Factors associated with the reason for a dental visit reported by pregnant women at a Brazilian public school of dentistryAbstract
Background: Pregnancy is a period marked by significant hormonal, physiological, emotional, physical and behavioral changes that can pose risks to oral health.
Objective: This observational cross-sectional study investigated the profile of pregnant women who attended a public dental school during 2000–2019 and the reason for seeking dental care and associated factors.
Method: Data on the pregnancy, sociodemographic characteristics, the reason for a dental visit, medical history, systemic condition, deleterious oral habits, oral condition status, access to dental care, and oral hygiene habits were collected by assessing dental records (n=834). The associations between independent variables and the outcome (pain as the reason for seeking dental care) were tested by simple and hierarchical multiple logistic regression models.
Results: Only 4.2% sought care for routine/prevention. The presence of pain was reported by 46.6% of the pregnant women, and the associated predictors (p<0.05) were the presence of dry mouth (odds ratio – OR=1.50; 95% confidence interval – 95%CI 1.09–2.07) and no use of dental floss (OR=1.48; 95%CI 1.08–2.02).
Conclusions: Complaints of pain were reported by almost half of the pregnant women and were significantly associated with dry mouth and not using dental floss.
Keywords:
oral health; pregnant people; prenatal care
Resumo
Introdução: A gravidez é um período marcado por importantes alterações hormonais, fisiológicas, emocionais, físicas e comportamentais que podem trazer risco à saúde bucal.
Objetivo: Este estudo observacional transversal investigou o perfil das gestantes atendidas em uma faculdade pública de Odontologia no período 2000–2019, bem como o motivo da procura por atendimento odontológico e fatores associados.
Método: Dados sobre a gravidez, características sociodemográficas, motivo da consulta odontológica, histórico médico, condição sistêmica, hábitos orais deletérios, estado da condição bucal, acesso ao atendimento odontológico e hábitos de higiene bucal foram coletados por meio da avaliação dos prontuários odontológicos (n=834). As associações entre as variáveis independentes e o desfecho (dor como motivo da consulta odontológica) foram testadas em modelos de regressão logística simples e múltiplo hierárquico.
Resultados: Apenas 4,2% procuraram atendimento por rotina/prevenção. A presença de dor foi relatada por 46,6% das gestantes e os preditores associados (p<0,05) foram a presença de boca seca (odds ratio – OR=1,50; intervalo de confiança de 95% – IC95% 1,09–2,07) e o não uso de fio dental (OR=1,48; IC95% 1,08–2,02).
Conclusões: Conclui-se que as gestantes com hábitos de higiene bucal inadequados ou que tinham a sensação de boca seca mostraram maior probabilidade de procurar atendimento odontológico por motivo de dor.
Palavras-chave:
saúde bucal; gestantes; cuidado pré-natal
INTRODUCTION
Pregnancy is a period marked by significant hormonal, physiological1,2, emotional, physical3,4 and behavioral1 changes that can pose risks to oral health5. During this phase, inadequate oral hygiene habits1,2, associated with the increased frequency of sugary foods6 and hormonal changes, can increase the risk of developing tooth decay and make pregnant women more susceptible to periodontal diseases7,8. Although they usually regress in the postpartum period, periodontal diseases can negatively impact the quality of life of pregnant women1,8 and are associated with adverse pregnancy outcomes, such as premature birth, pre-eclampsia, low birth weight, and miscarriage9-11.
Pregnancy can encourage the adoption of better hygiene habits12,13 that may be extended to the baby and other family members14. However, few women have access to guidance and oral health care during routine prenatal care15,16. Most of them do not seek dental care during pregnancy and, when they do, prevention is not the main reason for the consultation17-19.
Barriers related to dental care during pregnancy have been described as the cost of treatment17,20, fear that dental procedures are harmful to fetal development and the progression of pregnancy20-24, the insecurity of dentists in providing care to pregnant women, lack of interprofessional collaboration20, non-prioritization of oral health by pregnant women22, transportation problems, dissatisfaction with the quality of dental services21 and lack of perception of treatment needs25. Additionally, the importance of oral health care is still frequently neglected by doctors and nurses responsible for routine prenatal care26.
Therefore, to better target campaigns and specific public policies that promote the oral health of pregnant women, conducting studies that investigate the variables that influence the demand for dental care during pregnancy becomes relevant. Thus, this study aimed to investigate the profile of pregnant women attending a school of Dentistry from 2000 to 2019, the reason for seeking dental care, and the associated variables.
