Oral-health awareness among pregnant women in the region of Republika Srpska

Summary Introduction Oral diseases during pregnancy are an important reason for enhanced dental care of this vulnerable population. The aim of this study was to determine the degree of oral health awareness among pregnant women and examine their oral hygiene habits, attitudes and behaviors in relation to the professional qualification. Material and methods The study was conducted in Foča, East Sarajevo, Bijeljina and Pale (Republika Srpska, Bosnia and Herzegovina). A total of 198 respondents voluntarily filled an anonymous survey, specially created for this research. Results In addition to toothbrush and toothpaste, 39.8% of pregnant women did not use any additional oral hygiene resources. When brushing their teeth, 60.1% of pregnant women had bleeding gums. Also, 54.1% of pregnant women visited dentist, while 34.3% did not. Obstetrician did not advise 69.7% of respondents that the should visit dentist during pregnancy. Furthermore, 80.8% of pregnant women thought that they were more susceptible to pregnancy caries, and 29.6% of them thought that caries is disease that cannot be prevented. Respondents with university education understood that minerals from the mother’s teeth were not lost during pregnancy, which was statistically significant compared to pregnant women with secondary education. Conclusion The level of oral health awareness of pregnant women is low. It is important that all women perform regular dental examination during pregnancy, as they will receive useful information from their dentist how to prevent oral diseases.


INTRODUCTION
Pregnancy is dynamic period in the life of a woman followed by numerous physiological and emotional changes. A healthy lifestyle and proper nutrition in pregnancy play a key role in general health of women, as well as proper growth and development of a child. Oral diseases during pregnancy are an important reason for enhanced dental care of this vulnerable population [1]. During pregnancy the level of sex hormones (estrogen and progesterone) is significantly increased in relation to non-pregnant women [2]. As result of a hormonal disbalance soft tissue changes in mouth are visible and followed by various degrees of tissue inflammation and bleeding marginal gingiva [3].
Periodontal diseases during pregnancy can be associated with preeclampsia, premature birth, and birth of a baby with low body weight [4]. Literature data indicate that transfer of cariogenic microorganisms from mother to child is one of the key factors in development of children's decay [5]. Modern dentistry aims to promote health and favors preventive over curative measures [6,7]. Prophylactic-preventive measures in pregnant women have dual function: create optimal conditions for intra-uterine formation and teeth development and prevent the occurrence of oral diseases in pregnant women. However, the fact is that only when a disease occurs, future mothers show interest in prevention [8]. Therefore, it is especially important that dentists insist on applying timely preventive measures in the period of early pregnancy.
The American Academy of Dentistry recommends that oral health care in children should begin in prenatal period by their parents oral health improvement [9]. A large number of pregnant women have not developed awareness of the impact of their own oral health and poor oral hygiene during pregnancy on the child's oral health. It is the fact that pregnant women, in most cases, have need for frequent and increased intake of sweet or sour food and beverages and ignore oral hygiene habits [8].
Parents play an important role in children's life, therefore their oral health knowledge and attitudes have major impact on the child's behavior model [10]. Many women during pregnancy are not visiting dentists. Literary evidence show that dental services are provided to low number of pregnant women even in industrialized countries: USA (23-49%), Great Britain (33-64%) and Greece (27%) [11]. During pregnancy, dental visits should be obligatory with the goal to obtain adequate information on how to preserve oral health of a child [12]. Advices should be understandable and practically applicable so that future mothers could easily implement their knowledge toward oral and general health [13].
The aim of the study was to determine the degree of oral health awareness among pregnant women as well as oral hygiene habits, attitudes and behaviors in relation to the professional qualifications.

MATERIALS AND METHODS
The study was conducted in 4 municipalities: Foča, Istočno Sarajevo, Bijeljina and Pale (Republika Srpska, B&H). Criteria for inclusion in the study were pregnant women regardless of age, education and social status chosen by random selection in obstetrical ambulances during regular checkups. All respondents gave written consent to participate in research. A total of 198 subjects, who were examined in the period from 8th to 38th week of gestation, voluntarily filled an anonymous survey, specially created for this research. The questionnaire consisted of 25 questions in order to receive the following information: socio-demographic data, oral hygiene habits of pregnant women, acquired knowledge and patterns of behavior during pregnancy as well as perception of pregnant woman about the harmfulness of dental interventions and medications on fetus. The obtained data were numerically processed using standard statistical procedures in statistical program SPSS 19.0 for Windows. Chi-square test was used to test the difference between the survey responses. Values p/q<0.05 were considered statistically significant.

