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Background: An important aim of antenatal care is to improve maternal health- and well being of which oral health is an important part. This study aimed to estimate the prevalence of oral impacts on daily performances (OIDP) during pregnancy, using a locally adapted OIDP inventory, and to document how periodontal status, tooth-loss and reported periodontal problems are related to oral impacts. Methods: Pregnant women at about 7 months gestational age who were members of a community based multi-center cluster randomized community trial: PROMISE EBF: Safety and Efficacy of Exclusive Breast feeding in the Era of HIV in Sub-Saharan Africa, were recruited in the district of Mbale, Eastern Uganda between January 2006 and June 2008. A total of 877 women (participation rate 877/886, 98%, mean age 25.6, sd 6.4) completed an interview and 713 (participation rate 713/886, 80.6%, mean age 25.5 sd 6.6) were examined clinically with respect to tooth-loss and according to the Community Periodontal Index, CPI. Results: Seven of the original 8 OIDP items were translated into the local language. Cronbach’s alpha was 0.85 and 0.80 in urban and rural areas, respectively. The prevalence of oral impacts was 25% in the urban and 30% in the rural area. Corresponding estimates for CPI>0 were 63% and 68%. Adjusted ORs for having any oral impact were 1.1 (95% CI 0.7-1.7), 1.9 (95% CI 1.2-3.1), 1.7 (1.1-2.7) and 2.0 (0.9-4.4) if having respectively, CPI>0, at least one tooth lost, tooth loss in molars and tooth loss in molar-and anterior regions. The Adjusted ORs for any oral impact if reporting periodontal problems ranged from 2.7(95% CI 1.8-4.2) (bad breath) through 8.6(95% CI 5.6-12.9) (chewing problem) to 22.3 (95% CI 13.3-35.9) (toothache). Conclusion: A substantial proportion of pregnant women experienced oral impacts. The OIDP impacts were most and least substantial regarding functional- and social concerns, respectively. The OIDP varied systematically with tooth loss in the molar region, reported chewing-and periodontal problems. Pregnant women’s oral health should be addressed through antenatal care programs in societies with limited access to regular dental care facilities. © 2009 Wandera et al; licensee BioMed Central Ltd.
Participating women of the present study were members of a multicentre randomized community trial and birth cohort study (“Safety and efficacy of exclusive breast feeding (EBF) promotion in an African setting with high prevalence of HIV”- PROMISE EBF) conducted in Uganda and three other sub Saharan African countries – Burkina Faso, Zambia and South Africa. A district was selected as the intervention site with the randomization unit being 1-2 villages of on average 1000 inhabitants (35 infants per year given a birth rate of 3.5%). Pregnant women resident in twenty four villages selected for randomization in urban and rural areas of Mbale district, Eastern Uganda, were recruited consecutively by local community leaders into the Promise EBF study between January 2006 and June 2008. Urban villages were sited within Mbale municipality while rural villages were sited in Bunghoko sub-county. A total of 886 pregnant women were eligible to participate in interviews and oral clinical examination. This number satisfied a sample size of 800 pregnant women calculated for the oral sub-study, assuming a prevalence of tooth loss (i.e. at least one tooth lost) of 50%, a precision of 0.05 and a design effect of 2. As this study included several outcomes, the size of the sample was calculated separately for each of them and the largest sample size required was adopted. The procedures of recruitment and participation in the Promise EBF study are detailed in another publication [24]. Ethical Clearance was obtained from the Ethical board, Faculty of Medicine, Makerere University. Written consent was obtained from all participants in the study and verbal consent was obtained prior to each examination and interview. Structured interviews were designed with EpiHandy software to be used on handheld computers [25]. Interviews were conducted in face to face settings with participants at household level. The interview schedules were developed in English and translated into the local language of Lumasaaba. Oral health professionals reviewed the interview schedule for semantic, experiential and conceptual equivalence and sensitivity to culture and selection of appropriate words were considered. The interview schedules were piloted before administration. The conceptual model adapted from the model of Wilson and Cleary [26] linking indicators of oral diseases to their symptomatic-, functional- and disability consequences was applied to identify factors to consider as determinants of OHRQoL and to structure the multivariate analyses. The interviews covered questions on mother’s health status, socio-demographic characteristics and perceived oral health status. Self-reported periodontal problems were assessed by asking respondents about their experience with bleeding gums, color change in gums, swollen gums, tooth decay, bad breath, bad taste toothache and pain in gums. Responses were categorized as no = 0 and yes = 1. Self-reported chewing problems were assessed by asking women whether or not they anticipated difficulties eating seven Ugandan food items (green banana, millet bread/maize meal, rice, cassava, meat, vegetables and fish) (responses were 0 = no, 1 = yes) The food items were identified through discussions with residents of the area prior to designing the interview. The seven food items were added into a chewing problem index (range 0-7) and