METHOD
This observational cross-sectional study was carried out at Universidade Estadual Paulista "Júlio de Mesquita Filho", School of Dentistry, Araraquara (FOAr/Unesp), by evaluating dental records of pregnant women from 2000 to 2019. This study was approved by the Research Ethics Committee (Certificate of Presentation for Ethical Appreciation—CAAE 61525116.2.0000.5416) and conducted following the guidelines of Resolution nº 466/12 of the National Health Council and all the complementary regulations regarding ethics in research with human beings. Furthermore, all pregnant women gave their informed consent prior to inclusion in the study.
For data collection, we selected the dental records of pregnant patients who attended the Collective Health III clinic in the period considered (n=917). Thirty-seven were excluded due to duplicated records and 46 due to the absence of a valid answer for the variable "reason for the dental visit", totalizing a final sample of 834 dental records of pregnant women. The referred clinic offers preventive procedures, oral environment adequacy, periodontal, restorative, and low-complexity surgical treatment for children, adolescents, pregnant women, and breastfeeding women.
The variables collected were recorded by undergraduate students of the 3rd year of the Dentistry course, supervised by professors, during the patients’ anamnesis. They included information about the pregnancy, sociodemographic characteristics, reason for a dental visit, medical history, systemic condition, deleterious oral habits, oral condition status, access to dental care, and oral hygiene habits.
Efforts to address potential sources of bias relating to data collection were taken, such as great attention to the correct recording of data.
All collected data were directly registered in Microsoft Excel® spreadsheets. Initially, descriptive analyses of the data were performed. Then, associations between the independent variables and the outcome (pain as the reason for the dental appointment) were studied. Simple logistic regression models were adjusted for each variable individually. Variables with p<0.20 in these simple analyses were studied in a hierarchical multiple logistic regression model. The variables were introduced in the model from the first level (predisposing variables) to the last (use of services), with adjustments for the previous levels (need; health practices), considering the behavioral model of the use of health services proposed by Andersen27. Such conceptual model seeks to explain the factor associated with usage of health services according to predisposing factors, enabling factors, and need. In the present study, the predisposing variables included: race/skin color, age, pregnancy stage, medical advice on dental treatment, anxiety perception. Need variables were: habit of biting lips/cheeks, frequent mouth ulcers, usually having dry mouth, gum bleeding when brushing teeth. Health practices included daily brushing frequency, flossing. Use of health services was assessed by questions about previous dental care during pregnancy and last visit to the dentist. These variables were introduced in the model from the first level (predisposing variables) to the last (use of services), with adjustments for the previous levels (need; health practices). The final model was composed of the variables that remained at p≤0.05 after adjustments for the other variables. Crude and adjusted odds ratios were estimated with 95% confidence intervals. The model’s fit was analyzed by the Akaike Information Criterion (AIC). All analyses were performed using the R Core Team® program.
Concerning missing data, it was assumed in the analyses that the absence of information occurred by chance. Then descriptive analyses of the cases with absent responses in each independent variable related to the outcome were carried out. The "no information" categories on each independent variable were not included in the simple and multiple regression models.
Moreover, Pearson’s correlation analysis was performed between the percentage of pregnant women with pain complaints and the year.
RESULTS
Data from 834 medical records of pregnant women who sought dental care at the School of Dentistry of Universidade Estadual Paulista "Júlio de Mesquita Filho" (FOAr/Unesp) from 2000 to 2019 were collected and analyzed (Figure 1). The mean age of patients was 26.4 years and standard deviation was ±6.1 years. The majority reported being of white ethnicity (77.7%), living in Araraquara (93.4%), having the first, second or third pregnancy (76.6%) and in the second or third school trimester (70.0%). Of the evaluated pregnant women, 13.4% smoked (7.8% did not provide the information), and 1.2% reported consuming alcoholic beverages (65.0% did not provide the data). Most did not have allergies (79.4%), reported being under medical treatment (69.3%), taking medications (77.9%), and not having received medical advice to seek dental care (58.6%). Diabetes, epilepsy, heart problems, and previous serious illnesses were reported by 2.6, 0.7, 4.6, and 6.6%, respectively.
About 46.4% noticed some oral alteration, 46.9% reported changes in eating habits during pregnancy, 30.0% reported having the habit of biting lips/cheeks, 13.3% reported having frequent thrush, 30.6% dry mouth, and 54.0% gingival bleeding when brushing teeth. Prevention was the reason for the dental visit for 4.2% of the studied pregnant women, while 46.6% reported pain as their primary complaint, and 57.6% had a tooth with pain at the time of the dental evaluation. About 29.5% reported having received dental care while pregnant, with the average time since the last dental visit being 2.1 years, standard deviation was ±6.2 years. Anxiety/fear regarding the need to undergo dental treatment was reported by 38.1% of pregnant women. Just over half of the analyzed records provided information on brushing and flossing daily regarding oral health habits. About 68.1% of pregnant women reported brushing their teeth up to three times a day, and 45.7% used dental floss.
