|Year : 2016 | Volume
| Issue : 1 | Page : 53-58
Prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba
Modupeoluwa Omotunde Soroye1, Partricia Omowunmi Ayanbadejo2
1 Department of Preventive Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
2 Department of Preventive Dentistry, College of Medicine, University of Lagos, Lagos State, Nigeria
|Date of Web Publication||6-May-2016|
Dr. Modupeoluwa Omotunde Soroye
Department of Preventive Dentistry, Faculty of Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Objective: To determine the prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of a tertiary health institution in Lagos State, Nigeria. Materials and Methods: A single-point assessment was conducted using a self-reported questionnaire completed by participants. Information such as patients' age, gestational age, educational status, occupation, and perception of gingival colours was obtained. Furthermore, the participants were examined by trained dentists to determine their gingival colours and the presence and severity of gingival inflammation. The data obtained were processed, and descriptive and comparative analyses were done using Epi info version 3.5.1 (2008). Statistical significance was established at P values <0.05. Results: Four hundred and forty-five pregnant women aged between 18 years and 43 years [mean age: 30.3 (±4.61) years] participated in the study. Gestational age was between 4 weeks and 41 weeks with a mean of 23.49 (±9.53) weeks. The prevalence of gingivitis was 85.2%. Two hundred and thirty (51.7%) participants described their gingival colour as pink, 127 (28.5%) as red, 51 (11.5%) as black, 3 (0.7%) as white, 2 (0.4%) as brown, and 32 (7.2%) could not determine the colour of their gingivae. Two hundred and ten (47.2%) participants knew that pink was the normal colour of a healthy gingiva. From objective clinical examinations by dentists, 344 (77.3%) patients had pink gingivae, 85 (19.1%) had pigmented gingivae, and only 16 (3.6%) had red gingivae. Conclusion: The higher prevalence of gingivitis during pregnancy is well-established and that observation is corroborated by this study. Since a change in gingival colour may be an early indication of gingival inflammation, early detection and prompt treatment could prevent further periodontal deterioration. Hence, there is the need to incorporate and intensify oral health education during antenatal care so that pregnant women are able to identify changes in gingiva colour, especially when it is associated with periodontal inflammatory diseases.
Keywords: Gingival colour, gingivitis, pregnant women
|How to cite this article:|
Soroye MO, Ayanbadejo PO. Prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba. J Orofac Sci 2016;8:53-8
|How to cite this URL:|
Soroye MO, Ayanbadejo PO. Prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba. J Orofac Sci [serial online] 2016 [cited 2020 Jul 3];8:53-8. Available from: http://www.jofs.in/text.asp?2016/8/1/53/181930
| Introduction|| |
The periodontium consists of the gingiva (gum), cementum, periodontal ligaments, and the alveolar bone. The gingiva is that part of the oral mucosa, which covers the alveolar process of the jaws and surrounds the neck of the teeth.  The colour of the healthy gingiva is generally described as coral pink and is determined by the vascular supply, the thickness and degree of keratinization of the epithelium, and the presence of pigment-containing cells (melanin). , It varies according to the individual's complexion, being lighter in those with a fair complexion than in those with a dark complexion in whom a brownish tinge may be imposed by their greater melanin pigment. ,,,, However, the gum becomes red and swollen when inflamed and it may also assume different colours such as blue, black, or brown with various pigmented lesions of the oral mucosae. ,
Pregnancy, which is associated with hormonal changes ,, increases the risk of gingivitis (inflammation of the gum), which if not property treated can lead to periodontitis (inflammation of the entire tooth-supporting tissues). It has been known to worsen gingiva diseases as well as cause changes in the gingival colour due to hormonal changes.  During pregnancy, the level of progesterone in the body can be 10 times higher than normal,  a situation that enhances the growth of certain pathogenic bacteria implicated in gingivitis. Also, the immune system is altered, thereby changing the normal host reaction to bacteria plague and worsening gingivitis.  As a result of both the hormonal and immune changes, 40% of gravid women develop pregnancy gingivitis at times during their gestation period. ,, In fact, a study has shown that pregnant women are 2.2 times more likely to have gingivitis than nonpregnant women. 
