p<0.05), but showed no association with age (p>0.05).
The
present study also showed significant association between antenatal visit and
pregnant females having dental caries in bivariate analysis. This explains that
pregnant females who regularly visit their antenatal clinics for check-ups
could have slightly lower chance of developing caries. There is lack of
awareness among pregnant women regarding dental visits 14 and present study also showed that
most of the females did not visit antenatal clinic.
The
present study also sought medical factors associated with pregnant women having
dental caries. The results showed that gestational hypertension and diabetes
have positive association with dental caries among pregnant women. However, the
results showed that 66 females with dental caries had gestational hypertension
and 58 had gestational diabetes. In other study 28, it was found that 38% pregnant women had gestational
diabetes. In a study, gestational diabetes was found to cause enamel
development defects in new born of diabetic female29. Though there is a significant association between
diabetes and caries 30,however,
the study showed that the findings are similar and few pregnant women having
gestational diabetes experienced dental caries.
This study might be helpful
in providing baseline data regarding frequency and associated factors of dental
caries which could lead to improvement in awareness of pregnant women. Since
this was a cross-sectional study; therefore it cannot establish temporal
associations and in this regard future longitudinal studies are suggested to
establish causal associations for risk factors with dental caries.
Additionally, true results (wider confidence interval for odd ratios) might
have been hampered due to reporting bias or limited sample size.
CONCLUSION
In
pregnant women, the frequency of dental caries was high. Dental caries were
closely related to education, residence, gestational hypertension and
gestational diabetes mellitus. For better outcomes, oral hygiene awareness
should be encouraged in womenby gynecologists during first trimester of
pregnancy.
ETHICAL
APPROVAL: The study protocol was approved by the Ethical
Review Committee of Sir Syed College of Medical Sciences for Girls Karachi,
Pakistan.
AUTHORS
CONTRIBUTION: MA concept & idea of the study, give the
final review. IK and AAS literature review & final approval. SI and MH data
collection and literature review. KA data analysis, wrote the manuscript.
CONGLICT
OF INTEREST:All authors do not have any conflict of
interest.
FUNDING:None.
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