dichotomized into 0 = no difficulties with chewing food items and 1 = difficulty with chewing at least one food item. Oral disadvantage or the psychosocial consequences of oral disease and tissue damage were measured broadly using seven of the original eight item OIDP inventory (i.e. During the previous 6 months – how often have problems with your teeth and mouth caused you any difficulty with; eating, speaking, cleaning teeth, smiling, sleeping, work performance and social contact). The OIDP item considering emotional stability was removed due to problems with translation into the local language and possible misinterpretation by the study group. Each frequency item was scored 0-3, where (0) never, (1) less than once a month, (2) once or twice a month up to once or twice a week, (3) 3-4 times a week or more often. Finally, the extent of oral impacts, OIDP-extent, (range 0-7) was calculated as a simple count score (OIDP SC); i.e. summing dichotomized frequency items in terms of (1) affected (including the original categories 1,2,3) and (0) not affected (including the original category 0). Socio-demographics were assessed in terms of place of residence, age, educational level, last dental visit, parity and months of pregnancy. Family wealth was assessed as an indicator of socio-economic status in accordance with a standard approach in equity analyses [27]. Household durable assets indicative of family wealth (e.g. bicycle, television, car, motor cycle) assessed as (1) available/in working condition, (2) not available/nor in working condition were analyzed with principle component analysis, PCA. The first component resulting from the analysis was used to divide households into four approximate quartiles of wealth status ranging from 1st quartile (least poor) to 4th quartile (most poor). The socio-demographic variables controlled for in the analyses, their coding and the number of subjects (%) according to categories in urban and rural residence are shown in Table Table11. Socio-demographic indicators among pregnant women in urban and rural areas of Mbale district. (n = 877) *The total number of the various categories do not add to 877 due to missing values A trained and calibrated dentist (MW) carried out all clinical oral examinations under field conditions based on the World Health Organization (WHO) criteria [28], recording the data on a prepared record sheet. All fully erupted permanent teeth were scored, excluding third molars. Oral examinations were performed at house hold level with subjects seated, examiner using a headlamp as source of illumination, mouth mirror and a periodontal probe. Neither radiographic examination nor drying of teeth was performed. Periodontal status was assessed using a specially designed lightweight CPITN probe with a 0,5 mm ball tip with periodontal pockets were measured from the edge of the free gingiva to the bottom of the pocket. Using the epidemiological part of the CPITN, the Community Periodontal Index (CPI) [28,29] with 10 index teeth (17,16,11,26,27,47,46,31,36,37) and 6 sextants (17-14, 13-23, 24-27, 38-34, 33-43, 44-47) per individual, four indicators of periodontal status were applied. Only index teeth were examined and the criteria used were; healthy periodontal status (code 0), bleeding on probing observed (code 1), calculus detected during probing (code 2), pocket 4-5 mm (code 3) and pocket >5 mm (code 4). Each index tooth was scored on 2 sites (buccal and lingual) and each sextant was scored according to its highest CPI score. If no index tooth was present in a sextant, all the remaining teeth in that sextant were examined and the highest score is recorded as the score for that sextant. In accordance with the hierarchical assumption of the CPI index, teeth with score 3 were assumed positive with respect to bleeding and calculus whereas teeth with score 2 were assumed positive with respect to bleeding [30]. Prevalence of bleeding-, calculus and pocket sextants was assessed as the percentage of subjects affected, or percentage of subjects having at least one affected sextant. Prevalence of healthy sextants was assessed as the number of subjects having 6 healthy sextants. Severity of periodontal condition was assessed by the mean number of sextants having CPI code 0,1,2,3 and 4. Total CPI was also presented as the percentage distribution of dentate subjects according to highest score in the mouth. For analyses this total CPI score was dichotomized into CPI = 0 and CPI>0. Tooth-loss was recorded for all teeth except the third molars and in terms of loss of any tooth (1 = yes, 0 = no), at least 1 tooth lost in both anterior & premolar regions (1 = yes, 0 = no), at least one tooth lost in molar region only (1 = yes, 0 = no) and at least 1 tooth lost in both in anterior & molar regions (1 = yes, 0 = no). Duplicate clinical examinations were carried out on 50 mothers considered to be representative of the study participants after a period of one month. Analysis performed on the duplicate examination recordings gave Kappa values of 0.91 for missing teeth. With respect to indicators of periodontal condition, kappa values ranged from 0.48 (CPI index tooth 11) to 0.85 (CPI index tooth 31). These figures indicate moderate to good intra examiner reliability according to WHO [28]. Data was analyzed using SPSS version 15.0 (Chicago, IL, USA). Cross tabulation, chi square statistics and Univariate ANOVA were used to assess bivariate relationships. Logistic regression analyses were conducted with OIDP and chewing problems using the logit model and 95% Confidence intervals (CI) given for the odds ratios.
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