Knowledge, attitudes and practices of a group of medical practitioners in Trinidad toward oral health during pregnancy

Visha Ramroop, Ramaa Balkaran, Arlana Bissoon, Anne Kowlessar, Darren Dookeram

Corresponding Author

Visha Ramroop
School of Dentistry, UWI (St Augustine)
[email protected]   

Ramaa L. Balkaran
School of Dentistry, UWI (St Augustine)
[email protected]

Arlana Bissoon
School of Dentistry, UWI (St Augustine)
[email protected]

Anne Kowlessar
School of Dentistry, UWI (St Augustine)
[email protected]

Darren Dookeram
Sangre Grande General Hospital
[email protected]

DOAJ: 7341e2f92de346fcb16d83d887a7b580
DOI: https://doi.org/10.48107/CMJ.2022.06.001

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2022 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association.

Abstract

Objectives
To determine the knowledge, attitudes and practices of a group of medical practitioners in Trinidad toward oral health and dental treatment during pregnancy.

Methods
One hundred and four medical practitioners practicing at both public and private institutions in Trinidad were invited to participate in this cross-sectional study over a period of 6 months. Participants were asked to complete a previously piloted self-administered 25 item questionnaire.

Results
There was 100% response rate. Mean age 34.8 years, 54.8% male, the majority (72.1%) had been practising for 10 years or less. Almost half (48.1%) thought that swollen gums were not associated with pregnancy, and an even higher percentage (60.6%) of participants felt that bleeding gums were not associated with pregnancy. The majority felt that dental examination (98.1%), tooth brushing and flossing (99%), and the use of mouthwash (95.2%) were safe during pregnancy. All respondents in this study would advise their pregnant patients to have dental examinations but fewer (94.2%) would recommend routine cleanings for these patients.

Conclusions
These data provide the first insight into the knowledge, attitudes and beliefs of medical doctors on pregnancy and oral health in the Caribbean.  Dental health and pregnancy have several associations and medical doctors are suitably placed to advise their patients on the importance of the effects of dental treatment on pregnancy outcomes.

Introduction
Poor maternal oral health may be associated with poor pregnancy outcomes including preterm births as well as low birth weights^1,2 particularly among women from lower socio-economic backgrounds. ¹

Preterm low birth weight (PLBW) is associated with high infant mortality rates and may also produce high levels of morbidity including long term neurological complications. There is ongoing debate in the scientific community regarding the effect of periodontal treatment on PLBW with several studies suggesting that such treatment during pregnancy can in fact reduce the rates of preterm births. ^3,4

Despite the debate about the relationship between periodontal disease and pregnancy outcomes, there is little doubt as to the potential public health implications for this association given that periodontal disease is preventable.

However, the opportunity for pregnant women to benefit from such dental treatment remains small as there is evidence to suggest that oral health care seeking behaviour among this group is low, ⁵ though all dental prevention, diagnosis and treatment can be safely provided during the entire pregnancy. ⁶ The reason for this pattern is multifaceted in nature and includes low maternal awareness and misinformation, socio economic factors as well as misinformation among medical practitioners which may all act as barriers to care among those pregnant women who attempt to access dental services. ⁷ Current evidence suggests no basis for the avoidance of oral care during pregnancy but yet still, review studies continue to show that healthcare workers involved in providing maternal care remain poorly informed about the impact of poor maternal health and reluctant about referring their patients for such care. ^8,9

Further, current guidelines advocate the need for all antenatal care providers to undertake oral health education, assessment and referral during early pregnancy. ^1-3

In Trinidad and Tobago, the public healthcare system includes public healthcare centres and regional hospitals. The majority of the births (86.5 %) occur in the public healthcare system. ¹⁰ The main antenatal care providers are medical doctors and midwives. ¹¹ Prenatal care services are offered at all maternity and health centres in the primary health care network with a referral system to hospitals for high-risk clients. ¹² Research has shown that 95 percent of all women in Trinidad and Tobago received some type of prenatal care service. ¹⁰

The high levels utilisation of antenatal care services implies that health care workers including nurses, midwives, and general medical practitioners are well placed to deliver appropriate oral health care advice and anticipatory guidance to expectant mothers. These health care workers can also aid in providing appropriate referral pathways to dentists so that pregnant women may be able to access suitable dental care. Research has shown that misinformation, among general medical practitioners, concerning the safety of dental treatment during pregnancy can act as a barrier to dental care among pregnant women.