Pregnancy gingivitis is the swelling and inflammation of the gums of pregnant women due to bacterial plague, especially early in their pregnancy. In this state, plaque irritates the gum tissue more, making it tender, bright red, swollen, sensitive, and easily bleed. ,, Usually, the peak occurrence is between the second month and eighth month of gestation and tapers off after delivery.  The earliest clinical signs could be changes in gingival colour from the usual coral pink of healthy gingiva to red and progressing to bleeding on tooth brushing and then to spontaneous bleeding from the swollen gum. The most common site is the front of the mouth.  Tooth brushing twice daily, dental flossing once daily, and the use of antimicrobial mouth rinses have been known to reduce the risk of pregnancy gingivitis. 
A number of studies ,,,,,,,,,,,,,, have demonstrated a link between periodontal disease and premature birth and low birth weight. Consequently, it has been recommended that all pregnant women have periodontal examination as part of prenatal care, even as statistics have shown that up to 50% of them do not receive proper dental care. ,, It is the authors' opinion that women who are properly informed of this risk and trained to identify changes in gingival colour might be able to detect early signs of pregnancy gingivitis and quickly seek periodontal health care. Hence, this study is a pioneer effort in our environment to assess the knowledge and perception of pregnant women about the colour of the gingiva in a healthy and nongravid state and in pregnancy. It is also a further attempt to quantify the prevalence of pregnancy gingivitis among expecting mothers in Nigeria.
| Materials and Methods|| |
This is a cross-sectional study conducted at the antenatal clinic of Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos State, Nigeria. Participants were drawn from women who attended the clinic between September 1, 2011 and October 31, 2011. All consecutive patients who signed a written informed consent were recruited.
A self-reported questionnaire was used to obtain information such as the participant's age, gestational age, ethnicity, educational status and occupation, perception of self-gingival colour, and opinion on normal gingival colour. Furthermore, the participant's medical and dental histories were taken and extraoral and intraoral examinations were performed on each participant by a qualified dentist to determine the existence of gingivitis. Four dentists participated in the exercise. The questionnaire was pretested among pregnant women attending an antenatal clinic in another government hospital to determine its validity and reliability and necessary adjustments made.
The examinations were performed in the antenatal clinic using an artificial light source. Each patient's mouth was examined using disposable latex gloves, disposable facemasks, and sterile dental mouth mirrors (www.cdc.gov/epiInfo/html/prevVersion.htm. Adequate infection control was ensured before the examinations as examiners had to scrub their hands with soap after which antiseptic lotion (hibitane in methylated spirit) was applied and the hands were dried with a sterile towel. The protocol was observed in between every consecutive subject.
To ensure reliability and consistency, the standard criteria for diagnosis were defined and the examiners were calibrated using the statistical test of reliability of Cohen's kappa. The criteria for diagnosis include the presence of changes in gingival colour, gingival swelling, and gingival bleeding on probing estimated using the gingival index (GI) of Loe and Silness, 1963.  The index scores the marginal and interproximal tissues separately on a scale of 0-3 as follows: 0 = normal gingiva; 1 = mild inflammation - slight change in colour and slight edema but no bleeding on probing; 2 = moderate inflammation - redness, edema and glazing, bleeding on probing; 3 = severe inflammation - marked redness and edema, ulceration with tendency for spontaneous bleeding.
Bleeding was assessed by probing gently along the wall of soft tissue of the gingival sulcus. The scores of the four areas [mesial, distal, buccal (facial) and lingual (palatal)] of the tooth was summed and divided by 4 to give the GI for each tooth. The GI of the individual was obtained by adding the values for each tooth and dividing by the number of teeth examined. The GI was scored for all surfaces of all teeth as follows:
0.1-1.0 = mild inflammation
1.1-2.0 = moderate inflammation
2.1-3.0 = severe inflammation
The study protocol was approved by the Health Research and Ethics Committee (HREC) of LUTH, Idi-Araba, Lagos State, Nigeria.
