ORAL HEALTH PRACTICES AND TREATMENT NEEDS OF PREGNANT WOMEN IN THE THIRD TRIMESTER AT THE KENYATTA NATIONAL HOSPITAL MATERNITY WARDS. A Research Proposal for a Community Dentistry Project Submitted in Partial Fulfillment of the Degree of Bachelor of Dental Surgery UNIVERSITY OF NAIROBI PRINCIPAL INVESTIGATOR: KARANJA P. M, BDS ill SUPERVISORS: DR. L. Mutara, BDS (U.O.N), MPH (U.O.N) DR. K. Mulli, BDS (U.O.N) DURATION OF STUDY: TWO MONTHS (July-August, 2002) COST OF STUDY: Kshs 5258 SOURCE OF FUNDING: SELF
2 CONTENTS 1. Table of contents 2 2. Abbreviations 4 3. Summary 5 Chapter 1: 4. Introduction 6 Chapter 2: 5. Literature review 8 Chapter 3: 6. Problem statement 10 7. Justification 10 8. Objectives 10 9. Hypothesis 11 10. Variables 11 Chapter 4: 11. Methodology 12 Study area 12 Study design 12 Sample size 13 12. Inclusion criteria 13 13. Exclusion criteria, 14 14. Data collection instruments and techniques 14 15. Logistics 18 16. Ethical considerations 20 17. Data presentation and analysis 21 18. Perceived benefits 21 19. Budget 22 20. References 23
3 21. Appendix Questionnaire 24 Clinical examination form..27 Investigators' ManuaL...28 Letter of approval 32
4 ABBREVIA TIONS CPI CPI stands for Community Periodontal Index.This index is based on a modification of an earlier used Community Periodontal Index of Treatment Needs (CPITN). Indicators used for this assessment are: gingival bleeding, calculus and periodontal pockets. DMF- The Decayed-Missing-Filled index. The DMF index IS applied to permanent teeth. D-Used to describe decayed teeth M- Missing teeth due to caries or very badly decayed teeth indicated for extraction. F- Teeth that have been previously filled. KNH- Kenyatta National Hospital OHI - Oral hygiene instructions Uo.N- University of Nairobi
5 SUMMARY The aim of this study is to assess the oral health practices and treatment needs of a cohort of pregnant women in the third trimester. Pregnant women are prone to develop pregnancy gingivitis, pregnancy tumors and dental caries due to hormonal and dietary factors. Gingivitis is reported to occur in 60-75% of all pregnant women". Similar studies to this one done in other countries have revealed a need for special attention to their oral health after finding it to be inadequate. New research suggests a link between pre-term low birth weight babies and maternal gingivitis; therefore addressing their oral health issues is justified. This is a cross-sectional descriptive study. The study area will be KNH maternity wards. The calculated sample size is 316. All the women in their third trimester of pregnancy will be included. Data will be collected by use of questionnaires and clinical examination forms. DMF and CPI indices will be used to assess the treatment needs of the study population. The data so collected will be analyzed manually and presented in form of prose and charts, which will be included in the project report. It is expected that the study population has a range of unmet treatment needs, which this study intends to ascertain. Benefits that will accrue from this study will be setting up of a oral health program that specifically targets pregnant women or the implementation of the same through MCHlFP clinics as part of primary oral healthcare.