To the best of our knowledge, there is no data that exist either locally in Trinidad and Tobago or regionally in the wider Caribbean regarding the oral knowledge of maternal health care workers including nurses, midwives, general medical practitioners and obstetricians. The aim of this study therefore is to determine the knowledge, attitudes and practices of medical practitioners in Trinidad, toward oral health during pregnancy.

The objectives of the current study included the following:

1. To elicit information regarding the knowledge, attitudes and practices of medical practitioners toward oral health during pregnancy by means of a self-administered questionnaire.
2. To determine the views of medical practitioners on the relationship between pregnancy and gingival inflammation and periodontal disease
3. To determine the views of medical practitioners on the relationship between periodontal disease and preterm birth and low birth weight
4. To determine the attitudes of medical practitioners toward safety of dental procedures and dental treatment during pregnancy
5. To determine the advice provided by the medical practitioners to their pregnant patients in relation to oral health care during pregnancy.

The practical implications of the study include development of educational campaigns highlighting associations between pregnancy and oral health for medical practitioners.

Methods
The study involved a convenience sample of 104 medical practitioners working in both private and public health institutions in Trinidad whereby medical practitioners were approached until the six-month period of data collection was complete (January- June 2016). The major hospitals and health centres in Trinidad were selected and on different days of the week, the researchers went to these hospitals and health centres and approached doctors in the clinic. Once the participants agreed to the study, a consent sheet with a brief description of the study and questionnaire was given separately to the participants. A copy of the consent form was left with them and the questionnaires were collected when completed, by the researchers. There was no refusal to participate in the study.

A piloted, self-administered, structured questionnaire was used to collect information regarding the knowledge, attitudes and beliefs of the study participants regarding oral health during pregnancy.

The questionnaire (Appendix 1) consisted of 25 items divided into three sections as follows:

Section 1: This section consisted of 9 questions which sought to determine the respondent’s knowledge of associations between pregnancy and oral health. In the first four questions respondents were asked to indicate whether pregnancy was associated with swollen gums, bleeding gums, tooth decay and tooth loss. The remaining five questions in this section sought to determine whether participants felt that there was a relationship between gum disease and various pregnancy outcomes such as preterm birth, low birth weight, spontaneous abortion, still birth and pre-eclampsia. All questions in this section had a response category of “yes”, “no” and “don’t know”.

Section 2: This section consisted of 12 items which sought to determine the respondent’s attitudes and practice towards oral healthcare during pregnancy. The first eight questions in this section asked about the safety of various dental procedures including dental examinations, radiographic examination, tooth brushing, flossing as well as the use of mouth wash, local anaesthetic and antibiotics during pregnancy. Again, the response categories included “yes”, “no” and “don’t know”. The remaining questions in this section sought to identify whether practitioners would advise on dental visits during pregnancy, which types of dental treatments they would advise their patient to receive and their sources of information on oral health and pregnancy. The response categories for these questions were “yes/ no”.

Section 3: In this section participants were asked to indicate demographics, place of work, and number of years in practice and area of speciality.

Data were analysed using SPSS version 22. Descriptive analyses were performed.

Ethical approval for the study was granted by the Ethics Committee of the University of the West Indies and data collection occurred over the course of a six-month period.

Results
Knowledge of associations between pregnancy and oral health
Almost half (48.1%) believed that pregnancy was not associated with swollen gums and an even higher percentage (60.6%) felt that pregnancy was not associated with bleeding gums. Just under one fifth (18.3%) felt that pregnancy was associated with tooth decay with a similar percentage (20.2%) indicating that pregnancy was associated with tooth loss.  (Table 1).

Table 1. Knowledge questions on pregnancy and oral health

The respondents were divided when it came to their knowledge of the relationship between gum disease and pre-term birth. Some 29.8% believed that there was an association between the two while 39.4% felt that there was no association. A relatively high percentage (30.8%) remained unsure about the relationship between gum disease and preterm birth.

