Knowledge and Practices of Pregnant Women regarding Oral Health in a Tertiary Care Hospital in Nepal

ABSTRACT Introduction Poor dental hygiene has been associated with various perinatal complications in studies done worldwide but few studies in Nepal have explored the knowledge of pregnant ladies regarding dental hygiene. The aim of the study was to know the knowledge and practices of pregnant women regarding oral health in a tertiary care center in Nepal. Methods A qualitative study was carried out in Nobel Medical College and Teaching Hospital from January 15, 2018 to June 15, 2018 after approval from the Institutional Review Committee of Nobel Medical College. Convenience sampling was done. Fifty pregnant women admitted in antenatal ward were interviewed regarding their knowledge of dental care in pregnancy, the common dental problems they faced and the treatment taken. A predesigned proforma was used and results were analyzed using SPSS version 17. Results Twenty two (44%) patients reported dental problems during pregnancy. Bleeding gums was seen in 7 (14%) and toothache in 7 (14%) were commonly reported dental problems. Forty seven (94%) patients acknowledged that routine dental care was needed for health, only 6 (12%) were aware that poor dental health could affect baby weight. Oral health not seen as priority in 24 (48%) was the main barrier to seeking dental care in pregnancy followed by costs of treatment in 18 (36%) and safety concerns in pregnancy in 8 (16%) cases. Conclusions Though dental problems were a common occurrence in pregnancy, utilization of services was low for the same. The participants reported significant barriers to obtaining dental care including lack of knowledge about the importance of maternal oral health and the treatment costs.


INTRODUCTION
Oral hygiene and its adverse perinatal outcome is an often neglected issue especially in a developing country like Nepal. With growing body of evidence, maintaining oral health in pregnancy has been recognized as an important health concern worldwide and neglect has been proven to be associated with adverse pregnancy outcomes like low birth weight, premature pre-labor rupture of membrane and prematurity with all its complications. The safety of dental treatment during pregnancy and its impact on improved perinatal outcomes have been well established in recent years. [1][2][3] However, pregnant women often don't seek dental advice and treatment during pregnancy. 4 Therefore to address this issue, it is fundamental to know the knowledge and prevalent practices regarding oral hygiene among the pregnant ladies. 5 The aim of the study is to know the knowledge of pregnant women about oral health, to know the common dental problems in pregnancy and to identify the barriers in seeking care for dental problems in pregnancy in a tertiary care hospital of Nepal.

METHODS
This is a qualitative study where a survey of pregnant women admitted in antenatal ward in Nobel Medical College and Teaching Hospital in Nepal was undertaken from January 15, 2018 to June 15, 2018. Ethical approval was obtained from the Institutional Review Committee of Nobel Medical College and written informed consent was obtained from all participants. All pregnant ladies who were admitted to the maternity ward due to various complications of pregnancy or for delivery irrespective of the period of gestation and those who were willing to be included in the study were enrolled. Patients who did not give consent or were unable to give interview were excluded.
Convenience sampling method was used. Data was collected from 50 pregnant women and the participants were interviewed as per the pre-designed proforma. All data collected were entered in Excel and analyzed using SPSS version 17.

RESULTS
The most common oral health problem reported by participants were bleeding gums in 7 (14%) followed by toothache in 7 (14%) participants (Table 1). Loose tooth 0 (0) The main barriers to seeking dental care for these women were oral health not seen as a priority in 24 (48%), dental costs in 18 (36%) and safety concerns regarding dental treatment during pregnancy in 8 (16%) participants ( Figure 1).
Further, only 5 (10%) of pregnant women had seen a dentist in between 6 to 12 months. In terms of oral hygiene habits only 18 (36%) of women reported brushing twice daily which indicate inadequate knowledge about maternal and infant oral health, especially relating to good oral hygiene habits during the prenatal period (Table 2).  Traditional products(eg. Neem sticks" datwan") 5 (10) When was the last time you saw a dentist? <6months 1 (2) 6 to<12months 4 (8) 1yr to<2yrs 3 (6) 2yrs to<5 8 (16) >5yrs 34 (68) However, analysis of individual knowledge items showed that pregnant women had inadequate knowledge about potential impact of poor maternal oral health. Only 7 (14%) women were aware that dental decay could spread from the mother to the baby's mouth and only 6 (12%) women knew that mother's poor oral health may contribute to low birth weight baby. It is also apparent that some confusion exists among pregnant women regarding acquiring dental care both during pregnancy Free Full Text Articles are Available at www.jnma.com.np and early childhood. Nearly 42 (84%) women were unsure about the best time for first dental visit for a baby (Table 3). First dental visit should be done between 2-3 yrs.

12%
The age of expectant mothers were in the range of 17-38 years, with mean of 25.12±5.4. Twenty eight (56%) were primipara and 28 (56%) of women had finished their primary education (Table 4). Forty five (90%) women were in their third trimester. In a study done in Jaipur, India by Mital et al the authors found that 42.5% of pregnant women brushed their teeth twice a day whereas in our study it was only 36%. 11 Similar studies done in Denmark showed a 96% of subjects brushed their teeth twice a day. 12 In this study most of the pregnant women used flouride toothpaste (90%) whereas 10% used traditional products (eg. Neem sticks-datwan). Similar studies done in Sydney showed more than two thirdof pregnant women brush twice a day using flouridated toothpaste (98.3%), mouthwash (40.7%) and dental floss (42.7%) or other oral hygiene products used. 8 In our set up knowledge and use regarding dental products other than toothpaste was very poor. Only 10% of the subjects seeked dental consultation in last one year which is similar to study done in our neighbouring country India by Mittal et al 11 (11%) whereas utilization rates were higher (45.6%) in study done by George et al. 8 One of main reason for poor maternal oral health is the physiological changes in hormone levels and dietary changes during this period which predispose the pregnant women to various dental problems. 10 This study showed that 44% of patients had reported dental problem which was comparable to studies done by George et al 8 where it was around 46%. But only 10% of these patients had visit to dentist in last one year even when a problem existed. The low use of dental services among pregnant women is well documented worldwide more so in underdeveloped and developing countries like Nepal. 4,[13][14][15] The low use of dental services in our study was mainly due to (48%) oral health not seen as priority followed by high cost of dental services (36%) and safety concern (16%). Similar study done by George et al. showed cost of dental services as main barrier for seeking dentist (29.2%). 8 This highlights the basic lack of knowledge regarding the ill effects of dental problems on pregnancy. It is well documented that high dental cost are significant barrier for pregnant women seeking dental care worldwide. 2,16 The result from this study was almost same with study  3 shown slightly higher rate (84%)of women gave correct response. We can say that the dental knowledge and oral health practices are much better in developed countries when compared with that in Nepal. In this study most commonly reported dental problems during pregnancy were bleeding gums (14%) and toothache (14%), cavities (6%) and sensitivity (8%) which was similar to studies done elsewhere. 7,8 The study has been done in small settings so the results cannot be generalized. It is recommended that further studies can be done in large settings.

CONCLUSIONS
This study highlights that poor maternal knowledge regarding oral health is significant issue in eastern Nepal because most of pregnant women do not visit dentist for their dental problems. There is a gap in knowledge and practices related to oral and dental healthcare in women during pregnancy. Oral health not seen as priority, followed by costs was the common barriers to seek dental care during pregnancy. The study suggest the need for preventive strategies involving dentists and antenatal providers to improve maternal oral health in eastern Nepal by reinforcing need to maintain good oral hygiene during pregnancy and the importance of dental visits. Larger studies are required to get a proper national scenario regarding this issue.