 Abstract | | |
Objective: Recent studies have shown relationship between poor oral health in pregnant women and adverse pregnancy outcomes. So it was decided to assess the knowledge of interns who will be the future practitioners regarding management of dental needs of pregnant patients.
Material and Methods: A cross-sectional questionnaire survey was conducted among 380 interns from eight dental colleges in Karnataka. Questionnaire comprised of 25 knowledge based questions and five questions regarding their training, number of pregnant patients treated by them and their confidence level in dental management of pregnant patient. Excel spread sheet was used for mathematical calculations.
Results: More than 80% of the interns had knowledge about usage of NSAIDS (92%) antibiotics (82%) and local anesthetic (80%). Conversely many did not know about the FDA category of drugs to be used (80%) and safety of dental radiographs (89%) in pregnant patients. Results also showed lack of confidence in interns to provide dental care to pregnant patients.
Conclusion: There is definitive need to improve the knowledge and thus the confidence levels of the interns. Keywords: Drugs, dental care, oral health needs, pregnant, radiographs
How to cite this article:
Tantradi P, Madanshetty P. Knowledge of dental interns about management of dental needs of pregnant patients. J Educ Ethics Dent 2013;3:76-80 |
How to cite this URL:
Tantradi P, Madanshetty P. Knowledge of dental interns about management of dental needs of pregnant patients. J Educ Ethics Dent [serial online] 2013 [cited 2023 Jun 9];3:76-80. Available from: https://www.jeed.in/text.asp?2013/3/2/76/136050 |
| Introduction | |  |
Pregnancy in a woman's life is an important and a special time and good oral health is essential for the health of mother as well as the baby. Efforts to promote oral health of pregnant woman have increased in the recent years due to identified link between maternal transmission of bacterial and early childhood caries. [1] In addition poor maternal oral health has also been linked to adverse pregnancy outcomes. [1],[2],[3] Nutritional intake of pregnant woman can also be affected due to poor oral health which in turn can impair the supply of nutrients necessary for fetal growth and survival. [1]
Most pregnant patients are generally healthy and hence dental treatment need not be denied/deferred solely because they are pregnant. [1],[4] There is concern among dentists that dental procedures that cause bacteremia may lead to uterine infections, spontaneous abortions or preterm labor. However there is no evidence that dental procedure induced bacteremias increases the woman's risk of experiencing fetal loss or preterm labor or delivery. [5] Inspite of this, practitioners may hesitate to treat pregnant patients for the fear of injuring either the mother or the unborn child. [1],[5],[6]
In a pregnant woman untreated dental disease can lead to pain, infections and unnecessary exposure to medications which might be harmful to the developing fetus. Hence, comprehensive oral examination of pregnant patient is recommended to diagnose disease processes that need immediate treatment as they may also self-medicate with potentially unsafe over the counter medications to get relief from dental pain. [1] Further comprehensive dental examination and care during pregnancy are needed to ensure the oral health. [1],[2] In a study it was found that general dentists with low/moderate knowledge were less likely to provide comprehensive care for the pregnant patient. [7] So a survey was conducted to assess the knowledge of interns studying in Karnataka state, regarding drug administration, infection consequences, oral findings, treatment aspects and radiation exposure with respect to pregnant patients.
| Material and Methods | | |
A cross-sectional questionnaire survey was conducted among dental interns of Karnataka. The survey instrument was a structured, self-administered anonymous questionnaire. The study included a random convenience sample comprising of 380 interns from eight dental colleges in Karnataka. Ethical clearance was obtained from institute's research ethical committee.
A pilot test was conducted among 25 interns not included in the sample. Based on the feedback from 5 out of these 25 pilot participants the questions were modified for improved clarity and comprehension. Test-retest procedure was conducted among the remaining 20 interns to assess reliability of the questionnaire. The reliability was found to be 0.82. The questionnaires were mailed/delivered personally to the DCI recognized eight participating dental colleges in year 2011-12. A competent person at each institute was given responsibility of getting the forms filled by interns willing to participate in the study and mailing back the filled questionnaires. Participation was on a voluntary basis.
The interns were made to answer the questionnaire in small groups. The questionnaire had total 30 questions, 25 knowledge based questions and five questions regarding their training, number of pregnant patients treated by them and their confidence level in dental management of pregnant patient. Out of 25 knowledge based questions 17 were on a three point scale (yes, no or do not know) the remaining eight questions had three to four options. These questions were formulated to obtain information about a dental internee's knowledge regarding drug administration, infection consequences, oral findings, treatment aspects, and radiation exposure with respect to pregnant patients. In addition, suggestions if any was solicited to help them confidently manage dental needs of pregnant patient and their interest in attending CDE programs regarding the same was recorded. Internee's gender detail along with miscellaneous details like year of passing, college name was also collected.
