Original Article

Evaluation of the Knowledge Level, Behavior, and Attitudes of Obstetrics and Gynecology Specialists on the Relationship Between Periodontal Diseases and Pregnancy Outcomes

10.4274/meandros.galenos.2021.24381

  • Gülbahar Ustaoğlu
  • Ülkü Mete Ural
  • Tuğçe Paksoy
  • Handan Ankaralı

Received Date: 07.09.2021 Accepted Date: 01.12.2021 Meandros Med Dent J 2022;23(1):114-124

Objective:

To investigate the knowledge and awareness level of obstetricians on the relationship between periodontal diseases (PDs) and adverse pregnancy outcomes, and to compare them regarding gender, age, professional experience and institution to identify the pertaining issues requiring improvement.

Materials and Methods:

Data were collected by the administration of an online questionnaire. The link was sent to the e-mail addresses of 80 obstetricians (50 female, 30 men). The questionnaire consisted of 23 questions focused on the determination of the personal characteristics, attitudes, and the level of knowledge of obstetricians about the relationship between periodontal diseases and preterm labor.

Results:

The presence of gingival disease (GD) was higher in females (p=0.001). Females were found to be more aware and sensitive about the relationship between the periodontal diseases and poor obstetric outcomes (p<0.05). Obstetricians in training and research institutions and obstetricians in the early postgraduate period were more likely to believe that there was a significant relationship between GD and obstetric outcomes (p<0.05).

Conclusion:

The knowledge and awareness level of obstetricians on the relationship between PDs and adverse pregnancy outcomes may be influenced by gender, age, professional experience and institution. Active collaboration between periodontologists and obstetricians will provide benefits in monitoring and follow-up of the oral health of pregnant women in terms of prevention of poor obstetric outcomes.

Keywords: Awareness, periodontal diseases, pregnancy, preterm labor, questionnaires

Introduction

Periodontal diseases (PDs) are destructive, chronic, and multifactorial diseases with the primary etiological factor of microbial dental plaques, affecting the supportive tissues of the tooth (1-3). It is a well-recognized fact today that PDs are associated with systemic diseases such as cardiovascular, respiratory system diseases, diabetes, as well as with poor obstetrical outcomes, including premature birth, low birth weight, and pre-eclampsia (4). Increased estrogen and progesterone levels during pregnancy and developing immunosuppression may influence the biological and clinical characteristics of periodontal infections in the presence of microbial dental plaques and may aggravate the response to irritation (5,6). The number of Prevotella intermedia, Bacteroides species, and Campylobacter rectus increases in pregnancy. The increased availability of these pathogens enhances the susceptibility to periodontal damage by interfering with the periodontal microflora (5).

Several epidemiological studies are available on the adverse outcomes of periodontal infections in pregnancy, including abortions, premature birth, very premature birth, low birth weight, very low birth weight, and pre-eclampsia (7-9). Premature birth and low birth weight associated with PD are explained in the literature by the release of inflammatory products into the systemic circulation as a result of the maternal and fetal immunological responses against the hematogenous spread of oral bacteria (5,10). Periodontal disease is critical for both maternal and neonatal well-being, as several study reports support that adverse obstetric outcomes are prevented by treating this situation (11,12). However, pregnant women are not routinely referred to a dental examination during their follow-up (13,14). The adequate level of knowledge of obstetricians on the association between the complications of pregnancy and dental and PDs is critically important in terms of reducing the negative pregnancy outcomes by questioning and referring the pregnant women to a periodontologist for the symptoms of PD (15). Datas from the studies demonstrate that there is knowledge and awareness of periodontal disease and its potential role as a pregnancy risk factor but suggest limited incorporation of dental care into clinical medical practice (16,17) and the attitudes of these obstetricians were not in agreement with their apparent knowledge regarding PDs and their possible repercussions (18).

Our study aimed to investigate the knowledge and awareness level of obstetricians on the relationship between PD and adverse pregnancy outcomes, to compare them according to age, gender, professional experience, and institution and to identify the pertaining issues requiring improvement.


Materials and Methods

The study protocol was approved by the Bolu Abant İzzet Baysal University Faculty of Medicine, Clinical Researches Ethics Committee (decision no: 2018-71, date: 12.04.2018). This cross-sectional study was conducted to evaluate the awareness on periodontal health during pregnancy and its association to delivery of preterm low birth weight infants by collecting information with an online questionnaire, the link of which was e-mailed to 80 obstetricians in Turkey. One-to-one interviews were made with obstetricians in the National Obstetrics and Gynecology Congress and their e-mail addresses were obtained after their consent. Participants were obstetricians or perinatologists who were dealing with pregnants only. Specialists focusing on gynecology or general obstetrics were excluded from this study.