A similar pattern of responses was seen in relation to the relationship between gum disease and LBW, with 22.1% indicating that there was an association, 37.5% stating that there was no association and 39.4% being unsure of the role of oral disease in giving rise to LBW among infants.

Very few (8.7%) felt that oral disease was associated with stillbirth and even fewer (6.7%) believed that gum disease was associated with preeclampsia.

Attitudes toward safety of dental procedures and dental treatment during pregnancy
The majority felt that dental examination (98.1%), tooth brushing and flossing (99%), and the use of mouthwash (95.2%) were safe during pregnancy. Just over half (51%) were of the belief that dental radiographs were safe.  The majority (71.2%) felt that tooth extraction could be safely performed during pregnancy and most (87.5%) also believed that the use of local anaesthetic was safe. Just over one fifth (21.2%) felt that it would not be safe for a pregnant woman to be prescribed penicillin, cephalosporin or erythromycin.

Very few respondents in this study (9.6%) would advise their patients to delay dental treatment until after pregnancy (Table 2).

Table 2. Attitudes questions on pregnancy and oral health

Practices of doctors in relation to recommending certain dental procedures to pregnant patients.
All respondents in this study would advise their pregnant patients to have dental examinations and most (94.2%) would recommend routine cleanings for these patients. The majority (86.5%) would advise expectant mothers to have periodontal (gum) cleanings. Over one third (37.5%) said that they would not advise their patients to have fillings/crowns done during pregnancy. 41.3% of participants would not advise their patients to have extractions performed (Table 3).

Table 3. Doctors’ Recommendations and Practices on pregnancy and oral health

Sources of information on the relationship between oral health and pregnancy

Characteristics of the participants

Just over a half of the participants (54.8%) were male. Similarly, just over half (51.9%) were specialised. The majority (72.1%) had been practising for 10 years or less.

Discussion
Dental care during pregnancy is often misunderstood by both patients and the health professionals who manage them during this important period of their lives. The authors of this study have recognized that there is little published information on the knowledge and attitudes of medical practitioners towards oral health during pregnancy in the Caribbean. To our knowledge this is the first study of this kind to be conducted in Trinidad and Tobago.

The first report of the association between maternal periodontal infection and pre-term, low birth weight delivery in 1996 has since emphasized the need for the promotion of oral health during pregnancy.¹³ Gingivitis during pregnancy is a well-recognized change in the oral cavity. Oestrogen is elevated during this state, which results in increased capillary permeability, and predisposes the pregnant women to gingivitis and gingival hyperplasia. ¹⁴ This study demonstrated that almost half of the medical practitioners surveyed (48.1%) believed that pregnancy was not associated with swollen gums and an even higher percentage (60.6%) felt that pregnancy was not associated with bleeding gums. Other studies published on the subject reflected greater knowledge by physicians on the association of gingival inflammation and pregnancy with 81% of the participants agreeing that pregnancy increases the tendency to have gingival inflammation in a study by Al-Habashneh et al in 2008. ¹⁵ This paucity of knowledge of the association between gum disease and pregnancy reflected by the physicians in our study may indicate that medical practitioners in Trinidad and Tobago require education on the oral changes among pregnant women during this dynamic physiological state.

The findings in our study reflected that approximately one fifth (20.2%) of physicians believe that pregnancy is associated with tooth loss. This percentage is relatively low when compared to a study by Al-Habashneh et al 2008 in which 53% of their participants agreed with the statement “a tooth for a baby”. ¹⁵ Hormonal changes during pregnancy can affect the periodontium which can in turn cause teeth to loosen. Despite this, in the absence of periodontal disease, this should be a transient effect and is not associated with tooth loss. ¹⁶ However, untreated periodontal disease during pregnancy and otherwise can lead to destructive breakdown of the periodontium and consequent loosening of teeth which can ultimately result in loss of the tooth. ¹⁷

There was little consensus among the participants in our study about the relationship between gum disease and preterm birth and low birth weight. This finding indicates some confusion amongst medical practitioners in this country and is perhaps a reflection of the lack of consensus among the scientific community about the exact role that periodontal disease plays in causing preterm birth and LBW. ¹