6 Chapter 1: INTRODUCTION There are old myths that suggest that "teeth are drained of calcium during pregnancy" and that "One tooth is lost with every pregnancy". These and other old wives tales suggest a need to learn the facts about maintaining healthy teeth and gums during this period. Some changes in oral health may be experienced during pregnancy. The primary change is a surge of hormones particularly an increase in estrogen and progesterone - which is linked to an increase in plaque levels and an increased sensitivity of the gingivae to the effects of plaque'. This increases the possibility of developing gingivitis, which reportedly occurs in 60-75% of all pregnant women'. Pregnant women are also at risk of developing pregnancy tumors of the gingiva Cravings that lead to indulgence in sweet foods during this period leads to a constant lowering of oral PH leading to possible initiation and progression of carious lesions. Pregnant women are therefore prone to develop the following conditions: i) Pregnancy gingivitis ii) iii) Pregnancy tumors Dental caries A study done in Sri-Lanka showed that despite similar scores for plaque levels in both pregnant women under study and non-pregnant women as controls, the gingival index of pregnant women was significantly increased during 1st and 2 nd trimesters and further during the 3 rd trimester'. This suggests that pregnant women are at a higher risk of developing periodontal diseases than non- pregnant population. Yet another study done in three American states showed that only a little over 50% of the women who had dental problems during their pregnancy visited a dentist'. A study in Lagos revealedthat 50% of the pregnant women subjects needed scaling, polishing and OHI 2 No statistics are available as to the prevalence of dental diseases in pregnant women in Kenya, however the literature available even from other studies carried out on the same reveal that there is a dental health problem that needs to be addressed in pregnant women.
7 The researcher noted that while MCHlFP clinics are widespread in the country, most of them do not give adequate attention to oral health issues for one reason or another. Dental health is not perceived to be high in the list of priorities during pregnancy. There is need to sensitize health-care givers on the relationship between oral health and the general well being of any individual. There are plenty of opportunities being wasted that could be used to impart good oral health practices to pregnant women who can then teach the same to their children and in the end a significant decrease in oral diseases could be registered. The aim of this study is to determine the oral health practices and treatment needs of pregnant women in the third trimester at the KHN maternity wards.
8 Chapter 2: LITERATURE REVIEW In a cohort study of young minority women in New York, 213 women were enrolled and examined clinically for dental plaque, calculus, bleeding or probing and pocket death. Birth outcome data was available from 164 women. One group was subjected to oral prophylaxis during pregnancy and a second group received no prenatal periodontal treatment Subgingival plaque samples were analyzed by checkerboard DNA hybridization with respect to twelve (12) bacterial species. The prevalence of preterm low birth weight (PLBW) deliveries was 16.5%. No clinical periodontal status differences were observed between PLBW cases and women with normal birth outcome. However PLBW mothers had significantly higher levels of Bacteroids forsythus and Compylobacter rectus and consistently elevated counts for the other species examined. PLBW occurred in 18.9% of the women who did not receive periodontal intervention and in 13.5% of those who had such therapy." The journal of American Dental Association published an article on July 2001 of 'Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system (PRAMS). PRAMS is an ongomg, population-based survey designed to obtain information from mothers, who delivered live born infants about their experiences and behaviours before, during and after pregnancy. Reports of dental care use ranged from 22.7 to 34.7%. In 3 states, of the 12.2-25.4% who had a dental problem, only 44.7-54.9% went for care. The conclusion was that most mothers did not go for dental care during their pregnancy. The practice implication: Attention toward oral health needs of pregnant women is warranted. A coordinated effort from the dental and obstetric communities to establish guidelines could benefit maternal oral health and perinatal outcomes. 5 A study done in Sri-Lanka showed that despite similar scores for plaque levels in both pregnant women under study and non-pregnant women as controls, the gingival index of pregnant women was significantly increased during 1st and 2 nd trimesters and further
9 during the 3 rd trimester but dropped at 3 months post partum. Values for loss of periodontal attachment (LA) did not show significant differences from that of controls during any stages of pregnancy. It concluded that pregnancy had an effect only on gingival and not on periodontal attachment levels and that the effects of estrogen and progesterone could give rise to a more florid response to the irritant effects of plaque, resulting in severe gingivitis." In a study of oral health status and treatment needs of pregnant women in Lagos, Nigeria, a coded questionnaire was admitted to pregnant women followed by their oral examination in the dental clinic. The mean oral hygiene index score increased progressively throughout pregnancy: 1st trimester 0.72, 2 nd trimester 1.06 and 3 rd trimester 1.23. Community periodontal index of treatment needs (CPITN) revealed that 50% of 250 pregnant women required scaling and polishing and oral hygiene instruction, 13.6% required oral hygiene instructions only and 32.2% did not require any treatment. DMFT was 1.54, 51. 72% required fillings, and 23.27% required extraction due to caries and 16.38% required partial dentures.'