The questionnaire was comprised of 23 questions prepared with respect to previously published questionnaires (15-18). The questions were initially translated to Turkish by three lecturers with fluent English language skills. These translated questions were back translated to English by a native English speaker, and the translations which were more consistent with the original version were determined. These steps were taken by the method described by Beaton et al. (19) After checking the Turkish version of the questionnaire in terms of grammar, it was evaluated for validation, and necessary modifications were employed by a pilot study that was conducted on 10% of the total sample size. Those individuals who participated in the pilot study were excluded from the main study to prevent possible bias.

Information was gathered about the personal characteristics, attitudes, and the level of knowledge of obstetricians related to the relationship between PD and preterm labor.

Questions were presented in four sections: Personal data, experiences with oral health, awareness and knowledge of obstetricians on potential changes, which might occur during pregnancy, and on possible risk factors for preterm labor/low birth weight, and Physician behavior towards patients.

When the studies are examined, a power analysis was performed considering the effect of the professional experience in years (≤10 and >10 years) on the knowledge level, which is one of the primary outcomes of the study. Considering a similar study, the sample size was calculated considering Type I errors (0.05), targeted power (0.80), and it is concluded that there should be at least 40 people in each trial group (16).

Statistical Analysis

Descriptive values of the data obtained were expressed as numbers and percentage frequencies and tabulated. The internal consistency of the 10-item scale was evaluated with the Kuder-Richarson-20 (KR-20) coefficient. The relevance of answers to related questions was examined with the Pearson chi-square test or Fisher-Freeman-Halton test by evaluation of the percentage frequencies listed in the tables. The level of statistical significance was accepted as a p-value of less than 0.05. SPSS (version 23) program was used for statistical analyses.


Results

A total of 80 (50 female, 30 men) obstetricians, who were either residents or specialists participated in the study. Awareness of obstetricians on periodontitis and low birth weight premature infants were assessed using a scale, which included ten questions. The internal consistency of this scale was found to be 0.715 and was evaluated to be good.

The presence of PD was higher in females (p=0.001). The number of females answering “yes” to the following questions "May gingival/periodontal inflammation affect the outcomes of pregnancy?; Have your patients ever complained about gum bleeding or swelling or loose tooth during pregnancy?; Is PD a risk factor for premature births and low birth weight?; Can PD be safely treated during pregnancy?" was high (Table 1).

The presence of PDs was highest in the ≤45- year old group (p=0.001). The percentage of participants answering “yes” to the training history for oral health was higher in the >45- year old group (p=0.035). Answering “yes” to the taking care of the oral health of patients was found higher in the >45- year old group (p=0.004) (Table 2).

The number of answers given to the questions related to the time elapsed since the graduation from the medical school, and the number of PD cases treated were higher in dentists who graduated within less than ten years from medical faculty (p=0.010).

The frequency of PDs was highest in the participants with the duration of professional experience of ≤10 years in obstetrics and gynecology practice (p=0.039). The question about the history of gingival treatment was answered “yes” more commonly in obstetricians with an experience of ≤10 years in obstetrics and gynecology (p=0.004). Answering "yes" to the question "may gingival/periodontal inflammation affect the outcomes of pregnancy?" was found to be highest in the group with an experience of ≤10 years in obstetrics and gynecology (p=0.050) (Table 3).

Answering "≤1 year" to the question "When was the last time you visited a dentist for a control examination?" was higher in participants working at a private hospital (p=0.011). The presence of PDs treated was highest in participants working at a university hospital (p=0.016). Answering “yes” to the question “taking care of the oral health of your patients” was found lower in participants working at public hospitals (p=0.001). Answering “yes” to the taking anamnesis about oral health was found higher in participants working at university hospital compared to those working at a public hospital (p=0.028). Answering “yes” to the question “Does gum inflammation cause pre-eclampsia during pregnancy?” found lower in participants working at private hospitals compared to those working either at public hospitals or university hospitals (p=0.036). The number of participants working either at private hospitals or university hospitals answering “yes” to the following questions was higher “Can PDs be safely treated during pregnancy?; Can dental plaque scaling and root surface planing procedures be performed to eliminate periodontal disease during pregnancy?” (Table 4).

Answering “yes” to the suffering from a gingival disease was found to be higher in specialists and academic personnel (p=0.006). Answering “yes” to the taking care of the oral health of your patients was observed to be the highest in the academic personnel group (p=0.003). Answering “yes” to the taking anamnesis about oral health was lowest in the specialists’ group (p=0.003). Answering “yes” to the question, “Can dental plaque scaling and root surface planing procedures be performed to eliminate periodontal disease during pregnancy?” was found to be higher in academic personnel and director groups (p=0.007) (Table 5).