Data analysis was performed using Epi Info version 3.5.1 (www.cdc.gov/epiinfo) (August 2008) statistical software. Descriptive analyses were done and statistical comparison was accomplished with the chi-square test, taking P values <0.05 to be statistically significant.
| Results|| |
Interrater reliability analysis using the Cohen's kappa statistics was performed to determine the coherence among raters. K value of 0.8 for was obtained (note that K > 0.7 is generally considered satisfactory). [Table 1] shows the sociodemographic characteristics of the participants. There were four hundred and forty-five pregnant women with an age range of 18-43 years and mean age of 30.3 [Standard Deviation (SD) ±4.61] years who participated in the study. Gestational age was between 4 weeks and 41weeks with a mean value of 23.49 (SD ±9.53) weeks. This study comprised mostly educated women. Overall, 221 (49.7%) had at least a tertiary level of education while only 4 (0.9%) had no formal education.
Multiple Nigerian ethnic groups were represented with the Igbos (45.8%) constituting the majority.
More than half of the participants were professionals including medical doctors, lawyers, engineers, and self-employed elites; 74 participants (16.6%) were full-time homemakers.
The prevalence of pregnancy gingivitis is depicted in [Table 2]. Of the 445 participants, 85.2% (379/445) had pregnancy gingivitis. Among these, 86.3% (327/379) had mild gingivitis, 12.9% (49/379) had moderate gingivitis, and 0.8% (3/379) had severe gingivitis. Participants indicated their opinions regarding the colour of a normal healthy gingiva as follows: 210 (47.2%) indicated pink colour, 112 (25.2%) red, 42 (9.4%) black, 1 (0.9%) white, 4 (0.9%) brown while 76 (17.1%) felt that they did not know the normal colour [Figure 1]. On the other hand, 230 participants (51%) thought the colour of their own gingiva was pink, 127 (28.5%) indicated red, 51 (11.5%) black, 3 (0.7%) white, 2 (0.4%) brown while 32 (7.2%) did not know the colour of their gingiva [Figure 2]. However, upon clinical assessment, 344 (77.3%) patients were noted to have pink gingivae, 85 (19.1%) had physiologic black gingivae while 16 (3.6%) had red gingivae [Figure 3]. Chi-square test conducted to determine the difference between the individual's perception of gingiva colour and clinical observations of the participants' gingiva colour showed a significant statistical difference with a P value of <0.001 [Table 3].
|Table 3: A cross-tabulation of participants' perception of their gum colour and clinical assessment of their gingival colour|
Click here to view
| Discussion|| |
Pregnancy has been associated with a high prevalence of gingivitis. This observation is corroborated by this study in which we found a prevalence of 85.2%, a value comparable to 86.2% reported in Thailand.  Some other authors such as Chanduaykit et al.  and Ababneh et al.  made similar observations, reporting a prevalence of 86.2% and 97%, respectively. This high prevalence of pregnancy gingivitis has been ascribed to the altered immune response to stress and anxiety as well as hormonal imbalances known to be associated with pregnancy. ,,,,,, The altered host physiology tends to accentuate normal inflammatory reaction to plague accumulation, leading to rapid deterioration of the oral condition. , However, the degree of severity of pregnancy-related gingivitis appears to be largely determined by the individual's oral hygiene rather than the mere existence of pregnancy.  This fact may account for the observation of mild gingivitis in a large majority - about three-fourth of the participants in this study. Compared to a similar study conducted at the antenatal clinic of King Hussein Medical Center in Saudi Arabia where about 70% of the pregnant women had moderately severe gingivitis, our study population presented better oral hygiene. This may not be unconnected to the differential level of literacy and elitism between the two populations of participants in these studies. In our study, a majority of the participants were professionals and individuals of middle to high socioeconomic standings; the former study involved a population of largely illiterate women whose oral health consciousness was predictably lower. Only about 13% of the participants in our study expressed moderate to severe gingivitis.
Gingival colour change is one of the cardinal signs of early gingivitis. A healthy gingiva is generally coral pink in colour, depending on the individual's race and complexion; a variance of physiological pigmentation is accepted for normal gingiva. However, when the gingiva is inflamed, it becomes red and swollen and may also become bluish, blackish, or brownish in various diseased states. It is therefore, important that women are able to recognize the colour of a healthy gingiva so as to be able to detect changes that may indicate the onset of a disease. In this study, barely over half of the population (56.6%) knew the normal colour of a healthy gingiva. One-fourth of the population thought that red was normal while over 17% had no idea of what a normal gingiva colour could be. On the other hand, 63.2% of the participants perceived their own gingiva colour as pink while 28.5% considered their gingivae as red in colour. A few others (7.2%) could not even determine the colour of their own gingivae. These observations have significant implications since the ability of an individual to differentiate normal from inflamed or diseased gingiva could facilitate prompt seeking of periodontal care. Unfortunately, literatures discussing individuals' knowledge and perception of normal or personal gingiva colour are very sparse, and so we were unable to compare these outcomes. In fact, this study is a pioneer effort along this line of interest in periodontal research in the Nigerian environment.
