BMC Pregnancy and Childbirth BioMed Central

Research article Open Access

Oral and dental health care practices in pregnant women in
Australia: a postnatal survey
Natalie J Thomas*, Philippa F Middleton and Caroline A Crowther

Address: Discipline of Obstetrics and Gynaecology, The University of Adelaide, SA, Australia
Email: Natalie J Thomas* - [email protected]; Philippa F Middleton - [email protected];
Caroline A Crowther - [email protected]
* Corresponding author

Published: 21 April 2008 Received: 19 September 2007

Accepted: 21 April 2008
BMC Pregnancy and Childbirth 2008, 8:13 doi:10.1186/1471-2393-8-13
This article is available from: http://www.biomedcentral.com/1471-2393/8/13
© 2008 Thomas et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: The aims of this study were to assess women's knowledge and experiences of dental
health in pregnancy and to examine the self-care practices of pregnant women in relation to their
oral health.
Methods: Women in the postnatal ward at the Women's and Children's Hospital, Adelaide,
completed a questionnaire to assess their knowledge, attitudes and practices to periodontal health.
Pregnancy outcomes were collected from their medical records. Results were analysed by chi-
square tests, using SAS.
Results: Of the 445 women enrolled in the survey, 388 (87 per cent) completed the questionnaire.
Most women demonstrated reasonable knowledge about dental health. There was a significant
association between dental knowledge and practices with both education and socio-economic
status. Women with less education and lower socio-economic status were more likely to be at
higher risk of poor periodontal health compared with women with greater levels of education and
higher socioeconomic status.
Conclusion: Most women were knowledgeable about oral and dental health. Lack of knowledge
about oral and dental health was strongly linked to women with lower education achievements and
lower socioeconomic backgrounds. Whether more intensive dental health education in pregnancy
can lead to improved oral health and ultimately improved pregnancy outcomes requires further
study.

Background to achieve an optimal level of dental health throughout

The most important objective of dental health care in their pregnancy.
pregnancy is to establish a healthy environment through
adequate plaque control by brushing, flossing and profes- Periodontal disease may present as gingivitis or periodon-
sional prophylaxis including scaling, root planing and titis. Gingivitis is an inflammation of the soft tissues sur-
polishing [1]. Dental treatment can be safely provided at rounding a tooth or gingiva not causing loss of
any time during pregnancy [2] allowing pregnant women periodontal attachment, whereas periodontitis causes
inflammation and destruction of supporting tissues

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around the teeth [2]. Periodontal disease has the potential in relation to awareness of periodontal disease and
to affect pregnancy outcomes. A systematic review of 25 plaque, use of a family dentist, advice about dental health
studies (13 case-control, 9 cohort and 3 controlled trials) requirements during pregnancy, history of bleeding gums
has demonstrated that periodontal disease may be associ- and what, if any, actions were sought to treat perceived
ated with adverse pregnancy outcomes in humans [3]. gingival problems. Relevant clinical information, such as
Although some observational studies have indicated a sig- pregnancy care, parity, ethnicity, age and residential loca-
nificant association of periodontal disease with adverse tion, was sourced from the medical records of the woman
pregnancy outcomes [4,5], others have not [6,7]. and her infant.

