*Angelika Kobylińska1, Nicole Sochacki-Wójcicka2, Dariusz Gozdowski3, Dorota Bomba-Opoń2, Mirosław Wielgoś2, Dorota Olczak-Kowalczyk1
Dental care in pregnancy in Poland. A postnatal questionnaire study
Opieka stomatologiczna w czasie ciąży w Polsce. Postnatalne badanie ankietowe
1Department of Pediatric Dentistry, Medical University of Warsaw
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
21st Chair and Department of Obstetrics and Gynecology, Medical University of Warsaw
Head of Chair and Department: Professor Mirosław Wielgoś, MD, PhD
3Department of Experimental Design and Bioinformatics, Faculty of Agriculture and Biology, Warsaw University of Life Sciences
Head of Department: Krzysztof Pawłowski, PhD
Wstęp. Ciąża jest okresem zwiększonego ryzyka występowania chorób w obrębie jamy ustnej, mających wpływ na przebieg ciąży i zdrowie dziecka. Kobiety ciężarne powinny dbać o zachowanie zdrowia uzębienia i przyzębia poprzez intensyfikację działań profilaktycznych i leczniczych.
Cel pracy. Ocena powodów zgłoszenia się kobiet w ciąży do dentysty i rodzaju udzielanych im świadczeń stomatologicznych z uwzględnieniem wpływu czynników socjodemograficznych, w tym miejsca zamieszkania, oraz rodzaju placówki medycznej.
Materiał i metody. Przeprowadzono elektroniczne badanie ankietowe kobiet do 5 lat po porodzie (zgoda Komisji Bioetycznej WUM). Pytania dotyczyły danych socjodemograficznych, przebiegu ciąży i porodu, wizyt w gabinecie stomatologicznym w czasie ciąży, rodzaju wykonywanych procedur oraz placówek, w których je wykonywano. Do analizy statystycznej zastosowano test chi-kwadrat, współczynnik korelacji rang Spearmana. Przyjęto poziom istotności p ≤ 0,05.
Wyniki. Analizowano 3439 ankiety kobiet w wieku 13,1-45,4 roku, wypełnione od 2 tygodni do 5 lat po porodzie, w tym 40,9% mieszkanek dużych miast, 74,8% z wykształceniem ponadmaturalnym, 41% w dobrej sytuacji ekonomicznej. Wizytę w gabinecie stomatologicznym w czasie ciąży, częściej prywatnym, odbyło 62,3% kobiet. Najczęściej przyczyną wizyty była potrzeba lecznicza. Zgłaszalność i powody wizyty zależały od: wieku, statusu ekonomicznego, aktywności zawodowej, miejsca zamieszkania, poziomu wykształcenia, opieki stomatologiczna przed ciążą i zaleceń ginekologa. Świadczeń stomatologicznych udzielono 63% kobietom, które zgłosiły się do dentysty. Najczęściej leczono próchnicę zębów (53,7%), wykonywano skaling (13,6%) i leczenie endodontyczne (9,5%), najrzadziej zdjęcia radiologiczne (2,5%). Z wyjątkiem ekstrakcji i leczenia endodontycznego wszystkie procedury wykonywano częściej w gabinetach prywatnych niż posiadających umowę z NFZ.
Wnioski. Zgłaszalność ciężarnych do dentysty, modyfikowana czynnikami socjodemograficznymi, jest związana z potrzebami leczenia stomatologicznego i skierowaniem od ginekologa. Zbyt rzadkie wykonywanie procedur profilaktycznych i unikanie diagnostyki radiologicznej w czasie ciąży wskazują na konieczność rozpowszechnienia wiedzy dotyczącej zasad opieki stomatologicznej w czasie ciąży wśród przyszłych matek i lekarzy dentystów.
Introduction. Pregnancy is a period of increased risk of oral diseases that affect both the course of pregnancy and child’s health. Pregnant women should pay particular attention to dental and periodontal health by implementing intensified preventive and therapeutic activities.
Aim. An evaluation of the reasons for dental visits and the types of dental services among pregnant women, with reference to the impact of the socio-demographic factors such as place of residence and the type of medical facility.
