A Review on the Oral Health of Pregnant Women provided with Basic Oral Health Care

(BOHC) in the Province of Davao Oriental: A Local Perspective

Abstract

Despite the efforts of the government and partner associations, there is still a greater incidence
of oral health conditions among Filipinos of all ages. Moreover, the significance of women's
dental health and its relationship to total systemic health cannot be overstated. Poor dental
health can have a number of negative implications on a woman's health, particularly during
pregnancy. This article examines and provides statistics on pregnant women who received Basic
Oral Health Care (BOHC) in the province of Davao Oriental based on the 2019 FHSIS and
OHF 2 annual report. It also sought to guide local policymakers in developing and
implementing improved oral/dental health initiatives in the community.

Keywords

Oral health; Periodontal Disease; Dental Caries; Women’s Health; Pregnant Women provided
with BOHC

Introduction

Nutrition starts in the oral cavity; thus, oral health is acknowledged as an intrinsic and
indivisible component of every Filipino's entire health. Oral health is critical to general health,
well-being, and life quality. People with healthy mouths can eat, speak, and socialize without
pain, discomfort, or shame. However, it is frequently rated last in a person's priority list. The
frequency of dental caries cavities among Filipinos is 87.4 percent, whereas periodontal disease
is 48.3 percent (DOH, NMEDS 2011). This high prevalence is observed in all age categories.
This is consistent with the frequency of dental caries in WHO member nations in the South-East
Asia Region, which affects 70 percent to 95 percent of school-aged children and the majority of
adults. The increased availability of sugar contributes significantly to the frequency of dental
caries, and tooth decay is more prevalent in transitional economies due to a lower priority for
thorough treatment.
 The primary focus of this article will be on the oral health statistics and data of pregnant
women in the province of Davao Oriental for the year 2019. According to Carpenter et al.,
(2009), about 60 to 75 percent of pregnant women have gingivitis, an early stage of periodontal
disease in which the gums become red and swollen due to inflammation, which may be
exacerbated by altering hormones during pregnancy. Furthermore, Corbella et al., (2016) stated
that if gingivitis is not treated, the bone that supports the teeth might deteriorate and the gums
can get infected. Teeth with insufficient bone support might grow loose and may need to be
removed in the future. Periodontitis has also been linked to poor pregnancy outcomes such as
premature delivery and low birth weight. It is especially important to maintain good oral health
during pregnancy. Due to the increase in hormone levels, particularly estrogen and progesterone,
pregnant women are more at risk to develop inflamed gums, which if left untreated can lead to
gum disease.

The Philippine Dental Act of 2007 or R.A. No. 9484, directs the State in training and
nurturing competent, productive, morally upright, and well-rounded dental practitioners. The Act
regulates, controls, and supervises the practice of dentistry, dental hygiene, and dental
technology in the Philippines by administering license examinations and imposing penalties for
violations of the Act and other laws enacted under its provisions. This is the first dental Act to
acknowledge dental hygiene and dental technology as dental professions, as well as their value in
nation-building. The Philippine Dental Act of 2007 focuses on the dental professionals' scope of
practice.

The national government's primary responsibility is to create rules and guidelines for
local government entities. The Guidelines in the Implementation of Oral Health Programs for
Public Health Services were developed by the Department of Health in 2007 (AO 2007-0007).
The initiative seeks to reduce the prevalence of dental caries to 85% and periodontal disease to
60%. The program aims to achieve these goals by providing Filipinos with preventative,
curative, and promotional oral health care throughout their lives. This strategy establishes a
bundle of important basic oral health care (BOHC) for each lifecycle stage, from infancy to old
age, to offer a continuity of excellent treatment.

In the past few years, there has been a focus on determining the success of oral health
initiatives. This is in keeping with the growing need for evidence-based research and will assist
policymakers decide how to devote resources. A number of systematic reviews of the available
evidence have been done. These have demonstrated that oral health programs may be beneficial
in enhancing dental health care programs, hence aiding in the promotion of dental health and the
avoidance of dental illnesses. This review adds to the available literature on oral health in the
Province of Davao Oriental since systematic reviews are only as good as the underlying research
that underpins them, and prior reviews have highlighted the scarcity of studies in this discipline.

Review of Related Literature

Oral Health Conditions

Many nations have a significant health burden from oral disorders, which impact
individuals throughout their lives, causing pain, discomfort, deformity, and even death. These
disorders have risk factors in common with other major noncommunicable diseases (UNGA,
2011). Oral disorders are predicted to impact almost 3.5 billion people, according to the Global
Burden of Disease Study (2017). According to the Global Burden of Disease 2017, untreated
dental caries in permanent teeth is the most frequent health problem.

Treatment for oral health issues is costly and is typically not covered by universal health
care (UHC). Dental care accounts for 5% of overall health spending and 20% of out-of-pocket
health expenditure in the majority of high-income nations. Most low- and middle-income nations
lack the resources to prevent and treat oral health problems. A poor diet heavy in sugar, cigarette
usage, and hazardous alcohol consumption are all factors that contribute to oral illnesses. Most
oral health problems are mainly preventable and treatable in their early stages.