When clinician assessment of gingiva colour among participants was performed, we observed that over 77% actually had the normal pink gingivae and 28.5% had red gingivae as opposed to 3.6% who thought they did. The disparity of judgment is statistically significant. Although in this case, it appears that many participants might have misjudged their own gingiva colour as abnormal, the bottom line is that a considerable proportion could not properly recognize the gingiva colour or colour changes. On another occasion, the reverse could have happened in which subjects may have judged abnormal colours as normal. This goes to justify the need for incorporating dental health education into antenatal care. This would enable pregnant women to detect any abnormal colour change early enough to institute appropriate therapy and avoid undesirable sequelae of uncontrolled periodontal disease. Moreover, it must be emphasized that periodontal treatment during pregnancy is safe as several studies ,,,, have demonstrated the safety and beneficial effects of periodontal therapy in pregnancy.
| Conclusion|| |
This study has corroborated the observation of higher prevalence of gingivitis during pregnancy. Since a change in gingival colour may be an early indication of gingival inflammation, early detection and prompt treatment could prevent further periodontal deterioration. Hence, the need to incorporate and intensify oral health education during antenatal care cannot be overemphasized. This will enable pregnant women to identify gingival changes that may be associated with inflammatory and noninflammatory periodontal diseases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Newman MG, Takei HH, Carranza FA. Carranza′s Clinical Periodontology. 9th ed. WB Saunders Company; 2002.
Fox SI. Human Physiology. 4 th
ed. Dubuque, Iowa: Wm. C. Brown Publishers; 1993. p. 626.
Murthy MB, Kaur J, Das R. Treatment of gingival hyperpigmentation with rotary abrasive, scalpel and laser techniques: A case series. J Indian Soc Periodontol 2012;16;614-9.
Butchibabu K, Koppolu P, Tupili MK, Hussain W, Bolla VL, Patakota KR. Comparative evaluation of gingival depigmentation using a surgical blade and diode laser. J Dent Lasers 2014;8:20-5.
Desai U, Rai JJ, Dave D, Rathva V. Comparison of patient perception on gingival depigmentation using scalpel and diode laser. IOSR-JDMS 2013;11:33-8.
Carrillo-de-Albornoz A, Figuero E, Herrera D, Bascones-Martínez A. Gingival changes during pregnancy: II. Influence of hormonal variations on the sub gingival biofilm. J Clin Periodontol 2010;37:230-40.
Carrillo-de-Albornoz A, Figuero E, Herrera D, Cuesta P, Bascones-Martínez A. Gingival changes during pregnancy: III. Impact of clinical, microbiological, immunological and socio-demographic factors on gingival inflammation. J Clin Periodontol 2012;39:272-83.
Villa A, Abati S, Pileri P, Calabrese C, Capobianco G, Strohmenger L, et al
. Oral health and oral diseases in pregnancy: A multicenter survey of Italian postpartum women. Aust Dent J. 2013;58:224-9.
Gürsoy M, Pajukanta R, Sorsa T, Könönen E. Clinical changes in periodontium during pregnancy and post-partum. J Clin Periodontol 2008;35:576-83.
Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60:257-64.
Barak S, Oettinger-Barak O, Oettinger M, Machtei EE, Peled M, Ohel G. Common oral manifestations during pregnancy: A review. Obstet Gynecol Surv 2003;58:624-8.
Rakchanok N, Amporn D, Yoshida Y, Harun-Or-Rashid M, Sakamoto J. Dental caries and gingivitis among pregnant and non-pregnant women in Chiang Mai, Thailand. Nagoya J Med Sci 2010;72:43-50.
Güncü GN, Tözüm TF, Cağlayan F. Effects of endogenous sex hormones on the periodontium - Review of literature. Aust Dent J 2005;50:138-45.