Material and methods. An electronic survey was conducted among women up to 5 years postpartum (consent of the bioethical committee of Medical University of Warsaw). Socio-demographic data as well as information on the course of pregnancy, dental appointments during pregnancy, the type of dental procedures and the type of attended healthcare facilities were collected. The chi-square test and Spearman’s rank correlation coefficient were used for statistical analysis. A p ≤ 0.05 was accepted as statistically significant.
Results. A total of 3,439 questionnaires completed 2 weeks to 5 years after delivery by women aged between 13.1 – 45.4 years, including 40.9% of urban residents, 74.8% of women with higher education, and 41% of women in good economic situation, were analysed. A total of 62.3% of respondents reported attending dental appointments (usually private) during pregnancy. The need for treatment was the most common reason for the visit. The attendance and the reasons for dental visits depended on the age, economic status, professional activity, place of residence, level of education, dental care before pregnancy and gynaecologist’s recommendations. A total of 63% of women who reported to the dentist received dental care. The most common procedures included dental caries treatment (53.7%), dental scaling (13.6%) and endodontic treatment (9.5%). Dental radiography was less common (2.5%). Except for tooth extraction and endodontic treatment, all procedures were usually performed in private practices rather than those having a contract with the Polish National Health Fund.
Conclusions. Dental attendance among pregnant women, which is modified by socio-demographic factors, is associated with the need for dental treatment and a referral from a gynecologist. The limited use of preventive procedures and avoiding diagnostic radiology during pregnancy indicate the need to educate both future mothers and dentists on dental care in pregnancy.
Changes occurring in the woman’s body during pregnancy, especially those having effects on the endocrine and immune system, salivary quantity and quality, as well as gastrointestinal disorders, may have negative effects on the quality of life, the overall health status of the woman, the course of pregnancy and child’s health. A relationship was demonstrated between periodontitis in a pregnant woman and low birth weight and premature delivery as well as between high cariogenic bacterial count and primary dental caries in the child (1-5). Dental care in pregnancy should be enhanced and comprehensive (the concept of a whole mouth therapy), i.e. it should include intensive prevention of oral diseases, treatment of dental caries and its complications, periodontal diseases and oral mucosa (6-9).
In Poland, pregnant and puerperal women are entitled to a greater range of therapeutic and preventive procedures reimbursed by the National Health Fund, which allows for regular check-up visits at 3-month intervals, necessary preventive and therapeutic procedures, as well as individual health education. The Ordinance of the Minister of Health of 23 September 2010 (which was replaced with the ordinance of 20 September 2012) additionally introduced standards for the management in pregnancy and puerperium, which emphasise the need for dental care and the importance of maintaining oral health during pregnancy. These include healthy lifestyle promotion, including oral health (until 10 weeks pregnant), oral health monitoring (at pregnancy weeks 11-14, 21-26, and 33-37) as a part of prevention provided by a doctor or midwife as well as dental check-up visits, including oral health assessment, determination of preventive and therapeutic needs and setting a treatment plan by the 10th week of pregnancy. Promotional and educational activities targeting oral health are also implemented, among other things, during parentcraft classes, by regional authorities, scientific associations and the Ministry of Health.
The aim of the study was to assess the reasons for dental appointments and the types of dental services among pregnant women, considering socio-demographic factors, such as the place of residence and the type of medical facility.
Material and methods
This was an anonymous, electronic survey including women whose pregnancy was terminated within 5 years before the date of completing the questionnaire. The study was conducted in April and May 2017. The questionnaire included questions regarding age at pregnancy termination and at questionnaire completion, the place of residence (large/small urban or rural region), level of education, family financial situation, professional activity, the course of pregnancy and delivery (comorbidities, date and type of delivery), child’s birth weight, the use of dental care in pregnancy, reasons for dental appointments, as well as preventive and therapeutic procedures performed. Incorrect or incomplete questionnaires were excluded from the analysis. The questionnaire regarding the period of pregnancy was approved by the Bioethics Committee of the Medical University of Warsaw (approval no. KB/93/2015 dated May 5, 2015).
The obtained data were analysed statistically with the chi-square test and a correlation analysis using the Spearman rank correlation coefficient. Statistica 12 (Statsoft) was used in the analysis and a p ≤ 0.05 was accepted as statistically significant.