RESULTS
The average age of examined subjects was 33.3 years. Most pregnant women (67.7%) had secondary education; slightly more than half of them were unemployed. 39.9% of respondents were pregnant for the first time (Table 1). Table 2 shows oral hygiene habits and behavior of pregnant women. In addition to toothbrushes and toothpastes, 39.8% subjects did not use any other oral hygiene resources. More than three-quarters of pregnant women (76.9%) with university education used additional oral hygiene resources and that was significantly different from pregnant women with secondary education, (p<0.05). When brushing teeth, 60.1% of pregnant women had bleeding gums, while nausea and vomiting were present in 55.0%. The survey showed that 15.1% of respondents would eat at nighttime, 13.6% were smokers, and 2.0% pregnant women consumed alcohol. One third of respondents (30.6%) had fear of dental intervention. More than half of respondents (54.1%) visited dentist during pregnancy, while 34.3% declared that they did not have any intention to do so. The survey showed that 69.7% of obstetritions did not advise women to visit dentists during pregnancy ( Table 2). Table 3 shows level of knowledge, behavior and opinion of pregnant women about the impact of dental interven-tion on the fetus. About two-thirds of pregnant women thought that during pregnancy they should not remove or treat unhealthy teeth, and they should not receive local anesthetic. Also, 80.8% of pregnant women thought that pregnancy makes teeth more susceptible to decay, and almost one third (29.6%) believed that caries is disease that cannot be prevented. Respondents with university education in a significantly higher percentage considered that minerals from mother's teeth couldn't be lost during pregnancy (p < 0.05) ( Table 3).