A 2013 systematic review found that Maternal periodontitis is modestly but significantly associated with LBW and preterm birth.² Despite a positive correlation between periodontal diseases and low birth weight being reported, a causal explanation has not been found in many studies. ¹⁸ In spite of the debate in the scientific community, periodontal disease is a preventable condition, thus dental education to prevent its occurrence is of paramount importance to pregnant women and to the health professionals who manage their care. This is especially so given evidence which suggests that periodontal disease has been associated with a range of health outcomes including adverse pregnancy outcomes, cardiovascular disease, stroke, pulmonary disease, and diabetes. ¹⁹ However, the causal relations between these diseases and periodontal disease have not been established. ¹⁹

This lack of consensus emphasises the need for continuing education on oral health and pregnancy outcomes to this group of health professionals so that they can be kept up to date with the latest research findings and guidelines regarding this issue.

In terms of the attitudes of medical practitioners toward safety of dental procedures and dental treatment during pregnancy, a finding of concern was that just over a third of respondents (36.5%) felt that radiographs were contraindicated during pregnancy and 11.5% were uncertain about whether radiograph examination of a pregnant patient was safe. The scientific literature actually indicates that dental radiation is negligible to the foetus and can be performed if necessary.⁴ Thus, dental radiographs are not deemed unsafe during pregnancy. However, routine radiographs should be avoided in all trimesters of pregnancy and the benefit of the dental radiographic examination must outweigh the risk. They should be used selectively with the radiation protection principle of justification in mind. ²⁰

Approximately one fifth (21.2%) of the respondents felt that it would not be safe for a pregnant woman to be prescribed penicillin, cephalosporin or erythromycin although the use of these antibiotics has been shown to be safe. ²¹

It was also very encouraging to note that very few participants (9.6%) would encourage their patients to delay dental treatment until after pregnancy. Pregnancy is not a reason to defer routine dental care or treatment of oral health problems.⁶ The majority of participants (94.2%) would recommend routine cleanings for these patients and a slightly lower number (86.5%) would advise expectant mothers to have periodontal cleanings.  Although there is a lack of evidence on whether treating periodontal disease can prevent adverse pregnancy outcomes periodontal treatment is essential during pregnancy, due to the hormonal changes taking place rendering patients more susceptible to plaque accumulation and gingival inflammation.²² Best practice suggests that because it has been shown to be safe and effective in reducing periodontal disease and periodontal pathogens, periodontal care should be provided during pregnancy.²² In addition, given the evidence to support the link between periodontal disease and other chronic diseases such diabetes and  cardiovascular disease it is imperative that the disease not be left untreated during pregnancy.²³

The finding that all respondents in this study would advise their pregnant patients to have dental examination is a positive one. Not only do dental examinations during pregnancy allow for detection of dental disease and early intervention but such visits can also provide the opportunity for dental practitioners to provide anticipatory guidance to expectant mothers.

Despite the high awareness of medical practitioners in this study with respect to safety and importance of various dental procedures during pregnancy, this knowledge did not always translate into their practices. For example, 71.2% felt that tooth extraction could be safely performed during pregnancy, however when asked specifically whether they would refer a pregnant patient for such treatment, 41.3% of participants said that they would not advise their patients to have extractions performed. Therefore, it is the opinion of the authors that educational campaigns highlighting associations between pregnancy and oral health, dental practice guidelines for pregnant patients and associations between oral disease and poor pregnancy outcomes be developed to ensure that these patients receive the most appropriate management. However, more studies are required to evaluate the impact of dental education intervention on the utilization of dental services during pregnancy. Currently, in Trinidad at the U.W.I Faculty of Medical Sciences, both medical and dental students participate in integrated learning through PBL (problem-based learning) in their pre- clinical years. However, there is no specific course on oral health and pregnancy designated for medical students. Undergraduate and post graduate training on oral health and pregnancy should be encouraged. This has been highlighted in a recent study which showed that the knowledge of both undergraduate medical and dental students towards dental treatment during pregnancy was low.²⁴

Limitations of the study may be that the participants of this study are not representative of all medical practitioners in Trinidad and the sample size is small.