A total of 3,439 of 3,455 completed questionnaires were included in the analysis. The socio-demographic characteristics of respondents are shown in table 1. The questionnaires were completed 2 weeks to 5 years after termination of pregnancy (on average after 1.78 ± 1.44 years). Maternal age ranged between 13 and 43 years (mean age 26.79 ± 4.06 years) at delivery and between 13.1 and 45.4 years (mean age 28.84 ± 4.04 years) at the time of questionnaire completion. A total of 2,524 (73.4%) women were primiparas. General disorders were experienced during pregnancy by 1,019 (29.6%) respondents. The most commonly reported anomalies included the risk of premature delivery (16.1%), thyroid disease (18.17%), hypertension (8.5%) and diabetes (7.7%). Preeclampsia (2.0%) and gestational cholestasis (1.7%) were less common. Full-term delivery was reported by 92.9% of women, with the dominance of vaginal delivery (61.8%). Emergency and elective caesarean section was performed in 22.1 and 16.1% of respondents, respectively. A total of 170 (4.9%) children had birth weight below 2500 g (mean birth weight 3,389 ± 532 g).
Tab. 1. Socio-demographic characteristics of respondents
|Total number of respondents||3439 (100%)|
|Age at delivery (years)||≤ 20||200 (5.8%)|
|> 30||584 (17%)|
|Age at questionnaire completion (years)||≤ 20||62 (1.8%)|
|> 30||1124 (32.7%)|
|Place of residence ||rural area||911 (26.5%)|
|small town||1122 (32.6%)|
|large city||1406 (40.9%)|
|Education||primary/middle/basic vocational||117 (3.4%)|
|incomplete higher/higher||2574 (74.8%)|
|Professional activity during pregnancy||2750 (80.0%)|
|Financial situation ||bad||316 (9.2%)|
|good or very good||1410 (41%)|
|The use of dental care before pregnancy ||when needed||1625 (47.3%)|
|once a year||1139 (33.1%)|
|more than once a year||607 (17.7%)|
A total of 2,142 (62.3%) respondents used dental care during pregnancy, with lower attendance among women from rural (58.6%) and smaller urban (60.6%) vs. larger urban (66.0%) areas. In addition to the place of residence (r = 0.047), the use of dental care was also associated with the financial situation (Spearman’s rank correlation coefficient [r] = 0.076), level of education (r = 0.090), professional activity during pregnancy (r = 0.068), referral from a gynaecologist (r = 0.287), as well as the use of dental care before pregnancy (r = 0.249). Factors associated with the general maternal health condition, pregnancy and delivery had no effects on dental attendance.
The majority of appointments took place in the middle (47.9%) and the first (37.9%) trimester. A total of 87 women did not remember the trimester of their first dental visit. Among women who attended dental appointments, 529 (24.7%) were referred by their gynaecologists, including 255 (48.2%) women required to present a written feedback on their oral health status. The reasons for reporting to the dentist during pregnancy and the types of procedures performed are shown in table 2 and figure 1.
Tab. 2. Reasons for dental appointments and types of performed procedures among pregnant women depending on the place of residence
| ||Rural area|
|Dental appointment ||534 (100)||680 (100)||928 (100)||–||2142 (100)|
|Reason for dental appointment|
|referral from a gynaecologist ||108 (20.2)||128 (18.8)||175 (18.9)||0.722||411 (19.2)|
|– need for prevention ||141 (26.4)||215 (31.6)||301 (32.4)||0.002*||657 (30.7)|
|– caries prevention ||44 (8.2)||57 (8.4)||108 (11.6)||0.005*||209 (9.8)|
|tartar removal||119 (22.3)||178 (26.2)||253 (27.3)||0.007*||550 (25.7)|
|– need for treatment ||403 (75.5)||528 (77.6)||642 (69.2)||0.445||1573 (73.4)|
|– gingival bleeding||62 (11.6)||98 (14.4)||102 (11.0)||0.218||262 (12.2)|
|– caries treatment ||335 (62.7)||400 (58.8)||501 (54.0)||0.830||1236 (57.7)|
|– dental pain ||151 (28.3)||192 (28.2)||240 (25.9)||0.939||583 (27.2)|
|– tooth extraction ||32 (6.0)||36 (5.3)||46 (5.0)||0.924||114 (5.3)|
|Types of dental procedures|
|dental caries treatment||294 (55.1)||375 (55.1)||481 (51.8)||0.627||1150 (53.7)|
|scaling ||47 (8.8)||103 (15.1)||142 (15.3)||< 0.001*||292 (13.6)|
|endodontic treatment||60 (11.2)||64 (9.4)||80 (8.6)||0.622||204 (9.5)|
|tooth extraction||30 (5.6)||35 (5.1)||44 (4.7)||0.970||109 (5.1)|
|local anaesthesia||160 (30.0)||205 (30.1)||275 (29.6)||0.454||640 (29.9)|
|fluoride varnishing||28 (5.2)||42 (6.2)||71 (7.7)||0.049*||141 (6.6)|
|radiography ||18 (3.4)||16 (2.4)||20 (2.2)||0.517||54 (2.5)|
*statistical significance p ≤ 0.05
Fig. 1. The frequency of preventive and therapeutic dental procedures throughout pregnancy trimesters
Urban respondents statistically significantly more often attended dental visits for the prevention of oral diseases than their rural counterparts. The impact of other socio-demographic factors is shown in table 3. Significant correlations were also reported between the risk of preterm delivery and reporting to dental offices due to gingival bleeding (r = 0.068) and dental pain (r = 0.044).