Oral tissues are known to be affected by pregnancy with Eligible women were approached on the postnatal ward
the most frequent and greatest changes occurring in the and given a study information pamphlet. Women who
gingival tissue [8]. Pregnant women may be more suscep- gave informed written consent were asked to complete the
tible to periodontal disease since higher concentrations of questionnaire and place it in the reply paid envelope.
oestrogen and progesterone can induce hyperaemia, Women who failed to return the questionnaire within
oedema and bleeding in periodontal tissues [9], increas- three weeks were posted out a reminder letter and another
ing the risk of bacterial infections. The incidence of perio- questionnaire. Women who did not return the question-
dontal disease has been positively correlated with lower naire were telephoned as a reminder.
educational achievement and lower socio-economic sta-
tus [9-11]. Analysis was performed with SAS [15]. Descriptive statis-
tics were reported as well as cross-tabulations by age, par-
Periodontal disease is both preventable and treatable. ity, education and socio-economic status. Inference on the
Controlling plaque by brushing, flossing and professional cross-tabulations was performed, using chi-square tests to
prophylaxis, including scaling and root planing, all help test for general association and Mantel-Haenszel chi-
to achieve good dental health in pregnancy [1]. There is, square tests to test for linear association where appropri-
however, minimal information available on women's ate.
understanding of dental hygiene and whether pregnant
women comply with current oral health strategies. In order to show a significant difference between women
with a tertiary education compared with women without
The aims of this survey were to assess women's knowledge a tertiary education who brushed their teeth at least daily,
and experiences about dental hygiene in pregnancy in a sample size of 374 women was needed. This was calcu-
Australia and assess the self-care practices of pregnant lated estimating a difference of 9% between groups based
women in relation to their oral health. We hypothesised on 95 per cent of mothers who had a tertiary education
socio-economic status and educational qualifications and 86 per cent of mothers who did not have a tertiary
would influence a woman's knowledge and choices about education (p < 0.05; 80% power) would brush their teeth
oral health in pregnancy. at least daily. The sample size was adjusted upward to
allow for a 14 per cent non-completion rate.
Methods
All women who gave birth to a live born infant at the During the enrolment period a total of 505 eligible
Women's and Children's Hospital, Adelaide, over a five women were approached; 445 (88%) consented and 388
month period were eligible for the study. Women who (87%) returned their questionnaire. Although small num-
gave birth to an infant with a major congenital abnormal- bers of responses were missing from some questions, a
ity, had a perinatal death or who needed an interpreter denominator of 388 was used to calculate results (except
were ineligible. The study was approved by the Hospital in the cross-tabulation in Table 1).
Research and Ethics Committee.
Results
A questionnaire was developed to assess women's dental Baseline demographic characteristics
health knowledge, oral health experiences and prefer- Women who returned the survey were more likely to be
ences over the preceding twelve months and provide older (p < 0.05) than non-respondents. Just over half of
information on their educational status. Fifty questions the women enrolled in the study were over the age of 30
were selected from three validated questionnaires; the (n = 219, 56%). The majority of women who completed
National Dental Telephone Interview Survey (NDTIS) the questionnaire were caucasian (344, 89%). About half
[12], Oral Health Impact Profile (OHIP) [13] and The were in their first pregnancy (185, 48%), had some form
World Health Organization's Comparing Oral Health of tertiary education (199, 51%) and lived in a low to mid
Care systems; a second international collaborative study socio-economic index area (216, 56%) (Table 2).
(ICS II) [14]. Additional questions included information

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Table 1: Dental health of women completing the postnatal survey

Perceived dental problems in previous 12 months n (%)

Broken or chipped natural tooth 73 (18.8)

Gums that hurt or bleed 231 (59.5)
Sores on tongue or inside mouth 58 (14.9)
Bad taste in mouth 103 (26.5)
Persistent bad breath 50 (12.9)

Current dental health problems caused often n (%) occasionally n (%) rarely n (%) never n (%) don't know n (%)

Pain/discomfort 47 (12.1) 98 (25.3) 107 (27.6) 120 (30.9) 7 (1.8)

Limitation 15 (3.9) 34 (8.8) 40 (10.3) 292 (75.2) 0
Uncomfortable to eat 39 (10.1) 66 (17.0) 67 (17.3) 210 (54.1) 5 (1.3)
Unsatisfactory diet 11 (2.8) 19 (4.9) 31 (8.0) 314 (80.9) 10 (2.6)
Embarrassment 30 (7.7) 38 (9.8) 31 (8.0) 282 (72.7) 6 (1.6)
Less satisfying life 20 (5.2) 23 (5.9) 27 (7.0) 312 (80.4) 4 (1.0)

Knowledge of dental practices surveyed knew that fluoride, whether in toothpaste (350,
Most women had a good understanding of good oral 90%) or water (310, 80%), helped to prevent tooth decay.
hygiene, with 382 (99%) women agreeing brushing their
teeth would help prevent gum disease. Likewise, most Women with a university education were more likely than
women understood using dental floss (325, 84%) would other women to strongly agree that the use of dental floss
help prevent gum problems. The majority of the women would help prevent gum and tooth problems (p <
0.0001). Women with lower educational levels knew less
about the beneficial effects of fluoride toothpaste (p <
Table 2: Demographics of women who completed the survey
0.01), fluoridated water (p < 0.001) and the ability of flu-
oride to prevent tooth decay without harm (p < 0.01).
Completed survey (388 women) n (%) Women with a university education had better knowledge
of periodontal disease (p < 0.001) and dental plaque (p <
Age (years) 0.03). Women in the high socio-economic index (SEI)
< 20 10 (3) were more likely than other women to strongly agree that
20 – 29 159 (41)
30+ 219 (56)
the use of dental floss would aid in the prevention of gum
Parity problems (p < 0.02).
0 185 (48)
1–3 187 (48) Women above thirty years of age were more likely to
≥4 16 (4) strongly agree that the use of fluoridated water (p < 0.001)
Race helps prevent tooth decay, to know about periodontal dis-
Caucasian 344 (89)
ease (p < 0.04) and to use dental floss more often then
Asian 19 (5)
Aboriginal/TSI 11 (3)
younger women (p < 0.03). Higher parity was associated
Other 14 (4) with greater knowledge of fluoridated water preventing
Education tooth decay (p < 0.02) and fluoride preventing tooth
Not completed 76 (20) decay (p < 0.02).
secondary school
Completed 113 (29) Knowledge of dental disease and gingival health
secondary school
TAFE/diploma 91 (23) Most women had some knowledge of dental disease and
University 108 (28) gingival health with the majority of women surveyed
Socio- agreeing sweet foods could cause tooth decay (326, 84%).
economic Likewise, they were aware that dental problems can be
status
serious (387, 100%) and can cause other health problems
Low SEI 109 (28)
Low-mid SEI 107 (28)
(355, 92%). Although the majority of women knew about
Mid-high SEI 67 (17) dental plaque (366, 94%), 317 (82%) of the women sur-
High SEI 105 (27) veyed did not know about periodontal disease.