Table 1 shows the distribution of other variables collected in the study.
Data distribution on variables collected among pregnant women with valid responses for "reason for the dental visit". Araraquara, SP, 2000–2019.
Table 2 presents the results of the association analyses. Among the predisposing variables, only age showed p<0.20 and was studied in the multiple model. The variables "bites lips/cheeks" and "usually dry mouth" were included in the multiple model. Only the variable "usually has a dry mouth" remained significant (p<0.05). Then, the variable "dental flossing" was included, and the two variables ("usually dry mouth" and "dental flossing") remained in the final model (p<0.05). Among the pregnant women who did not report having a dry mouth, 45.1% sought dental care due to pain, while, among those who used to have dry mouth, this percentage was 54.5% (p<0.05). The pregnant women who reported having a dry mouth were 1.50 (95% confidence interval – 95%CI 1.09–2.07) times more likely to have gone to a dental appointment due to pain (p<0.05). About 44.1% of pregnant women who used dental floss sought dental care due to pain; among those who did not use it, this percentage was 54.3% (p<0.05). The pregnant women who did not use dental floss were 1.48 times (95%CI 1.08–2.02) times more likely to have gone to a dental appointment due to pain (p<0.05).
Association analysis (crude and adjusted) between the reason for pregnant women’s dental visit and independent variables. Araraquara, SP, 2000–2019.
There was a significant decrease in the percentage of pregnant women seen due to complaints of pain over the years (r=-0.57, p<0.05; Figure 2).
Dispersion between the percentage of pregnant women with pain as the main reason for dental visit and year, r=-0.57, p=0.0084.
DISCUSSION
This study sought to outline the profile of pregnant women attending at FOAr/Unesp from 2000 to 2019 and analyze the reason for seeking dental care and the associated variables. Our findings can instigate discussions on the oral health care practices during pregnancy and on public policies aimed at promoting the oral health of this group.
Most pregnant women (70.0%) sought care in the second or third trimester of pregnancy. Although dental care can be provided during pregnancy and emergencies must be promptly resolved, regardless of the gestational trimester28, in general, the second trimester is considered the ideal and safest for dental treatment29-32. Most dental procedures can be performed safely during pregnancy if some precautions are observed, such as planning short sessions, adapting the chair’s position, and avoiding morning consultations because pregnant women tend to have nausea and risk of hypoglycemia28.
Despite the importance of dental appointments during pregnancy, more than half of the pregnant women (58.6%) did not receive medical advice to seek dental care, which corroborates the findings of previous studies33,34. These findings can be explained by the uncertainty of professionals responsible for prenatal care about the safety and adequacy of dental care during pregnancy31.
In fact, pregnant women whose doctors advise visiting the dentist are more likely to seek dental services35,36. Another important aspect is the role of the multidisciplinary prenatal team in demystifying beliefs and myths related to the oral health of pregnant women37.
Despite the National Oral Health Policy38 and other crucial national publications4,30,39-42 guiding the referral of pregnant women to dental appointments, the recommendations to seek a dentist are primarily due to pain or discomfort13. In the present study, only 4.2% of pregnant women sought care through routine/prevention, and almost half (46.6%) reported the presence of pain as their primary complaint.
Previous studies have also shown that routine and prevention consultations are not the main reason for seeking dental care among pregnant women19,21,25,43-45. Given this context, pregnant women and health professionals who have the first contact with them must recognize the importance of dental evaluation so that a dental visit is scheduled early in pregnancy.
Demographic, socioeconomic, psychological, and behavioral factors can influence the search for dental care during pregnancy22,35,36, with greater demand for oral health services among pregnant women with higher family income and higher education levels18,35,36,46. Among the behavioral aspects that can influence the search for dental care is the fear that the procedures are harmful to fetal development and the progression of pregnancy20-24.
In the present study, 38.1% of pregnant women reported having anxiety/fear in receiving dental treatment, corroborating previous studies18,44. Although most pregnant women47 recognize the importance of oral health and dental follow-up, many are reticent to some procedures, such as radiographs and the use of local anesthetics, and report difficulties in accessing services15,48. Moreover, some pregnant women believe that caries, toothache, and gingival bleeding are expected and inherent in the gestational period35. Thus, working on health promotion and education with this group helps demystify dental care and prevent oral changes, providing a better quality of life for pregnant women and babies15,23,49,50.