Scoring points were given to 25 knowledge based questions and entered in Excel spread sheet (Office 2007; Microsoft corp., Redmond WA) to perform mathematical calculations. No scoring point was given to other five questions. For each correct, incorrect and not sure answers, one, minus one and zero points, respectively, were assigned. A total score was obtained by adding the points given for each answer. An intern's total score could range from -25 points (all incorrect answers) to + 25 points (all correct answers). A higher score indicated a greater level of knowledge. The interns knowledge was assessed as poor if total score is < 50%, moderate if total score is between 50 to 75% and good if total score is >75%.
| Results | | |
A total of 391 interns participated in the study. Eleven questionnaires were incompletely filled, hence excluded from the study. Out of 380 interns 123 were male and 257 were female. The intern's answers regarding 25 knowledge based questions are tabulated [Table 1].
More than 80% of interns knew the safest NSAID (92%) and antibiotic (82%) to be used in pregnancy. However, only 20% knew the category of drugs with minimal risk to pregnant patient as per FDA classification system. Eighty-two percent were aware that untreated infection is more harmful than the risk of treatment, but only 37% were aware that acute infection has to be treated promptly in all three trimesters of pregnancy. Further 88% did not know that it is safe to obtain dental radiographs if routine safety measures are adhered to.
A greater proportion (51 and 68% respectively) of interns claimed to have received no theoretical or clinical training. Many (90%) have also not attended any CDE program regarding dental management of pregnant patients. However 348 interns (92%) out of 380 were interested to attend CDE program [Table 2].
Several interns had got an opportunity to manage dental needs of pregnant patients. Many have treated less than five pregnant patients but very few more than five patients [Table 3]. Confidence level rating and percentage scored by interns is mentioned in [Table 4] and [Table 5], respectively.
Out of 380 interns 66 have given suggestions. They were keen on being theoretically as well as clinically trained and insisted on CDE programs devised to help them in management of dental needs of pregnant patients.
| Discussion | | |
Literature is scarce on studies which have tested intern's knowledge about dental needs of pregnant patients. However, there are couple of studies that have been carried out among general dentists regarding their attitudes, beliefs and practices regarding dental care for pregnant patients and to which extent they provide comprehensive dental care. [2],[7]
It is vital to have awareness of oral health needs of pregnant patient and preventive care, dental treatment and drugs that can be provided safely during pregnancy. The result of our study throws light on the lacunae of knowledge in the assessed interns. However, the difference in scoring among interns and their confidence levels could be due to the different teaching methods of the colleges and the amount of exposure to patients. In addition the results of this study may not have external validity.
For drug administration Food and Drug Administration (FDA) has classified drugs into five categories of safety for use during pregnancy. [1],[8] Acetaminophen is the safest and should be the NSAID of choice. It is rated as a FDA category B drug for all the three trimesters of pregnancy. [1],[4],[6],[9] Ibuprofen in the first and second trimesters is a category B analgesic, but because it has been associated with lower levels of amniotic fluid, premature closure of fetal ductus arteriosus and inhibition of labor when taken during third trimester, it is a category D drug during this time. [4] Penicillins and cephalosporins which are beta-lactum ring derived antibiotics are the first choice for orofacial infections. These antibiotics are known to be safe when used in pregnancy inspite them crossing the placenta. [9] Drugs such as metronidazole, erythromycin estolate and tetracycline must be avoided throughout pregnancy. [8] The use of metronidazole in pregnancy is controversial as the reduced form of drug is teratogenic but humans are not capable of reducing metronidazole and so should not be at risk. It is currently recommended for use in the second and third trimesters only even though it has not been associated with adverse fetal affects. [10] Because of deleterious effects on mother's liver the estolate form of erythromycin should be avoided. [4],[8] Tetracycline is grouped under category D as it chelates calcium orthophosphate causing a hypoplastic matrix, tooth discoloration and inhibition of bone development and may result in maternal hepatotoxicity. [11] During pregnancy local anesthetics (LA) administered with epinephrine are considered relatively safe. [12] Lidocaine with FDA category B rating is the recommended LA for use. [1],[4],[6],[11] Use of epinephrine in the doses used for dental treatment is not associated with fetal abnormality and is considered to be safe during pregnancy [9] as long as normal precautions are taken. [6] These precautions include avoiding injection within the blood vessels and maintaining total dosages at or below 0.04 mg of epinephrine. [6] Overall more than 50% of interns had knowledge about the seven questions regarding drug administration with more than 90% having awareness about the safest NSAIDS to be used, tetracycline's effect on fetus and that drug administered to mother can reach fetus. However, only 20% of the interns were aware about the FDA category of drugs with minimal risk in pregnancy.
