Beliefs about Oral Health and the Occurrence of Dental Caries in Pregnant Women: Cross-Sectional Study Nested in a Prospective CohortABSTRACT
Objective: To analyze beliefs about oral health in pregnant women and their association with the average number of decayed teeth in these women.
Material and Methods: This is a cross-sectional study nested in a prospective cohort involving 202 pregnant women from a Hospital in Northeast Brazil. Information on oral health beliefs during pregnancy was collected through face-to-face interviews. The number of decayed teeth was assessed by clinical examination (ICDAS-II). Mann-Whitney test was used to estimate the association between beliefs and dental caries (α=5%).
Results: The mean age of pregnant women was 25.6 (±6.0) years. The mean number of decayed teeth was 5.9 (±4.0) and for active decay was 3.5 (±3.6). More than 50% of women believe that pregnant women cannot have teeth extracted (76.82%), receive dental anesthesia (75.56%), or undergo X-rays (64.83%). They also believe pregnant women have caries (70.3%) or gum problems (61.4%) regardless of care, and that babies absorb calcium from mothers’ teeth and bones (50.79%). Pregnant women had an average of 5.9 decayed teeth. Healthy tooth surfaces were predominant (22.8±4.7), while early and advanced carious lesions were infrequent. Although there were no significant differences, the average number of decayed teeth differed most in beliefs like “Pregnant women cannot undergo dental treatment” (3.3±0.6 caries for those who agree vs. 6.8±5.4 for those who disagree; p=0.299), “Pregnant women cannot undergo X-rays” (6.7±4.4 vs. 3.8±2.9; p=0.177), and “It is normal to develop cavities during pregnancy” (4.5±4.9 vs. 6.6±5.4; p=0.157). For all other beliefs, the average number of caries was also similar.
Conclusion: Unfounded beliefs about oral health and dental care during pregnancy persist among pregnant women. The experience of decay during pregnancy proved to be high, regardless of beliefs.
Keywords:
Oral Health; Pregnancy; Dental Caries; Epidemiology.
Introduction
Pregnancy is a period marked by intense physical, physiological, and behavioral changes in a woman's body, including the oral cavity [1]. The most common oral conditions in pregnant women are gingival/periodontal diseases and dental caries [2-6]. Research indicates that immunological and hormonal changes during pregnancy are etiological factors for these pathologies, which can contribute to the impairment of both maternal and fetal health [7,8].
Dental caries is defined as a dysbiosis of the oral microbiota, which is sugar-dependent, involving various cariogenic species that cause damage to dental structures [9]. Interventions and screening for caries prevention during pregnancy should begin in the first or second trimester [2]. Prevention and oral health care during pregnancy are some of the main ways to mitigate the effects of changes occurring in this phase, consequently improving the quality of life of both mother and child [10-12]. However, this is a practice that is still rarely followed among pregnant women [13], especially in low and middle-income countries [14,15]. In many situations, healthcare professionals themselves do not provide adequate informational support to their patients, which can contribute to the dissemination of myths on the subject [14,16,17].
In 2011, the Brazilian Ministry of Health recommended that at least one dental consultation be mandatory during prenatal care through Ordinance 650, 1, as part of the women's and children's health care policy (Rede Cegonha) [18]. In 2019, the Previne Brasil Program included dental consultations as a financing criterion for Primary Health Care under the Brazilian Health System (SUS) [19]. However, the lack of awareness about the importance of oral care during pregnancy and the belief that dental treatments are unsafe for pregnant women may prevent them from seeking care [2,10,14,20,21]. Expectant mothers and their support networks need a better understanding of oral changes during pregnancy [21,22]. Over the past 20 years, studies have aimed to address myths and barriers preventing dental care, highlighting its benefits for both maternal and fetal health [2,13,20,21,23-25].
Dental guidance during pregnancy can expand the practice of oral care for the baby after birth and for other family members [17], as women historically assume the role of family caregivers [22,24]. In the long term, this can contribute to improving the dental landscape of the population. However, there are no studies registered on this topic in the pregnant population of Maranhão. Therefore, the intention is to study beliefs about oral health during pregnancy in a group of women from São Luís, MA, and their association with the number of decayed teeth in these women.