10 Chapter 3: PROBLEM STATEMENT Gingivitis has been reported to occur in 60-75% of all pregnant womerr'. This condition and its sequel have been shown to have association with duration of parity and birth weight of the infant. However no causal relationship has been established yet. Isolated studies such as one done in Sri-Lanka 4 have shown gingival index pregnant women to be higher than that of non-pregnant women controls despite similar levels of plaque score with that of non-pregnant women controls. Other studies have shown that most pregnant women don't seek dental treatment and in most instances, there are no oral preventive and treatment programs that specifically target them. JUSTIFICATION OF THE STUDY New research suggests a link between pre-term low birth weight babies and maternal gingivitis. Excessive bacteria can enter the bloodstream through the gingiva, travel to the uterus and trigger the production of prostaglandins, which are suspected to induce premature labor'. It is therefore worthwhile to determine the oral health practices and treatment needs during pregnancy in order to put measures in place to maintain their good oral health and prevent complications to the infant. No similar study has been done on pregnant women in Kenya. MAIN OBJECTIVE To determine the oral health practices of pregnant women in their third trimester in a local hospital's maternity wards and determine their oral treatment needs.
11 SPECIFIC OBJECTIVES 1. To determine the CPI of the study population 2. To determine the DMFT index of the study population 3. To determine oral health practices in the third trimester in terms of 1. Oral hygiene - toothbrushing and flossing 11. Dietary habits 4. To ascertain if there has been any changes in oral health status during the period of pregnancy HYPOTHESIS The oral health practices of the pregnant women population under study are less than adequate to maintain good oral health. They therefore have a wide range of treatment needs. VARIABLES Dependent Variables 1. DMFT 2. CPI 3. Oral health experiences Independent Variables 1. Plaque 2. Hormonal change in pregnancy 3. Oral hygiene practices 4. Dietary habits
12 METHODOLOGY STUD Y AREA: Background The area of study will be the Kenyatta National Hospital Maternity wards. This is a tertiary healthcare facility located in Nairobi on Ngong Road, near community and opposite the Nairobi Hospital. It is the largest and oldest institution of its kind having been started about 100 years ago. The hospital receives patients from the environs of the city and also referral patients from various district hospitals throughout the country. It is a government-run parastatal institution, which provides a wide spectrum of health services at subsidized fees. Most patients seeking treatment at the hospital are of middle and low socio-economic class. The head nurse at the maternity ward estimates the turnover of patients to be about 150 in a day. Most women stay two days unless complications arise during and after labor. Most are admitted while in labor. STUDY DESIGN This is a cross-sectional trimester will form the study population descriptive study. A cohort of pregnant women in the third SAMPLE SIZE Estimated prevalence of= 75% (pregnancy gingivitis) Confidence level = 95%: Z value = 1.96
13 Sample size (N) = Z2p(1_p) Where P is prevalence Cis (l-cl) CL is Confidence Level N = 1.96 2 X 0.75(1-0.75) = 0.7203 0.0025 = 288 +10% non- response N = 316 INCLUSION CRITERIA 1. The sample will be self-selected. All women in the KNH maternity wards in their third trimester may be included in the sample. 2. Any women in the wards who will have given birth within the past 2 days from the day of the study EXCLUSION CRITERIA 1. Any woman who does not cooperate in giving information or being examined clinically 2. Any woman in extreme discomfort or who at the time of examination is undergoing labor 3. Any woman not in the third trimester of pregnancy