Many studies have documented an association between periodontal disease and low birth weight babies, (3],[6],[7],[9],[13],[14],[15] preterm birth [3],[6],[7],[13],[14],[16],[17],[18] and pre-eclampsia. [3],[7] Intern's knowledge regarding risk of preterm birth and low weight babies was 59%. In comparison 68.8 and 77% of general dentists of North Carolina had awareness about risk of preterm birth and low birth weight babies, respectively. [7] Few clinical trials have shown that non-surgical periodontal therapy like plaque control instructions, scaling, polishing and root planing under local anesthesia can reduce the risk of preterm low birth weight babies [13],[19] and may be performed as required to maintain oral health. [4],[6],[12] If dental caries is a source of pain or acute infection in an otherwise healthy pregnant woman a dentist should provide prompt care irrespective of the patient's phase of pregnancy. [4],[6],[14] The risk of allowing an active infection to progress untreated is greater than the risk of providing care. [1],[20] In addition febrile illness and sepsis can precipitate a miscarriage. [12] Unfortunately, only 37% of interns were aware that acute dentoalveolar infection should be treated promptly.
Pregnancy gingivitis is the most common oral complication of pregnancy. [1],[12],[14] During pregnancy the inflammatory response to oral bacteria is exacerbated by fluctuations in estrogen and progesterone levels, changes in oral flora and a decreased immune response. [1],[14] In about five percent of pregnancies, pregnancy tumor is seen. Management is usually observational unless the tumor bleeds or interferes with mastication as lesions surgically removed during pregnancy are likely to recur. [1],[12],[14] Pregnant women are at higher risk of tooth decay due to consumption of small frequent carbohydrate rich meals, increased acid in the mouth from vomiting and limited attention to oral health. [1],[6],[14] Gastric acid exposure as result of morning sickness early in pregnancy and a lax esophageal sphincter during the later stages of pregnancy may also cause dental erosion. [1] Interns knowledge about oral findings was above 60%.
Elective treatment in a healthy pregnancy need not be deferred as it lacks medical justification. However as approximately one in five pregnancies end in spontaneous abortions and 85% occur in the first trimester, elective treatment other than prophylaxis and examinations may be postponed to the second trimester to avoid a correlation being made between dental treatment and spontaneous abortion. [11] During the second trimester organogenesis is completed and therefore the risk to the fetus is low and hence is the ideal and safest period for providing dental care. [1],[9],[14] However extensive elective procedures should be avoided. [4] Eighty-seven percent of interns knew that second trimester is the safest and best time to provide routine dental care in contrast to 73.7% of North Carolina dentist. [7] Though there is no risk to the fetus during the third trimester the pregnant woman may experience an increasing level of discomfort due to the increased size of the uterus. [1],[9] If treatment is to be rendered the patient should not be placed in the supine position because of the possibility of supine hypotensive syndrome and the increased risk of deep venous thrombosis. [21] If supine hypotension develops, rolling the patient on to her left side affords return of circulation to heart by moving the uterus off the vena cava. [1],[4],[12] Further problems can be minimized by scheduling short appointments, allowing the patient to assume a semireclined position and encouraging frequent changes of position. [12] In addition non-pharmacological methods are preferred when treating anxiety in the dental setting because they reduce the fetus's exposure to medication. [6] Dental radiography is one of the controversial areas in the management of the pregnant patient. However the safety of dental radiography has been well established, provided features such as fast exposure techniques (e.g. high speed film, digital imaging) filtration, collimation and lead aprons are used. [1],[4],[6],[9],[12] Only 11% of the interns knew that it is safe to obtain dental radiographs in pregnant patients compared to 74.7% of North Carolina general dentists. [7]
| Conclusion | | |
On analyzing the results it was concluded that an overwhelming majority (73%) of the interns assessed lacked confidence to manage the dental needs of pregnant patients. Inspite limitations of the study there is a definitive need to improve their knowledge. The lack of knowledge and confidence can be addressed by undertaking the following measures.
- Dental curricula strengthened with respect to oral health needs and care of pregnant patients to provide a strong foundation to the students.
- Conducting CDE programs periodically.
| Acknowledgements | | |
We would like to thank our friends and colleagues who have helped us. We would also like to thank all the participating interns for their cooperation.
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Correspondence Address:
Praveena Tantradi
Department of Oral medicine & Radiology, Maratha Mandal's N.G.H.Institute of Dental Sciences and Research Center, R.S.No. 47A/2, Bauxite Road, Belgaum - 590 010, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0974-7761.136050
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