Hey-Hadavi JH. Women′s oral health issues: Sex differences and clinical implications. Women′s Health Prim Care 2002;5:189-99.
Silk H, Douglass AB, Douglass JM, Silk L. Oral health during pregnancy. Am Fam Physician 2008;77:1139-44.
Honkala S, Al-Ansari J. Self-reported oral health, oral hygiene habits, and dental attendance of pregnant women in Kuwait. J Clin Periodontal 2005;32:809-14.
Offenbacher S, Lieff S, Boggess KA, Murtha AP, Madianos AP, Champagne CM, et al
. Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction. Ann Periodontol 2001;6:164-74.
Soroye MO, Oluwole AA. Preterm low birth weight and maternal periodontal status. IJRID 2013;1:159-69.
Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002;360:1489-97.
Gibbs RS. The relationship between infection and adverse pregnancy outcomes: An overview. Ann Periodontol 2001;6:153-63.
Jeffcoat MK, Geurs N, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection and preterm birth: Results of a prospective study. J Am Dent Assoc 2001;132:875-80.
Davenport ES, Williams CE, Sterne JA, Murad S, Sivapathasundram V, Curtis MA. Maternal periodontal disease and preterm low birth weight: Case-control study. J Dent Res 2002;81:313-8.
Lieff S, Boggess KA, Murtha AP, Jared H, Madianos PN, Moss K, et al
. The oral conditions and pregnancy study: Periodontal status of a cohort of pregnant women. J Periodontol 2004;75:116-26.
Sadatmansouri S, Sedighpoor N, Aghaloo M. Effects of periodontal treatment Phase I on birth term and birth weight. J Indian Soc Pedod Prev Dent 2006;24:23-6.
Ovadia R, Zirdok R, Diaz-Romero RM. Relationship between pregnancy and periodontal disease. Medicine and Biology 2007;14:10-4.
Rajapakse PS, Nagarathne M, Chandrasekra KB, Dasanayake AP. Periodontal disease and prematurity among non-smoking Sri Lankan women. J Dent Res 2005;84:274-7.
Goldenberg RL, Culhane JF. Preterm birth and periodontal disease. N Engl J Med 2006;355:1925-7.
Boggess KA, Beck JD, Murtha AP, Moss K, Offenbacher S. Maternal periodontal disease in early pregnancy and risk for a small-for-gestational-age infant. Am J Obstet Gynecol 2006;194:1316-22.
Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy outcomes: A systematic review. BJOG 2006;113:135-43.
Leo H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
Chanduaykit S, Buranasan N, Kulayasiri K. The Study of Dental Status of Pregnant Women in Antenatal Care Clinic of Mothers and Child Hospital, Research Report. Bangkok: Bang Ken Health Center; 1991. p. 15-22.
Ababneh KT, Abu Hwaij ZM, Khader YS. Prevalence and risk indicators of gingivitis and periodontitis in a multi-centre study in North Jordan: A cross sectional study. BMC Oral Health 2012;12:1.
Wu M, Chen SW, Jiang SY. Relationship between gingival inflammation and pregnancy. Mediators Inflamm 2015;2015:623427.
Goldenberg RL, Hauth JC, Williams AW. Intrauterine infection and preterm delivery. N Engl J Med 2000;20:1500-7.
Polyzos NP, Polyzos IP, Mauri D, Tzioras S, Tsappi M, Cortinovis I, et al
. Effects of periodontal disease treatment during pregnancy on preterm birth incidence: A meta-analysis of randomized trials. Am J Obstet Gynecol 2009;200:225-32.
Michalowicz BS, Hodges JS, DiAngelis AJ, Lupo VR, Novak MJ, Ferguson JE, et al
.; OPT Study. Treatment of periodontal disease and the risk of preterm birth. N Engl J Med 2006;355:1885-94.
Offenbacher S, Beck JD, Jared HL, Mauriello SM, Mendoza LC, Couper DJ, et al
.; Maternal Oral Therapy to Reduce Obstetric Risk (MOTOR) Investigators. Effects of periodontal therapy on rate of preterm delivery: A randomized controlled trial. Obstet Gynecol 2009;114:551-9.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]