Material and Methods
Study Design and Ethical Clearance
This study is a nested cross-sectional analysis within a prospective cohort of pregnant women in São Luís (MA). Entitled "Effects of biochemical, endocrine, and behavioral changes during pregnancy on the incidence of dental caries - GestAÇÃO," the primary aim was to assess the impact of gestational changes on the risk of dental caries development in these women. Evaluations were conducted at three intervals: during the first (T1) and third (T2) trimesters of pregnancy, as well as postpartum (T3). For this investigation, data from T1 were used. The research, approved by the Research Ethics Committee of the University Hospital of the Federal University of Maranhão (protocol 004417/2010-20, February 18, 2011), used a convenience sample due to the lack of reliable records. Pregnant women were recruited during prenatal consultations at the University Hospital of the Federal University of Maranhão, Maternal and Child Unit (HUUMI/UFMA) in São Luís, invited to participate, and followed until postpartum. Refusals and exclusions were recorded.
Data Collection
Data collection was conducted between July 2011 and June 2013. We screened 539 pregnant women at baseline, of whom 262 were in the first trimester of pregnancy and 277 were in the second or third trimester. Among the women in the first trimester, 208 answered the myths questionnaire, while 54 refused. Of those who responded, 115 underwent a dental examination, and 93 did not (Figure 1). Only women who signed informed consent were included. Women with severe endocrine-metabolic, renal, hepatic, or cardiocirculatory conditions, high-risk pregnancies were excluded. Gestational age was determined by first-trimester ultrasound, last menstrual period, or clinical estimation.
The dependent variable was the occurrence of dental caries in pregnant women, assessed using the ICDAS II index (International Caries Detection and Assessment System II) [26], which identifies six stages of the carious process, from initial enamel changes to severe cavitations. Each tooth surface was evaluated individually, with codes assigned to characterize the surface and assess the lesion, considering cavitation, anatomy (crown/root), topography (pits and fissures/smooth surfaces), and lesion status (active/inactive). Missing teeth were classified as extracted due to caries, absent for other reasons, or unerupted. For analysis, the number of teeth with caries lesions (cavitated and/or active white spots) per pregnant woman was considered. Examinations were conducted preferably during the first prenatal visit (up to 16 weeks of gestation), where pregnant women underwent medical and dental evaluations, received guidance on hygiene and dental care, and had their dental status recorded. Examinations were performed under artificial light, with teeth dried using air jets, patients seated in dental chairs, and sterilized mirrors, with findings documented on specific forms.
The following beliefs related to oral health and dental care during pregnancy were collected through face-to-face interviews using a structured questionnaire: 1. It is normal to develop cavities during pregnancy; 2. It is normal to have gum problems during pregnancy; 3. It is not possible to prevent cavities during pregnancy; 4. It is not possible to prevent gum diseases during pregnancy; 5. Having more children leads to more cavities during pregnancy; 6. Having more children leads to more gum problems during pregnancy; 7. Regardless of care, some pregnant women have more cavities than others; 8. Regardless of care, some pregnant women have more gum problems than others; 9. One tooth is lost with each pregnancy; 10. The baby absorbs calcium from the mother's teeth and bones; 11. Pregnant women cannot undergo dental treatment during pregnancy; 12. Pregnant women cannot receive dental anesthesia; 13. Pregnant women cannot have teeth extracted; 14. Pregnant women cannot use fluoride during pregnancy; and 15. Pregnant women should not undergo dental X-ray examinations. Variables characterizing the pregnant women and their pregnancies, as well as sociodemographic data, were included.
Data Analysis
Data was processed by a computer operator, coded daily by the interviewer, and verified by the field supervisor. Forms with errors or doubts were returned for correction. Inconsistencies and duplicate entries were checked and corrected. The absolute and percentage frequencies of each variable were calculated, as well as the 95% confidence intervals. The Shapiro-Wilk test assessed the normality of the data distribution. The comparison of means and medians of decayed teeth among pregnant women, according to their belief in oral health myths, was conducted using the Mann-Whitney test. A significance level of 5% was adopted to reject null hypotheses. The analyses were conducted using Stata software, version 14.0.
Results
The present study evaluated 208 pregnant women, with a mean age of 26.3 (±6.2) years, ranging from 14 to 43 years of age (Table 1).
The majority of pregnant women belonged to economic classes C and D-E (64.4%), with a low frequency of prenatal dental visits (mean of 0.2 ± 0.7) and relatively high Visible Plaque Index (VPI) values (14.4% ± 14.0). Furthermore, a significant percentage reported poor oral health conditions, with 39.9% describing their health as "poor" and 6.3% as "very poor" (Table 2).