Oral Health Situation in the Philippines and the Policies that were Instituted

Oral disease is a major public health issue in the Philippines. Throughout the years, the
frequency of dental caries on permanent teeth has typically stayed above 90%. Approximately
92.4 percent of Filipinos have tooth decay (dental caries), and 78 percent have gum disease
(periodontal disease) (DOH, NMEDS 1998). Despite the fact that they are avoidable, practically
every Filipino will be affected by one of these diseases at some point in his or her life.
 Filipinos are afflicted with gum disease from an early age. Gingivitis affects 74% of 12-
year-old children, according to NOHS. If not treated early, these children are predisposed to
irreparable periodontal disease when they enter puberty and into adulthood.

Tooth decay and gum disease, in general, do not immediately cause disability or death.
These illnesses, however, can weaken the body's defenses and act as entry points for more
serious and possibly lethal systemic diseases and infections. Arthritis, heart disease, endocarditis,
gastro-intestinal illnesses, and ocular-skin-renal diseases are all serious problems. Aside from
physical deformities, these two oral disorders can cause considerable speech impairment, which
can have an impact on work performance, nutrition, social relationships, income, and self-
esteem. Poor dental health has a negative impact on academic achievement and can lead to
failure later in life. Children with poor dental health are 12 times more likely to experience
restricted-activity days (USGAO 2000).

The Department of Health instituted the Oral Health Program for Public Health Services
(AO 2007-0007) on the year 2007. Its objectives and targets are the following: (1) The
prevalence of dental caries and periodontal disease are reduced to 5% reduction of prevalence
rate annually; (2) Dental caries experience is reduced to 5% of mean dmft/DMFT for 5/6 years
and 12 years old children annually; (3) The proportion of Orally Fity Children 12-17 months old
is increased by 20% annually. The DOH hopes to empower Filipino citizens by taking care of
their own personal oral health for an enhanced quality of life. In addition, these are the
policy/standards/ guidelines that were formulated in addressing dental health concerns in the
Philippines: a.  AO. 101 s. 2003 dated Oct. 14, 2003 – National Policy on Oral Health; b. AO
2007-0007 – Dated January 3, 2007 Guidelines In The Implementation Of Oral Health Program
For Public Health Services In The Philippines; c. AO 4-s.1998 – Revised Rules and Regulations
and Standard Requirements for Private School Dental services in the Philippines; d. AO 11-D s.
1998 – Revised Standard Requirements for Hospital Dental services in the Philippines; e. AO 3
s. 1998 - Revised Rules and Regulations and Standard Requirements for Occupational Dental
services in the Philippines; f. AO 4-A s. 1998 – Infection Control Measures for Dental Health
Services.

Furthermore, the strategies and action points that are carried out by DOH are the
following:
 1. Formulate policy and regulations to ensure the full implementation of OHP

a. Establishment of effective networking system (Deped, DSWD, LGU, PDA, Fit for
School, Academe and others)

b. Development of policies, standards, guidelines and clinical protocols

- Fluoride Use

- Toothbrushing

- Other Preventive Measures

2. Ensure financial access to essential public and personal oral health services

a. Develop an outpatient benefit package for oral health under the NHIP of the
government

b. Develop financing schemes for oral health applicable to other levels of care (Fee for
service, Cooperatives, Network with HMOS)

c. Restoration of oral health budget line item in the GAA of DOH Central Office

3. Provide relevant, timely and accurate information management system for oral Health.

a. Improve existing information system/data collection (reporting and recording dental

services and accomplishments)

- setting of essential indicators

- development of IT system on recording and reporting oral health service

accomplishments and indices

- Integrate oral health in every family health information tools, recording

books/manuals

b. Conduct Regular Epidemiological Dental Surveys – every 5 years

4. Ensure access and delivery of quality oral health care services.

a. Upgrading of facilities, equipment, instruments, supplies

 b. Develop packages of essential care/services for different groups (children, mothers and
marginalized groups)

-revival of the sealant program for school children

- toothbrushing program for pre-school children

- outreach programs for marginalized groups

c. Design and implement grant assistance mechanism for high performing LGUs

- Awards and incentives

- Sub-allotment of funds for priority programs/activities

d. Regular conduct of consultation meetings, technical updates and program

implementation reviews with stakeholders

5. Build up highly motivated health professionals and trained auxiliaries to manage and provide
quality oral health care

a. Provision of adequate dental personnel

b. Capacity enhancement programs for dental personnel and non-dental personnel

The current FHSIS indicators/parameters are the following:

a) Orally Fit Child (OFC)– Proportion of children 12-71 months old and are orally fit
during a given point of time. Is defined as a child who meets the following conditions upon oral
examination and/or completion of treatment a) caries- free or carious tooth/teeth filled either
with temporary or permanent filling materials, b) have healthy gums, c) has no oral debris, and
d) No handicapping dento-facial anomaly or no dento-facial anomaly that limits normal function
of the oral cavity

b) Children 12-71 months old provided with Basic Oral Health Care (BOHC)

c) Adolescent and Youth (10-24 years old) provided with Basic Oral Health care (BOHC)

d) Pregnant Women provided with Basic oral Health Care (BOHC)

 e) Older Persons 60 years old and above provided with Basic Oral Health Care (BOHC)

Fit for School is a program developed by the country's Department of Education to

combat tooth decay in school-aged children. Every day, children walk outside to clean their teeth
with fluoride toothpaste in the school courtyard. Fit for School not only encourages healthy
behaviors, but it also gives children with access to safe drinking water and washing facilities.
The Fit for School Approach has evolved into the Essential Health Care Program, which serves
about 2 million children across 40 provinces in the Philippines.