Among the oral changes reported in this study, gingival bleeding when brushing teeth was the most frequent, described by 54.0% of pregnant women. Gingival19 or periodontal25 alterations were also observed in most pregnant women in previous studies. Periodontal changes, frequent during pregnancy, arise in response to hormonal changes during this period, which induce greater vascularization of the periodontal and favor the growth of bacterial strains with greater pathogenicity1,2,6,8, especially Porphyromonas gingivalis and Prevotella intermedia31.
However, it is worth noting that pregnancy, and the changes it triggers, are not a determining condition for the development of periodontal diseases, although they increase the gingival response and change the clinical status in pregnant women who present oral hygiene habits and control of inadequate biofilm8,13,51,52. Thus, prenatal dental monitoring is essential to identify risks to oral health, carry out curative treatments and educational-preventive actions13,51,53,54.
Several studies have shown that periodontal diseases are associated with adverse pregnancy outcomes, such as low birth weight, pre-eclampsia10, and premature birth10,11,55,56. However, there is insufficient evidence that periodontal treatment during pregnancy can prevent such complications57,58, which are generally associated with poor living conditions, inadequate prenatal care, maternal age, and systemic complications7. However, it should be noted that periodontal therapy is safe during pregnancy and, even if it cannot avoid adverse outcomes, it should be recommended as part of prenatal care59.
The association analyses in the present study showed that pregnant women who responded that they usually have a dry mouth are 1.50 times more likely to have gone to a dental appointment due to pain. Some studies show that xerostomia is a frequent symptom among pregnant women60,61. At the same time, other researchers evidenced in a recent meta-analysis an increase in the rate of stimulated saliva flow in the third trimester of pregnancy62. Although data on changes in salivary flow in pregnant women are controversial63, it is worth noting that saliva plays a vital role in oral cavity homeostasis, being one of the protective factors against demineralization of dental tissues63. Therefore, changes in its flow, pH, buffering capacity, and biochemical composition63 may favor the progression of caries63,64 and dental erosion63. As many factors can regulate the flow63 and quality of saliva throughout pregnancy, it is suggested that future studies be conducted on the subject.
The present study also showed a greater chance of seeking dental care due to pain among pregnant women who did not use dental floss. Flossing is not a prevalent habit among Turkish65 and Brazilian25,66 pregnant women, and the absence of interproximal cleaning was significantly associated with periodontal disease in a national study25. We could not assess the relationship between no flossing and proximal caries lesions, gingivitis, periodontitis because no clinical data were collected. Anyway, it is speculated that pregnant women who do not use dental floss may have a poor dental and gingival condition and, consequently, pain related to such condition.
Despite the scarcity of studies on the factors associated with the reason for dental appointments among pregnant women, which makes it difficult to compare results, it is believed that the predictors found in this study can serve as indicators for the prenatal care health teams. Furthermore, the implications of these findings highlight the imminent need for campaigns and public policies aimed at pregnant women and professionals who take care of these women’s health to reinforce the importance of prenatal dental care and integrated care of pregnant women. Finally, the availability of updated guidelines for dental care for pregnant women and the assessment of the need to improve academic training and continuing/permanent education of health professionals can contribute to establishing and consolidating prenatal dental care as an essential element of public policies for pregnant women.
It is necessary to mention the limitations and strengths of this study. As limitations, we can mention the cross-sectional nature of the study, which makes it impossible to establish causal relationships; the lack of registration for some independent variables; the absence of data on socioeconomic status and clinical conditions; and the possible memory bias. The study’s strengths include the relevance and scarcity of studies on the topic and the quality of statistical analysis.
CONCLUSIONS
Pregnant women were mainly white, young women, in the second or third trimester of pregnancy, without harmful habits, with reports of gingival bleeding when brushing teeth and reported treatment needs as the primary complaint. Complaints of pain were reported by almost half of the pregnant women and were significantly associated with dry mouth and not using dental floss.
Data availability statement:
The datasets generated and/or analyzed during the current study are not publicly available due to ethical restrictions but are available from the corresponding author upon request.
How to cite:
Tagliaferro EPS, Matos M, Dorighello L, Silva SRC, Rosell FL, Valsecki Junior A, Santos MO. Factors associated with the reason for a dental visit reported by pregnant women at a Brazilian public school of dentistry. Cad Saúde Colet. 2025;33(3):e33030020. https://doi.org/10.1590/1414-462X202533030020
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Editor:
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