The mean number of decayed teeth per pregnant woman was 5.9 (±3.97), with a median of 4.0 (±5.0). The mean for active caries was 3.5 (±3.60), with a median of 2.0 (±5.0). For inactive caries, the mean was 1.94 (±2.49), with a median of 1.00 (±3.0). The analysis of the caries index (Table 3), according to the ICDAS-II criteria, indicates that healthy tooth surfaces were predominant (22.8 ± 4.7). However, early caries lesions, characterized by the first visual changes in enamel, such as opacity or discoloration (0.3 ± 0.8); enamel cavities with visible dentine (0.4 ± 0.8); and extensive caries affecting more than half of the tooth surface with visible dentine (0.5 ± 1.1) were infrequent. Advanced lesions, including underlying dark shadows from dentine (0.8 ± 1.7), localized enamel breakdown without dentinal involvement (1.2 ± 1.9), and distinct visual changes in enamel visible when wet and dry (1.9 ± 2.3), were observed at a slightly higher frequency.
The most common beliefs among pregnant women were that dental extractions (76.82%) and anesthetics (75.56%) were contraindicated during pregnancy. Additionally, 70.3% believed that the development of cavities was not related to hygiene care, and 71.61% thought that some women have inherently stronger teeth. On the other hand, less frequent beliefs included that "one tooth is lost with each pregnancy" (5.56%), that it is not possible to prevent cavities during pregnancy (6.19%), and that pregnant women cannot use fluoride during pregnancy (7.05%) (Table 4). No differences were found in the frequencies of beliefs regarding oral health and dental treatment between pregnant women with and without dental caries lesions (Table 5).
Average number of teeth with caries experience (± SD) and medians (± Interquartile Ranges) according to beliefs in myths related to oral health during pregnancy.
Discussion
The pregnant women evaluated in this study demonstrated inadequate knowledge regarding oral health and dental treatment during pregnancy. Many persistent beliefs exist regarding the potential harm that dental treatment could cause to pregnant women and their fetuses. However, these beliefs do not seem to influence the experience of dental caries in these pregnant women. The mean number of decayed teeth was 5.9, which is similar to findings from another study [27]. The most frequent beliefs in this study population were: pregnant women cannot receive dental anesthesia (75.56%); they cannot have teeth extracted (76.82%); regardless of care, some pregnant women will have more caries (70.30%) and periodontal disease (PD) than others (61.40%); and pregnant women cannot undergo dental X-ray examination (64.83%).
One cross-sectional study conducted in Saudi Arabia by Salam et al. [28] identified that 79% of 443 participants believed that "the fetus obtains calcium from the teeth and bones of the pregnant woman," while 50.79% of the population in the present study held this belief. Jain et al. [24] observed that 24.5% of the sample believed that local anesthesia could affect the developing baby's organs and 21.8% believed that dental extraction could cause miscarriage. It was noted that women who believed in such myths were more likely to have serious oral health problems during pregnancy. Education was described as a significant negative predictor of myth prevalence.
Despite a high prevalence of the belief that pregnancy contraindicates dental anesthesia and X-rays [10], studies show that standard oral local anesthesia is safe throughout pregnancy, with 2% lidocaine and 1:200,000 epinephrine considered to be the best anesthetic option for pregnant women due to the balance between safety and efficacy. Patients with pre-existing medical conditions, such as eclampsia, hypertension, hypotension, and gestational diabetes should receive epinephrine anesthesia with caution and dose control [29]. Additionally, if performed correctly, the amount of ionizing radiation produced during dental radiographic procedures is low and is unable to reach the teratogenic threshold, making it unlikely to cause congenital defects in the fetus. Dental radiography, if necessary, is safe at any stage of pregnancy as long as appropriate safety equipment is used [30].
Although the majority of this sample agreed that practicing basic hygiene care is a satisfactory method to prevent the progression of dental caries, many attributed its development to intrinsic factors such as host resistance. This is justified by the belief that some women naturally have stronger teeth and better oral health than others, so that caries would affect some women while sparing others. Nevertheless, some pregnant women did not report an association between pregnancy and greater tooth loss. Oziegbe and Schepartz [31] found a positive relationship between parity and tooth loss, with women having five or more children experiencing greater tooth loss; however, they did not justify this association. Morelli et al. [32] also observed that having more children was associated with more caries and tooth loss. This finding was not due to the gestational period, but rather to a low level of education, poor oral hygiene, and a lack of dental care throughout life. They indicated that social and behavioral factors are more relevant in the occurrence of oral diseases than any biological effect related to motherhood. It was also observed that having children at a younger age was linked to beliefs and behaviors that were detrimental to ones health, which increases the risk of dental diseases and their management.