In conclusion, these data provide the first insight into the knowledge, attitudes and beliefs of medical doctors on pregnancy and oral health in Trinidad.  Dental health and pregnancy have several associations and medical doctors are suitably placed to advice their patients on the importance of the effects of dental treatment on pregnancy outcomes.  Given the change in guidelines for dental treatment during pregnancy, continuing education on the relationship between pregnancy and oral health is recommended.

Appendix 1: Questionnaire

Participant Information Sheet                                                          ID#___________________

A Survey of the knowledge, attitude and beliefs of medical practitioners to oral health and dental treatment during pregnancy

Section 1

Guidelines to answer

• Answer ALL questions in each section
• Put a tick (√) in an appropriate box or answer as requested
• Please note there can be more than one response for some queries

Please tick the box that applies to you

1. What is your specialty?

General Practitioner       □
Gynaecologist        □
Other specialty      □

2. At which health centre/ hospital are you presently working?

 ————————————————————————————————————

3. How old are you?

 ————————————————————————————————————

 What is your Gender?

Male      □
Female  □

5. How many years have you been in practice?

<10      □
10-20   □
21-30   □
>31      □

6. What is your ethnicity?

Afro Caribbean       □
Indo Caribbean      □
Caucasian               □
Chinese                  □
Mixed                     □
Other                      □

END OF SECTION 1

Section 2

1. Do you think pregnancy increases the tendency for the gums to bleed, swell, or be red?
   Yes  □  No □  Don’t know □
2. Do you think tooth and gum problems could affect outcomes of pregnancy?
   Yes  □  No □  Don’t know □
3. Do you believe in the statement ‘a tooth for a baby’?
   Yes □   No □  Don’t know □
4. Do you believe calcium will be drawn out of the teeth by the developing baby?
   Yes □   No □  Don’t know □
5. Do you think that there is a possible connection between the health of the teeth and gums and pregnancy?
   Yes □   No □  Don’t know □
6. Do you believe that periodontal diseases can be treated safely during pregnancy with a procedure called scaling and root planning?Yes □   No □  Don’t know □

 END OF SECTION 2

Section 3

1. Would you advise your patient to receive the following dental treatment during pregnancy?
   Examination                                  Yes □   No □
   Routine Cleaning                          Yes □   No □
   Periodontal (gum) cleaning          Yes □   No □
   Fillings/ Crowns                            Yes □   No □
   Extractions                                    Yes □   No □
2. Would you advise your patient to visit the dentist during pregnancy?
   Yes □   No □
3. Would you advise your patient to delay the dental visit until after pregnancy?
   Yes □   No □
4. Would you advise your patient to include periodontal evaluation as part of their prenatal care?
   Yes □   No □
5. Where did you get your information about the relationship between pregnancy and oral health?
   Book, magazine, pamphlet   □
   Medical/ Dental Journal        □
   Undergraduate curriculum    □
   Clinical experience                 □
   TV                                           □
   Internet                                  □
   Other                                     □END OF SECTION 3

Ethical Approval
Granted by the Ethics Committee of The University of the West Indies
All Authors have contributed to study design, data collection and analysis and manuscript preparation.
Acknowledgements
The authors received no financial support for the research, authorship and/or publication of this article. The authors would like to thank the medical practitioners who participated in the collection of data for the study and Dr. Rishi Ramtahal, Dr. Natakki Dasent and Dr Christina Royer for their kind assistance with this study.