Tab. 3. Spearman’s correlation coefficients illustrating the relationships between socio-demographic factors and the reasons for dental visits as well as the types of procedures among pregnant women
|Socio-demographic factors||Reasons for dental visits||Procedure performed|
|scaling||gingival bleeding||caries |
|dental pain||tooth extraction||scaling||tooth extraction|
|professional activity ||0.083*||0.091*||-0.036||-0.030||-0.123*||-0.054||0.120*||-0.060*|
|financial situation ||0.006||0.027||0.004||0.026||-0.070*||-0.030||0.049||-0.032|
Preventive or therapeutic procedures were performed in 63% of women who reported to dental offices. Except for scaling, the frequency of these procedures was not significantly correlated with the place of residence (tab. 2). This procedure was also positively correlated with the age, professional activity during pregnancy and the level of education. The same factors were negatively correlated with tooth extraction (tab. 3). No relationship was found between implementing these procedures and factors associated with the general maternal health condition, pregnancy or delivery.
Among women attending dental offices, 65.9% used private dental care, 18.0% attended both private offices and those having contract with the National Health Fund, and 16.1% reported to the latter one only (tab. 4). The frequency of preventive and therapeutic procedures depended on the type of medical facility (r = 0.051 for private practice; r = -0.051 for dental offices having a contract with the National Health Fund). Endodontic treatment and tooth extractions were performed with similar frequency in all types of healthcare facilities. Other dental procedures were more often performed in private dental offices rather than those having a contract with the National Health Fund.
Tab. 4. Types of healthcare facilities attended by pregnant women and types of dental procedures performed
| ||Private office||Offices having a contract with the National Health Fund||Private office having a contract with the National Health Fund||p|
private vs. National Health Fund office
| ||n (%)|
|Dental appointment ||1413 (100)||343 (100)||386 (100)|| |
|Dental procedures performed:|
|– preventive and/or therapeutic procedures (total)||909 (64.3)||188 (54.8)||252 (65.3)||0.001*|
|– treatment of dental caries||776 (54.9)||159 (46.4)||215 (55.7)||0.004*|
|– scaling ||208 (14.7)||30 (8.7)||54 (14.0)||0.004*|
|– endodontic treatment||132 (9.3)||25 (7.3)||47 (12.2)||0.232|
|– tooth extraction||64 (4.5)||18 (5.2)||27 (7.0)||0.572|
|– local anaesthesia||451 (31.9)||75 (21.9)||114 (29.5)||< 0.001*|
|– fluoride varnishing||108 (7.6)||13 (3.8)||20 (5.2)||0.012*|
|– X-ray ||43 (3.0)||2 (0.6)||9 (2.3)||0.010*|
A dental check-up should be considered a crucial element of medical care in pregnant women. However, our study showed that one in four women do not attend dental appointments. Although the retrospective nature of the study and the time that has elapsed could have influenced the results, they correspond with the findings presented in the report from a nationwide survey assessing the incidence of alcohol, tobacco and psychoactive substance dependence in pregnant women. Among 2,749 respondents, only 51.2% women reported for a dental visit immediately after delivery (10).