Due to normal physiological changes, pregnancy is a period of particular vulnerability in terms of oral health [2]. Pregnant women require more knowledge about the many changes that occur in the oral cavity during pregnancy to prevent and treat oral health problems in a timely manner [33,34]. Maybury et al. [35], studying low-income pregnant women in the United States, found that 53% of the participants reported having consulted a dentist during pregnancy. However, they lacked adequate knowledge on how to prevent caries and did not practice behaviors to prevent this disease, indicating deficiencies in oral hygiene guidance. Brega et al. [36] also associated limitations in oral health guidance and knowledge among parents with these types of beliefs, resulting in children with poorer oral health indices, and recommended interventions in oral health education for families. The inclusion of oral health education during prenatal care can enhance the understanding of the relevance of oral health in pregnancy, resulting in benefits for both maternal and child oral health, especially in vulnerable populations [5,15,20,25,28,35,37-40]. However, healthcare models in most countries are based on a biomedical, curative, and mutilating approach; promotion and prevention measures have not been prioritized.
Historically in Brazil, treatment offered in the public sector was limited almost exclusively to pain relief through extractions, insufficient in terms of preventive and early treatment measures, which may have interfered over time in adherence to dental consultations during pregnancy. Referrals and guidance from other professionals involved in prenatal care increase awareness and, consequently, the frequency of dental consultations during pregnancy [2,6,17,39-43]. Therefore, it is necessary to encourage the participation of these professionals in the promotion and maintenance of perinatal oral health. Language should be clear to demystify misinformation about oral health and pregnancy [5,6,24,25,39,42-44].
Low adherence to prenatal dental care is still observed, especially due to socioeconomic, cultural, and educational factors. Despite advancements in scientific and technological knowledge in dentistry, aimed at enhancing human quality of life, the oral health of pregnant women has been neglected. It is crucial to implement educational measures signaling the need for dental care during prenatal visits and its safety, thus contributing to the well-being of both mother and baby [15,39,42]. Pregnancy is a phase where women are more receptive to information that can improve the baby's quality of life, making it an opportune moment to raise awareness and debunk misconceptions, leading to the acquisition of new behaviors extended to the family context, including oral health [20].
However, some dental professionals lack knowledge about the safety of dental treatment during pregnancy [45], while others feel unprepared to assist these women, particularly regarding the use of radiographs, prescriptions, and the ideal timing during pregnancy for treatments [46]. Knowledge gaps regarding oral health care during pregnancy affect the attitudes and behaviors of obstetricians, gynecologists, and dentists [45,47]. Professionals working in prenatal care recognize the importance of maintaining good oral health during pregnancy, yet their knowledge and practices regarding dental management during pregnancy remain deficient [48,49]. There is a need for professional qualification through ongoing education to establish competencies and behaviors for oral health prevention and promotion, in turn enhancing pregnant women's perceptions of oral health in a humanized manner, enabling comprehensive care in line with the principles and guidelines of the Unified Health System (SUS) [5,22,39,44,47,50].
This study had some limitations. Due to its convenience sample, the results may be biased, as the participants belonged to a specific group of pregnant women who received medical care at a university hospital, making it difficult to generalize the findings to pregnant women in general. It is possible that myths are even more prevalent in the general population. Additionally, causality cannot be inferred from the results of this study, only associations between variables. In addition, the data were collected in a municipality in the Northeast of Brazil, at the beginning of the implementation of the “Rede Cegonha”. Therefore, generalizations to other locations should be made with caution, and new assessments of beliefs should be made with more current data for the purposes of evaluating the potential effects of public policies on misunderstandings related to oral health during pregnancy. On the other hand, strengths include the assessment of the caries index using the ICDAS II, allowing for a more detailed evaluation of lesions, considering disease progression and activity. Moreover, the study involved a population located in a state with some of the worst socioeconomic indicators in the country, which may contribute to understanding and reducing health inequities nationally.
Conclusion
Beliefs about oral health and dental care during pregnancy are high. However, these beliefs were not determining factors for the occurrence of caries among women. Other factors, including access barriers and behavioral issues, may be more relevant determinants for the occurrence of caries in pregnant women.
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Financial Support
The Foundation for Research Support and Scientific and Technological Development of Maranhão (FAPEMA) (Grant no. PP-01250/09, Decree 08/2009, and APEC, Decree 011) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
Acknowledgments
The authors express their gratitude to the Mother-Infant Unit of the Federal University of Maranhão Hospital, the students Ana Basília dos Reis Oliveira, Danielle Gomes da Silva, Karen Lorena Teixeira Barbosa, Marcela Regina Araújo de Jesus, and Thalita Santana Conceição for assisting with data collection, and all the pregnant women who volunteered for this research.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
-
Academic Editor:
Wilton Wilney Nascimento Padilha
Publication Dates
-
Publication in this collection
08 Dec 2025 -
Date of issue
2026
History
-
Received
19 June 2024 -
Reviewed
23 Dec 2024 -
Accepted
26 Feb 2025