References

1. Corbella S, Taschieri S, Francetti L, De Siena F, Del Fabbro M. Periodontal disease as a risk factor for adverse pregnancy outcomes: a systematic review and meta-analysis of case-control studies. Odontology. 2012 Jul; 100(2):232-40.
2. Ide M, Papapanou PN. Epidemiology of association between maternal periodontal disease and adverse pregnancy outcomes–systematic review J Periodontal. 2013 Apr; 84(4 Suppl): S181-94.
3. Aljulayfi I, Alrusayni A, Alqahtani S, Hamam M K. Awareness of dental interns in managing cases of pregnant women in Saudi Arabia. Saudi J Dent Res. 2015; 6: 26–9
4. Kelaranta A, Ekholm M, Toroi P, Kortesniemi M. Radiation exposure to foetus and breasts from dental X-ray examinations: effect of lead shields. Dentomaxillofac Radiol. 2016 Jan; 45(1): 20150095
5. George A, Johnson M, Blinkhorn A, Ajwani S, Bhole S, Yeo AE, Ellis S. The oral health status, practices and knowledge of pregnant women in south-western Sydney. Aust Dent J. 2013 Mar; 58(1):26-33. doi: 10.1111/adj.12024. Epub 2013 Jan 30.
6. Hughes D, Lee P R. Oral Health During Pregnancy and Early Childhood: Evidence-Based Guidelines for Health Professionals. CDA Foundation, 2010 At: http://www.cdafoundation.org/Portals/0/pdfs/poh_guidelines.pdf Accessed: November 26, 2017
7. Shuk-Yin Lee R, Milgrom P. Dentists’ Perceptions of Barriers to Providing Dental Care to Pregnant Women” Women’s Health Issues September–October, 2010 ;20(5):359–365 https://doi.org/10.1016/j.whi.2010.05.0078.
8. Rabinerson D, Krispin E, Gabbay-Benziv R. Dental Care During Pregnancy. 2018; Harefuah May;157 (5):330-334
9. George A, Shamim S, Johnson M, Dahlen H, Ajwani S, Bhole S, Yeo AE. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current evidence and implications. Birth. 2012 Sep;39(3):238-47
10. United Nations Children’s Fund, (UNICEF), (2000). Multiple Indicator Cluster Survey: Trinidad and Tobago. [cited 2018 November 18] Available from: http://www.childinfo.org/files/trinidadtobago.pdf
11. Manual of Maternal and Child health from the Ministry of Health 2015 [ cited 2018 December18] Available from: http://www.health.gov.tt/downloads/DownloadDetails.aspx?id=357  Maternal-and-Child-Health-Manual-2015.pdf
12. Moonesar I and Vel P. Patients’ perception on prenatal care management at Trinidad & Tobago International Journal of Economic and Management Science,2012;( 2), 3: 6374
13. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al. (1996).Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 67(10 Suppl):1103-1113.
14. Soory M. Hormonal factors in periodontal disease. Dent Update. 2000; 27:380–83.
15. Al-Habashneh R1, Aljundi SH, Alwaeli HA. Survey of medical doctors’ attitudes and knowledge of the association between oral health and pregnancy outcomes. Int J Dent Hyg. 2008 Aug;6(3):214-20
16. Hashim R and Akbar M. Gynecologists’ knowledge and attitudes regarding oral health and periodontal disease leading to adverse pregnancy outcomes. J Int Soc Prev Community Dent. 2014 Dec; 4(Suppl 3): S166–S172
17. American Academy Periodontology.Periodontal (gum) diseases [ cited 2017 August 1] Available from: http://www.perio.org/consumer/2a.html
18. Sacco G, Carmagnola D, Abati S, Luglio PF, et al. Periodotal disease and preterm birth relationship. Minerva Stomatol. 2008; 57:233–46. 246–50.21.
19. LJ Jin, IB Lamster, JS Greenspan, NB Pitts, C Scully, S Warnakulasuriya Global burden of oral diseases: emerging concepts, management and interplay with systemic health Oral Diseases (2016) doi: 10.1111/odi.12428
20. Kusama T, Ota K. Radiological protection for diagnostic examination of pregnant Congenit Anom (khoto) 2002; 42:10–4
21. Norwitz E R and Greenberg J A, Antibiotics in Pregnancy: Are They Safe? Rev    Obstet Gynecol. 2009 Summer; 2(3): 135–136
22. Iheozor-Ejiofor Z, Middleton P, Esposito M, Glenny AM. Treating periodontal disease for preventing adverse birth outcomes in pregnant women. Cochrane Database Syst Rev. 2017 Jun 12; 6:CD005297
23. Muhammad A N    Prevalence of periodontal disease, its association with systemic disease and prevention. Int J Health Sci (Qassim). 2017 Apr-Jun; 11(2): 72–80
24. Balkaran R, Bissoon- Moonasar A, Deyalsingh L, Ford T, Hector T, Ramlogan N, Ramsahai D, Thorpe M, The knowledge, attitude and beliefs of undergraduate medical and dental students towards dental treatment during pregnancy. West Indian Medical Journal (2016) DOI:10.7727/wimj.2016.218