14 DATA COLLECTION INSTRUMENTS AND TECHNIQUES Data will be collected by two means: 1. Questionnaires- which will be self-administered so the subjects will be required to fill them out personally. However the investigator and assistants will be available for clarification if necessary. They will be translated to Kiswahili as that is the most widely used language by the study population. 2. Clinical examinationform. Instruments and supplies to be used for clinical examination 1. Dental mirror 2. CPI probe 3. Concentrated cidex solution 4. Hand towels 5. Gauze Examination will be carried out in a well-lit room using natural light and within the maternity ward. Where movement is difficult for the subject, examination will be carried out while on their respective hospital beds. The principal investigator will be aided by colleagues, who will be callibrated, to collect data. Instruments will be provided by the University of Nairobi Dental School! Hospital. Results from the examination will be recorded on clinical examination forms. These will be attached to individual questionnaires for respective subjects for ease of data analysis. Diagnosis Criteria The following indices will be used during clinical examination:
15 1. Dl\1F- The Decayed-Missing-Filled index Method The Dl\1F index is applied to permanent teeth. D- Used to describe decayed teeth M- Missing teeth due to caries or very badly decayed teeth indicated for extraction. F- Teeth that have been previously filled. All permanent teeth will be examined except: 1. Third molars 2. Unerrupted teeth 3. Congenitally missing and supernumerary teeth. 4. Teeth removed for reasons other than dental caries e.g. orthodontic treatment or impaction. 5. Teeth restored for reasons other than dental caries. Criteria for diagnosis of Dental Caries 1. Clinically visible lesion. 2. The explorer tip can penetrate deep into the soft yielding tissue. 3. There is discoloration or loss of translucency typical of undermined or demineralised enamel. 4. The explorer tip in a pit of fissure catches or resists removal after moderate to firm pressure is applied and when there is softness at the base of the area.
16 Coding Criteria for DMF Criteria E 1 2 3 Excluded tooth or tooth space Sound permanent tooth Filled permanent tooth Decayed permanent tooth For tooth absent o X Missing tooth-unerupted, Extracted permanent tooth. impacted, congenitally missing Calculation of the index Total each component, then all are totaled e.g. D+M+F=DMF 2. CPI This index is based on a modification of an earlier used Community periodontal index of treatment needs (CPITN). Indicators used for this assessment are: gingival bleeding, calculus and periodontal pockets.
17 Method The dentition will be divided into sextants for assessment of periodontal treatment needs. Each sextant is given a score, which is identified by examination of specified index teeth for the purpose of this study. A sextant will be examined only if there are two or more teeth present, which are not indicated for extraction (Note: this replaces the former instruction to include single remaining teeth in the adjacent sextant. The two molars in each posterior sextant are paired for recording and if one is missing, it is not replaced. If no index teeth or tooth is present in a sextant qualifying for examination, all the remaining teeth in that sextant are examined and the highest score is recorded as the score for the sextant. Distal surfaces of3 rd molars should not be scored. For subjects aged less than 20 years, only six index teeth will be examined. scoring deepened sulci associated with eruption as periodontal pockets". To avoid Coding Criteria for CPI Criteria x o 1 2 3 4 excluded sextant (less than two teeth present) No periodontal disease Bleeding observed during or after probing Calculus or other plaque retentive factors either seen or felt during probing. Pathological pocket 4-5mm deep (gingival margin within black band of the probe) Pathological pocket 6 or more mm deep (black band on the probe not visible) 9 Not recorded
18 Coding Criteria for treatment needs Criteria TN-O TN-l TN-2 TN-3 Code 0 or code X for all six sextants indicate no need for treatment Code 1 or higher indicates need for improving personal oral hygiene. a) Code 2 or higher indicates need for professional cleaning of teeth, removal of plaque retentive factors and oral hygiene instructions. b) Shallow to moderate pockets (4-Smm code 3) requires oral hygiene instructions and scaling to reduce inflammation and pocket depth to normal. A sextant scoring code 4( 6mm or deeper pockets) mayor may not be treated successfully by deep scaling and efficient personal hygiene measures. Code 4 is assigned 'Complex treatment needs" which may include surgery. Index teeth to be examined (grouped in sextants) 1_:_~----:-:-+---3-1:---I-:-:----:-~- LOGISTICS