TSI = Torres Strait Islanders; SEI = socio-economic index

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Current dental practices SEI women (p < 0.001) and were more likely to use dental
Of the women surveyed, 351 (91%) stated they brushed floss than lower SEI women (p < 0.02) (Table 4).
their teeth one or more times a day with just over half
(222, 57%) indicating they used dental floss weekly or Dental attendance and dental problems in the past 12
more. Just over half (221, 55%) of women said that they months
used mouthwash more than once a month. Tertiary edu- During the previous twelve months 193 (50%) women
cated women were also more likely to brush their teeth surveyed had attended the dentist with 91 (24%) of these
once or more a day and to use dental floss (p < 0.001) women attending only once in this period. One third of
(Table 3). women, 129 (33%), had at least one scaling and cleaning
of their teeth during these dental visits.
Almost two thirds (252, 65%) of the women surveyed
found problems with their teeth, dentures or gums had The majority of women, (231, 60%) stated they had gums
caused some pain and/or discomfort during the previous which hurt and/or bled at some stage during the previous
twelve months. For the majority of women (292, 75%) twelve months and 103 (27%) had a bad taste in their
these problems did not cause any limitations of their mouth. Only 50 (13%) had persistent bad breath and 58
usual activities (Table 1). Just under half of the women (15%) women had sores on their tongue and/or inside
(172, 44%) indicated it was uncomfortable to eat some their mouth. Only 73 (19%) women had a broken or
foods on one or more occasions but this did not cause chipped natural tooth during the previous 12 months
their diet to become unsatisfactory (314, 81%). The (Table 3).
majority thought any problems with their teeth, dentures
or gums during the preceding twelve months had not How women addressed these reported dental problems
caused them any embarrassment (282, 73%) or made varied. Some women intensified their oral hygiene (173,
their life less satisfying (312, 80%) (Table 1). 45%), while others increased the use of oral rinse prod-
ucts (93, 24%) or visited the dentist (47, 12%). However
The majority of women found their general health to be 86 (22%) women chose to take no action.
above average (334, 86%) with 158 (41%) believing it to
be very good. However, more women rated their dental Although 250 (64%) women were advised of dental
health as poor (40, 10%) compared with their general health requirements during pregnancy, only 116 (30%)
health (1, 0.3%). Women who had completed secondary women attended the dentist once or more whilst preg-
school were less likely to have bleeding gums during the nant. Most women were informed about dental health in
preceding 12 months (p < 0.004). High SEI women were pregnancy through conversations with their dentist (165,
more likely to agree fluoride toothpaste would prevent 43%), through reading material (116, 30%) and talking
tooth decay (p < 0.04) and dental problems could be seri- with their midwife or doctor (54, 14%).
ous (p < 0.001). They brushed their teeth more than lower

Table 3: Dental hygiene practices of women by education achieved

EDUCATION never n (%) monthly n (%) weekly n (%) daily+ n (%) p-value

How often teeth were brushed

- not completed secondary school 1 (1) 1 (1) 14 (18) 60 (79)
- completed secondary school 0 2 (2) 10 (9) 101 (89)
- TAFE/diploma 0 0 6 (7) 85 (93)
- University 0 0 3 (3) 105 (97) <0.0001

How often dental floss was used

- secondary school not completed 29 (38) 15 (20) 25 (33) 7 (9)
- secondary school completed 33 (29) 18 (16) 44 (39) 18 (16)
- TAFE/diploma 25 (27) 10 (11) 47 (52) 9 (10)
- University 23 (21) 13 (12) 57 (53) 15 (14) 0.005