A similar, low attendance among pregnant women (12.6-58%) was also observed in other regions of the world despite the high awareness of women on the importance of oral health check-ups during pregnancy (6, 10-17). Researchers attempting to define barriers in the access to dental care point to the importance of cultural, ethnic and socio-demographic factors, emphasising the low level of education, low economic status and the age of women (11, 13, 16, 17). Our results confirmed the effects of socio-demographic factors on the use of dental care among pregnant women. However, correlation coefficients for such factors as age, place of residence or economic status were significantly lower compared to a referral from a gynaecologist or regular dental visits before pregnancy. According to U.S. research, the risk factors for the lack of dental care include ethnic factors, age over 36 years, an annual income of less than $30,000, secondary or lower education and the lack of private insurance (12). The lack of regular dental care before pregnancy was considered the most common risk factor. Similar research in Canada confirmed the importance of the above listed factors and, at the same time, pointed to the great role of access to dental health (13). In contrast to the cited studies, the low Spearman’s correlation coefficient between the economic status and dental visits in our study indicates minor importance of this factor, which is probably due to the availability of free dental care in Poland. We also noticed a positive impact of women’s age, which corresponds with the findings of other authors (13, 16).
There was also a correlation between socio-demographic factors and the reasons for dental visits as well as the types of procedures among pregnant women. Urban residence, high level of education, higher age and professional activity were positively correlated with the willingness to perform scaling and negatively correlated with appointments due to dental pain or tooth extraction. In contrast to the U.S. research, we did not confirm the relationship between preventive dental visits and high incomes (16). Also, prevention was not the main reason for dental appointments. The need for caries treatment was the most common reason for a dental visit in our study. Only 12.2% of women reported to the dentist due to gingival bleeding. Similar reporting rates for gingival bleeding were observed by Thomas et al. The authors also observed relatively high reporting rates due to the need for caries treatment (32%) and a two-fold increase in the proportion of women requiring tooth extraction (11%) compared to our findings (15). In contrast to these observations, many authors consider gingival bleeding to be the main reason for dental appointments among pregnant women (12, 14, 18).
Studies devoted to the types of dental procedures in pregnant women are limited. Caries treatment and scaling were the most common procedures among our respondents. Unfortunately, fluoride varnish application was rare. Prophylactic treatments were more often performed in private practices, with similar rates for rural and urban residents. Importantly, no correlation was observed between tooth extraction and parameters for the general condition of a pregnant woman, the course of pregnancy or gestational age at delivery. At the same time, a relationship was found between the risk of preterm birth and reporting to the dentist due to gingival bleeding and dental pain. Although the study design, which was based on a self-assessment of oral health among women, does not allow for a conclusion that oral inflammation may be one of risk factors for preterm birth, the findings point to such a relationship. A research conducted in a group of 870 pregnant women with gingival inflammation showed that periodontal treatment, including scaling and oral rinsing with 0.12% chlorhexidine mouthwash, combined with daily oral hygiene significantly reduced the risk of premature birth and low birth weight (4).
However, the implementation of dental treatment, relatively high rates of endodontic treatment and tooth extractions do not correspond with the rates of diagnostic radiology. This may be due to the concerns of both dentists and future mothers about the potential foetal exposure to X-rays. Epidemiological research in the UK in a group of 7,375 mothers did not confirm the relationship between dental radiography in pregnancy and premature birth or low birth weight (19). Other researchers demonstrated that the use of significantly higher radiation doses in pregnant women compared to doses in dental radiography does not induce brain tumors (20). It should be noted that ionizing radiation at a dose < 0.05-0.1 Gy or 5 R does not increase the risk of developmental disorders or premature birth. Therefore, there are no contraindications to diagnostic radiology in pregnancy if it is necessary for dental treatment (7).
The increased reporting for the first dental visit in the first and middle trimester is a positive phenomenon. It should be also noted that most procedures were performed in the middle trimester, which is in line with the current guidelines for dental care in pregnant women.
The use of dental care among pregnant women is still insufficient. It is mainly associated with the need for oral disease treatment and modified by socio-demographic factors. A referral from a gynaecologist is a strong predictor of a pregnant woman’s visit to the dentist; therefore it seems advisable to raise doctors’ awareness on their significant impact on the oral health of their patients. Insufficient preventive procedures and avoiding diagnostic radiology during pregnancy point to the need for educating future mothers and dentists on dental care in pregnancy.
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