Discussion

A variety of studies have been conducted to evaluate the level of knowledge and behavioral patterns of obstetricians on the relationship between pregnancy and PD (17,18,20). Although the relationship between PDs and poor obstetric outcomes is known, the attitudes and knowledge on this subject are used in a limited manner in clinical medical practice. In our study, we found that among the participants, who have taken an anamnesis about the oral health of the patients were higher in academic personnel and >45 age, and who thought that dental procedures could be applied to eliminate periodontal disease during pregnancy were higher in academic personnel.

Fifty of the 80 participants in our study were female. Similar to our study, the proportion of females was between 40% and 60% in other studies (16,18). 75% of the participants in our study were in the ≤45 age, similar to the results of studies conducted in India and France (16,21).

When the experiences of the participants as specialists were categorized into 10-year intervals, it was observed that 32.5% of obstetricians had professional experience of 10 years or less. The study conducted in France reported that 39.5% of the participants had a professional experience of 10 years or less (16). The 48.75% of the participants reported that they had suffered from PD, however only 31.25% of them reported that they had received treatment. Cohen et al. (16) observed similar results to those of our study, reporting that 31.2% of obstetricians had a diagnosis of PD and 22.7% of them received treatment. As these findings demonstrated that treatment of PD could be neglected even in highly educated obstetricians, activities to raise awareness, and increase the level of knowledge should target all subgroups in the society.

According to our data, 57.5% of the participants reported that they did not receive any training on oral health. In this series, 53.75% of the participants reported that they did not take oral health history from their patients. Furthermore, 42.5% of the participants reported that they did not take care of the oral health of their patients. Other studies conducted in various countries reported lower rates as 26.3% in France and 49% in the United States (16,22). On the other hand, 96.25% of the participants in our study reported that pregnancy aggravated gingival inflammation, and 86.25% of them reported that PDs influenced pregnancy outcomes. Similar rates of impingement on pregnancy outcomes were reported by obstetricians from France and the United States as 84% and 74.7%, respectively (16,22). Despite the lower rates of participants receiving training on oral care and the lower rates of their taking care of oral health of their patients, their levels of knowledge were higher. This can be explained by the fact that theoretical knowledge has not been applied to clinical practice. Moreover, the percentage of obstetricians aged 45 years and over was higher in regards to being interested in the oral health of patients and in regards to taking anamnesis on oral health. A study in the literature reported that this situation might be related to a better level of knowledge and experience of obstetricians in the 45-50 years age group (17).

The majority of participants considered PD as a risk factor for premature birth and low birth weight and thought that treatment of PD in pregnancy could reduce the risk of premature births, and 36.25% of them reported that gingival inflammation could lead to pre-eclampsia. In a study conducted by Shah et al. (17) 87.9% of study participants reported that PDs posed a risk for low birth. The majority of obstetricians was aware of the term pregnancy gingivitis and reported that progesterone and estrogen levels in pregnancy cause gingivitis. In the literature, as current information about the effects of pregnancy on gingival inflammation, some studies concluded that increased estrogen and progesterone levels in pregnancy change subgingival microbiota and immunologic physiological mediators in periodontal tissue (23,24).

86.25% of the participants thought that PD could be safely treated and 76.25% of them thought that dental plaque scaling and root planning were possible during pregnancy. This difference can be explained by the fact that obstetricians may not have an adequate level of knowledge about the treatment procedures of PD. Similar to our results, several investigators reported that 84.6-97.4% of the obstetricians considered that dental/gingival treatments were applicable during pregnancy (16,25).


Conclusion

This study revealed that updating the periodontal disease and pregnancy information, the institution where the participants work, and their professional experiences affect the awareness of the obstetricians on the dental health of their patients. We think that conducting joint workshops and establishment of health care units enabling the active collaboration of periodontologists and obstetricians will provide benefits in monitoring oral health of pregnant women in terms of improving the dental approach and referral rates of obstetricians. Furthermore, questioning and referring pregnant women for the signs and symptoms of PD during routine pregnancy monitoring will reduce the risk of premature births and delivery of low birth weight infants, as well as decreasing the rates of perinatal mortality and morbidity, which will contribute to the national economy.

Ethics

Ethics Committee Approval: The present cohort study was designed as a survey and was approved by the Clinical Research Ethics Committee of Bolu Abant İzzet Baysal University (decision no: 2018-71, date: 12.04.2018).

Informed Consent: One-to-one interviews were made with obstetricians in the National Obstetrics and Gynecology Congress and their e-mail addresses were obtained after their consent.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: G.U., Ü.M.U., T.P., H.A., Concept: G.U., Ü.M.U., T.P., H.A., Design: G.U., Ü.M.U., T.P., H.A., Data Collection or Processing: G.U., Ü.M.U., T.P., H.A., Analysis or Interpretation: G.U., Ü.M.U., T.P., H.A., Literature Search: G.U., Ü.M.U., T.P., H.A., Writing: G.U., Ü.M.U., T.P., H.A.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.


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