|Year : 2014 | Volume
| Issue : 1 | Page : 51-54
A study of obstetricians' knowledge, attitudes and practices in oral health and pregnancy
Varun Suri1, N. C. Rao1, Neelam Aggarwal2
1 Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Barwala, Haryana, India
2 Department of Obstetrics and Gynecology, PGIMER, Chandigarh, India
|Date of Web Publication||11-Jun-2014|
Dr. Neelam Aggarwal
Assistant Prof., Department of Obstetrics and Gynecology, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
Background: Many studies have reported an association between periodontitis and adverse pregnancy outcomes, but there has been little research on the knowledge of obstetricians regarding oral care. The aim of the study was to assess the knowledge and attitudes of practicing obstetricians in India about the relationship between oral health and pregnancy outcomes, as well as their practice behaviors regarding oral healthcare in pregnant women in Indian settings. Methods: A structured online questionnaire was sent to 130 obstetricians in the city of Chandigarh and adjoining areas of the union territory. The questionnaire was prepared by dentists and obstetricians and was validated in a prior pilot study. Obstetricians' knowledge of the effects of pregnancy on oral health, and vice versa, were correlated with their experience and practices. Results: A total of 79.2% responded to the questionnaire. More than 70% of respondent obstetricians correctly knew of the effects of periodontitis on preterm birth and low birth weight babies. Only 40% recommended dental examination during pregnancy and 47% advised patients about oral care during pregnancy. There were significant correlations between knowledge of dental health effects on pregnancy and referrals of patients to dentists. Conclusions: This study found that although obstetricians generally were knowledgeable about appropriate dental care practices during pregnancy as well as the relationship between oral health and pregnancy outcomes, this knowledge often did not translate into appropriate practice behavior.
Keywords: Oral hygiene, pregnancy, preterm labor
|How to cite this article:|
Suri V, Rao NC, Aggarwal N. A study of obstetricians' knowledge, attitudes and practices in oral health and pregnancy. Educ Health 2014;27:51-4
| Background|| |
There is a growing body of knowledge that supports an association between oral health and pregnancy outcomes.  Changes in hormonal levels (estrogens and progesterone) during pregnancy can lead to an inflammatory response and increased permeability of blood vessels, thus causing gingivitis and periodontitis. , Preterm delivery and low birth weight are the most common causes for neonatal morbidity and mortality.  The highest rates of low birth weight babies are reported from Asia, and the incidence in India is quite high at about 20%.  In 1996 Offenbacher et al. first reported an association between periodontal disease and preterm delivery.  Many studies, systematic reviews and meta-analyses have since assessed the role of periodontal disease in causing adverse pregnancy outcomes and the findings have generally been supported. ,, Nevertheless, there is still a need for larger, randomized controlled trials to confirm this association.
There is limited data available on obstetricians' knowledge, attitudes and practice behaviors regarding oral health care during pregnancy. Wilder et al. in USA found that obstetricians know of the possible association between periodontal disease and adverse pregnancy outcomes, but they did not apply this knowledge in their practice.  Similar results were reported by Morgan et al. (USA) and Neves et al. (Brazil). , Zannata et al. evaluated gynecologists' knowledge and attitudes regarding oral health care during pregnancy and similarly observed that their knowledge is limited and is not consistent with established guidelines.  To date, all studies in this context have been carried out in the developed world and, paradoxically, no study has been conducted in developing countries where the incidence of prematurity and low birth weight is high. With this in mind, we planned this study in the Indian context to estimate the knowledge of obstetricians regarding oral healthcare during pregnancy, its effect on pregnancy outcomes, and their attitudes and behaviors in their practices.
| Methods|| |
This study used an online questionnaire, the link to which was mailed to the obstetricians of the city of Chandigarh and neighboring area of the union territory. In a single mailing, subjects were asked to complete the questionnaire. The study period was from June 2012 to August 2012.
The questionnaire was prepared with the help of dentists and obstetricians and was pilot tested with 20 dentists for item clarity. The questionnaire contained 23 questions, which were divided in four parts: (1) personal data and their personal dental care histories; (2) knowledge about changes in oral health during pregnancy and their effect on pregnancy outcomes (responses were yes, no and not sure); (3) knowledge of oral health care during pregnancy guidelines (e.g. those from the New York State Health Department) (yes or no); and (4) attitudes toward oral health care during pregnancy and reports of their own practice behavior.
The study was approved by the Institute's review board (IRB) of the Swami Devi Dyal hospital and Dental College, Barwala, Haryana, India.
Data obtained from the questionnaires were analyzed using SPSS (SPSS Inc, Chicago, USA). Frequency distributions and chi-square tests were used. Pearson's correlation coefficients were calculated to assess the relationship between obstetricians' experience and knowledge, and also between their knowledge and practice behaviors.
| Results|| |
A total of 103 responses were collected from 130 obstetricians (79.2% response rate). The mean age of respondents was 34.8 years. A total of 89% of respondents were female and 85% worked in government jobs. Their average number of years of experience as an obstetrician was 9.23 years.