DISCUSSION
Research of oral hygiene habits, knowledge and behavior of pregnant women in our areas are very scarce. This study was conducted with the aim of gaining information about knowledge of pregnant women about oral health, in order to develop adequate preventive measures and raise awareness of oral health importance. Pregnancy is period when women are highly motivated to acquire knowledge in order to improve both their own and their child's health. Therefore this period is suitable for identifying existing risk factors, educating women (future mothers) to be conscious that oral health can be preserved and improved.
Adequate oral hygiene is a prerequisite for teeth and complete mouth health. Pregnant women are usually occupied by their condition and positive habits may be ignored. There is no doubt that eating habits change during pregnancy, but the question is which bad habits may increase incidence of dental diseases. Good oral-hygiene habits are result of good oral health education. In  [8] where 75.5% of pregnant women brushed their teeth after every meal, while in the study Shabirr et al. [14] 98.5% of pregnant women brushed their teeth 1-2 times a day. Thomas et al. [15] indicated that the frequency of brushing teeth and use of additional means of maintain-ing oral hygiene is in correlation with professional qualifications. This research showed that pregnant women with university education brushed their teeth more often and that they used other oral hygiene products. Gingivitis is one of the most common oral complications during pregnancy. It usually occurs after the second month of pregnancy and is followed by the most common bleeding gums during brushing teeth. This research showed that SSS -secondary education; VSS -university education; SZ -statistical significance; p -statistical significance in responses when the whole sample of respondents concerned; q -statistical significance in responses in relation to the professional qualifications of respondents SSS -srednja stručna sprema, VSS -visoka stručna sprema, SZ -statistička značajnost; p -statistička značajnost u odgovorima kada je celokupan uzorak ispitanica u pitanju; q -statistička značajnost u odgovorima u odnosu na stručnu spremu ispitanica 60.1% of subjects had bleeding gums while brushing their teeth. Bleeding can be reason for not maininating proper oral hygiene, causing rapid development of caries and teeth loss [16]. Factors such as tobacco and alcohol increase the risk of low body weight in newborns, premature birth and other complications [17]. The results of this research showed that 13.6% of pregnant women smoked during pregnancy, while 2% of them consumed alcohol. Results of Esposito et al. [17] showed that 22.3% of women in Italy smoked the during pregnancy, while 28.9% consumed alcohol before pregnancy, and 7.2% of them continued using alcohol during pregnancy. These numbers are significantly higher compared to our results. On the other hand research from United States and Great Britain showed that 57.4%, and 46.0% of pregnant women, respectively, were consuming cigarettes during pregnancy [17,18]. There is no known relation between pregnancy and decay. However, in our study, as many as 80.8% of respondents considered that teeth in pregnancy were more susceptible to decay. Even though there is belief that "every pregnancy is taking one tooth", no data actually confirmed this thesis. Increased risk of developing caries lesions, gingivitis and periodontal diseases during pregnancy is primarily due to the change in hormonal status and change in eating habits [1]. In our study it was found that pregnant women with secondary education in higher percentage contemplated that every pregnancy resulted in a loss of minerals from the mother's teeth. Loss of teeth during pregnancy is primarily consequence of continuation of poor oral or hygienic habits that existed even before pregnancy.
Dental interventions (restorations, endodontic treatment and tooth extraction) can be safely administered in any trimester of pregnancy, while more complex and time-consuming interventions are recommended after giving birth [15]. In the current study, large percentage of pregnant women (67.0%) considered that dental interventions are not safe during pregnancy. When it comes to receiving local anesthesia 72.0% said that it was not recommended.
Different factors influenced dental visits of pregnant women: material status, lack of consciousness about the SSS -secondary education; VSS -university education; SS -statistical significance; p -statistical significance in responses when the whole sample of respondents concerned; q -statistical significance in relation to the professional qualifications of the respondents SSS -srednja stručna sprema; VSS -visoka stručna sprema; SZ -statistička značajnost; p -statistička značajnost u odgovorima kada je celokupan uzorak ispitanica u pitanju; q -statistička značajnost u odnosu na stručnu spremu ispitanica importance of teeth health, biases about the impact of pregnancy on teeth and concern about safety of fetus during dental treatment [8]. In our study, 45.9% of respondents did not visit dentist, while 34.3% had no intention to do so. These values are slightly higher than results of Mangskau et al. [19] where 39% of pregnant women declared that they had not visited dentist during pregnancy. Hashim et al. [20] found that more than 40% of pregnant women did not visit dentist, even though dental interventions for pregnant women are free. Most of dental interventions in pregnant women happened due to certain painful conditions in the mouth. Also, more than half of pregnant women in Australia and USA did not visit dentist during pregnancy [15]. On the other hand, Christensen et al. [21] reported that 90% of Danish pregnant women visited dentists during pregnancy. In our study, significant difference in dental visits in relation to professional qualifications was not recorded. 73.4% of pregnant women reported that they did not receive any advice related to maintenance of their oral health and oral health of children. Similar results were obtained in the research of Rogers et al. [22] and Gunay et al. [23], where it was shown that only less than onethird of respondents received advice about the effects of women's oral health on pregnancy and newborns. 69.7% of pregnant women reported that they did not receive advice from their obstetrician about dental visits. Research of Basser et al. [24] showed poor oral health knowledge among obstetricians, who first come in contact with pregnant women, providing them adequate medical care and advice. Similar results were shown in the studies of Zanata et al. [25] and Rocha et al. [26]. Therefore, education and motivation of health workers, in the first place obstetrician, is one of the possible preventive measures to improve oral health of pregnant women. Cardenas et al. [27] found in their research that knowledge of pregnant women was significantly improved after 10 minutes of oral health presentations by dentist and the same women 4 weeks after testing retained most of the informations.
It is necessary to emphasize that in the area where our study was conducted there is no organized counseling for pregnant women in which the dentist is involved. It is therefore desirable to achieve better cooperation with obstetrician, because teamwork is the guarantee of successful prevention.

CONCLUSION
The level of oral health education among pregnant women is low. It is important that all women perform regular dental examinations during pregnancy even if they have healthy oral tissues. Dentist is important to spread useful information about the prevention of oral diseases that will contribute to improvement of pregnant women overall health as well as the health of a future child.