How often mouthwash was used

- secondary school not completed 34 (45) 14 (18) 14 (18) 14 (18)
- secondary school completed 56 (50) 14 (12) 21 (19) 22 (20)
- TAFE/diploma 35 (39) 10 (11) 24 (26) 22 (24)
- University 49 (46) 21 (20) 9 (9) 27 (26) 0.074

+ more than daily

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Table 4: Dental hygiene practices of women by socio-economic status

SOCIO-ECONOMIC INDEX never n (%) monthly n (%) weekly n (%) daily+ n (%) p-value

How often teeth were brushed

- low SEI 1 (1) 2 (2) 17 (16) 89 (82)
- low-mid SEI 0 0 7 (7) 100 (93)
- mid-high SEI 0 0 5 (7) 62 (93)
- High SEI 0 1 (1) 4 (4) 100 (96) <0.001

How often dental floss was used

- low SEI 41 (38) 16 (15) 37 (34) 15 (14)
- low-mid SEI 30 (28) 14 (13) 50 (47) 13 (12)
- mid-high SEI 17 (25) 16 (24) 27 (40) 7 (10)
- high SEI 22 (21) 10 (10) 59 (56) 14 (13) 0.019

How often mouthwash was used

- low SEI 46 (42) 15 (14) 17 (16) 31 (28)
- low-mid SEI 51 (48) 17 (16) 18 (17) 21 (20)
- mid-high SEI 34 (51) 11 (16) 12 (18) 10 (15)
- high SEI 43 (42) 16 (16) 21 (20) 23 (22) 0.238

+ more than daily

Of the women surveyed, 239 (62%) stated they required This could be an independent risk factor whether preg-
a dental check-up with 174 (45%) needing scaling and nant women seek dental advice and treatment or not [17].
cleaning of their teeth. Only 39 (10%) women stated they
thought they needed gum treatment. At least one filling Many women surveyed reported signs suggestive of perio-
was needed by 124 (32%) women with 43 (11%) women dontal disease during the previous twelve months by the
needing teeth extracted. occurrence of bleeding, sore gums and a persistent bad
taste in their mouth. Our findings confirm bleeding and
Discussion sore gums are common among pregnant women [9,14].
In this survey of recently pregnant mothers, most women Although women indicated they had suffered discomfort
were knowledgeable about dental health but only a small from sore and bleeding gums and had bad taste in their
percentage knew about periodontal disease. mouth only a small proportion chose to attend the den-
tist.
Over half of the women surveyed revealed they did not
attend the dentist during the previous twelve months, and This survey highlights important gaps in dental knowl-
only 30% attended during their most recent pregnancy. edge and practices in women, particularly those with
The majority indicated they required a dental check-up lower educational achievements and lower socio-eco-
with just under half believing they needed scaling and nomic status. Better knowledge of dental hygiene and
cleaning of their teeth. The results from this survey are practices were found in women who had some form of
consistent with studies conducted in the United States of tertiary education and from a higher socio-economic sta-
America where more than 50% of pregnant women did tus. Similar results were found in the recent systematic
not receive dental care during their most recent pregnancy review of 25 studies [3]. Failure to attend a dentist on a
[11,16]. This raises serious concerns about dental care- regular basis and lack of understanding about the impor-
seeking behaviours as most adults would be due for their tance of maintaining oral hygiene may be because some
routine dental visits during any nine-month period, and women simply cannot afford to maintain an adequate
pregnant women may need extra periodontal care [1]. level of dental hygiene or regular dental visits. Educating
Over half the women surveyed (65%) recalled being and motivating women to maintain good oral hygiene
informed of the dental health requirements in pregnancy and providing affordable dental health care is fundamen-
yet they did not attend the dentist. tal in reducing dental disease. Improving dental education
may need to become a priority in antenatal care to educate
Cost of dental care may have an impact on the dental women at risk of the importance of maintaining oral
seeking behaviours of pregnant women in Australia. In health [18].
Australia women must have insurance or be prepared to
pay to cover private dental treatment or be placed on a Although this study has the limitations of relying on self-
waiting list to seek free treatment in the public system. reported data and therefore is subject to biases inherent to

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this method, such as misclassification of the question between periodontal disease and adverse pregnancy out-
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Competing interests 5:160-163.
The author(s) declares that they have no competing inter-
ests. Pre-publication history
The pre-publication history for this paper can be accessed
Authors' contributions here:
NT designed and administered the survey, under the
supervision of CC. All authors interpreted the data and http://www.biomedcentral.com/1471-2393/8/13/prepub
wrote the paper.

Acknowledgements
The women who took part in the survey and the staff on the postnatal ward
at the Women's and Children's Hospital; Kristyn Willson for statistical anal-
ysis and advice.

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