[Table 1] shows their responses to the various questions regarding their knowledge about pregnancy and oral health. More than 80% of respondents felt that there is a link between the health of gums and pregnancy. Eighty-five percent of respondents correctly stated that periodontitis in a pregnant patient can cause eventual preterm birth, and 75% correctly stated that it can cause low birth weight delivery. In contrast, 63% of the doctors did not believe that periodontitis can lead to preeclampsia in pregnancy.
|Table 1: Obstetricians agreement with various true statements about the effects of oral disease on pregnancy outcomes, pregnancy effects on oral health, and safe oral health interventions in pregnancy|
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Eighty-seven percent (90) of the surveyed obstetricians responded that dental examination should be included as an integral part of antenatal care. Almost all - 92%-correctly agreed that dental X-rays are safe during pregnancy, but fewer - 46%-indicated that needed dental extraction is advisable anytime during pregnancy (it is) and 69% believed that local anesthetic can be safely used, without vasoconstrictor, during pregnancy (it can be).
When asked about antibiotic safety, the most popular antibiotics reported prescribed by respondents were cephalosporins, penicillin, amoxicillin and ampicillin, in that order. Guidelines regard all of these particular antibiotics as safe in pregnancy. To the question of analgesics for dental pain during pregnancy, paracetamol (acetaminophen) was respondents' most popular (80%) choice (safe per guidelines). Government employed and private practitioners had equal knowledge scores. Physicians who underwent regular dental examinations themselves were slightly more likely to report that that they referred pregnant patients to dentists.
When questioned about their attitudes and practices, 40% of respondent obstetricians reported that they routinely recommended dental examinations during the prenatal period, 89% stated that they always made it a point to refer pregnant patients to a dentist in case of dental pain. Almost half (47%) of the obstetricians claimed that they make it a point to advise pregnant patients of the importance of maintaining oral hygiene. Two-thirds (65%) of the obstetricians felt that if they were approached by a dentist in consultation regarding oral intervention in a pregnant patient, it would be a positive thing.
There was no correlation between obstetricians' experience and knowledge (P = 0.69). There was significant correlation between obstetricians' self-reported knowledge and routine referral of pregnant patients to a dentist (P = 0.00001).
| Discussion|| |
Most of this study's Government and private obstetricians in and around the city of Chandigarh, India correctly knew that pregnancy could be associated with swollen and bleeding gums as well as excessive tooth decay. Only a few knew that tooth loss can occur in pregnancy. Pregnancy has been shown to exacerbate periodontal and gingival problems due to the effect of hormones and to changes in immunity.  Most respondents rightly believed that pregnancy does not lead to tooth loss, which is contrary to the experience by Al-Habashneh. 
Preterm birth and low birth weight are the significant causes for neonatal morbidity and mortality. , In a review, McDougall et al. summarized that it is impossible to draw definite conclusions in this area, even though some studies have reported positive associations between maternal poorer periodontal status and adverse pregnancy outcomes, specially preterm birth, low birth weight and preeclampsia.  In the present study, most respondent obstetricians had good knowledge of the effects of oral health on pregnancy outcomes. These findings are similar to the studies conducted by Wilder et al. (USA) and Mariano da Rocha et al. (Brazil). , Various authorities in the West recommend routine dental care and have generated guidelines for appropriate dental treatment during pregnancy. ,,
When it came to putting their knowledge into practice, only 40% of this study's obstetricians advised routine dental visits during pregnancy, and only 47% advised their patients about oral hygiene during antenatal period. Most stated that they referred to a dentist in case of dental pain, which is appropriate. Again these findings are similar to those of Wilder et al. and Mariano da Rocha et al. , Various studies have indicated that physicians do not look into the mouth of pregnant women due to lack of training ,, and because busy obstetricians have no time to look into patients' mouths. 
Mariano da Rocha et al. noted a correlation between obstetricians' level of experience and their referral practices to dentists.  In our study there was no correlation between obstetricians' number of years of practice experience and their knowledge of dental health and pregnancy and their stated likelihood of making routine referrals of pregnant patients for dental examinations. In contrast, there was a significant correlation between obstetricians' knowledge of the effects of pregnancy on oral health and knowledge of the effects of oral health and pregnancy with their routine referral of pregnant patients to a dentist.
This study found that although Indian obstetricians' generally had good knowledge about appropriate dental care practices during pregnancy as well as the relationship between oral health and pregnancy outcomes, many did not apply this knowledge in their own care of patients. Excluding any self-reporting bias that the obstetricians might have shown, these findings indicate that most obstetricians have a positive attitude about oral health and its relationship with pregnancy outcome. While most feel that joint consultations with dentists before oral interventions are a good thing, not many are of the opinion that they are absolutely necessary.
| Conclusion|| |
This study finds that Indian obstetricians have adequate knowledge about the relationship of periodontal health and pregnancy outcomes but there is a gap between their knowledge and practice. Their knowledge about guidelines for oral health in pregnancy is poor, perhaps from a lack of teaching in oral health and hygiene during their residency programs. Dentists' curriculum should include the appropriate care of oral health and do's and don'ts during pregnancy. Oral health care should be made an integral part of the obstetric examination in antenatal clinics and timely referrals to a dental specialist should be made to lower risks of abnormal pregnancy outcomes. Practicing obstetricians can be given in-service training on appropriate oral health care during pregnancy.
Limitations of the study
This was a descriptive study with convenience sampling, thus representing only a selected group of obstetricians. Also there was only informal validation of the questionnaire. All survey items are self-reports and behavioral items may be subject to response bias.
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