Pregnancy

The health of a pregnant woman and her fetus are inextricably linked, and the mother's
dental health may have an impact on both. Dental treatment is frequently delayed during
pregnancy due to concern on the side of the woman, the health care provider, or the dentist, but
poor maternal dental health can have serious ramifications for the pregnancy and pregnancy
outcomes. Dental treatment, including radiography, local anesthetic, and oral pain medication,
has been shown to be safe during pregnancy (Hummel et al., 2015). All pregnant women should
get dental consultations to assess their own oral health and lower the chance of their children
acquiring caries (Wright et. al., 2016).

Periodontal treatment for tooth decay can be done at any time during pregnancy, but the
best period is during the second trimester (14–28 weeks). The gravid uterus is still small enough
during the second trimester to not put too much strain on the vena cava as a woman reclines on a
dental chair. Pregnant women can be reassured that dental care is safe throughout pregnancy. A
pregnant woman should be referred if she has not seen a dentist in the past 6 months. Delays in
treatment might endanger both the mom and the fetus. Periodontal infection during pregnancy
has been connected to preterm birth, low birth weight, and poor glycemic management (Bansal
& Kumar, 2013). Furthermore, periodontal disease during pregnancy has been linked to the
development of preeclampsia (Varshney & Gautam, 2014).

Poor maternal dental health can have serious implications for pregnancy and prenatal care
 Periodontal disease affects around 40% of all pregnant women. Periodontitis has been
linked to premature delivery, increasing the risk of low birth weight and preeclampsia. Bacteria
in pregnant women with periodontitis can produce systemic inflammation, which can contribute
to premature labor. Treatment of periodontal disease during pregnancy has not yet been proved
to enhance outcomes; nevertheless, it has been established that dental treatment of periodontal
disease during pregnancy is safe. Women should consult a dentist early in their pregnancy to
avoid or treat any dental health issues (Kessler, 2017).

Gingival changes occur during pregnancy when the gums become extremely
vascularized, hyperplastic, and edematous, although only 63 percent of pregnant women visit a
dentist (Manchir, 2016). Pregnancy is frequently accompanied with bleeding gums caused by
high estrogen levels. Nonetheless, bleeding gums are a common symptom of periodontal disease
and should not be overlooked. It is believed that 40% of pregnant women have some kind of
periodontal disease.

Pregnancy nausea and vomiting might lead to tooth enamel degradation. Women should
be urged to clean their mouths with a baking soda and water solution after vomiting (American
College of Nurse-Midwives, 2014). A dentist may also suggest prescription-strength topical
fluoride to prevent caries caused by erosion.

Gestational diabetes mellitus is a carbohydrate intolerance disorder that is discovered

during pregnancy (Nainggolan, 2013). Periodontal disease and gestational diabetes mellitus have
a bidirectional link. Cytokines generated from inflammatory periodontal tissues are recognized
insulin antagonists with the potential to alter blood glucose regulation and contribute to disease
development. Diabetes mellitus and gestational diabetes mellitus both enhance a woman's risk of
periodontitis and tooth loss.

Pregnancy is a time of development. Pyogenic granuloma, often known as pregnancy

tumor, is a benign inflammatory lesion that is the most frequent in the oral cavity. Pyogenic
granuloma, which is influenced by pregnancy hormones, can be detected on the gingiva, tongue,
lips, or buccal mucosa but most usually develops on the labial portion of the anterior maxillary
area (Sun et.al., 2014). If present, pyogenic granuloma is generally detected around the second
month of pregnancy and grows to its maximum size at 8 months. A pregnancy tumor should be
removed only if it interferes with mastication or causes discomfort. Pyogenic granuloma
normally cures and disappears within 12 weeks after delivery. It is critical that health-care
practitioners remain aware of this issue, which can occur in 10% of pregnancies (Sun et al.,
2014).

It is critical that clinicians include an oral examination throughout pregnancy. A lady

should be advised to see her dentist during her first prenatal checkup. The significance of dental
care during pregnancy for the health of both the mother and the fetus should not be
underestimated. Both the oral examination and the referral should be noted in the patient's
medical record. Pregnancy education includes a discussion on healthy dental health behaviors.

Postpartum

The postpartum visit is an excellent opportunity for doctors to advise women to follow up
on their own dental treatment (if it has been delayed) and to educate them on how to care for
their newborn's mouth. Vertical transmission of Streptococcus mutans, the bacterium that causes
caries, from mother to child is widely documented. Streptococcus mutans can survive in
newborns' mouths, placing them at risk even before their teeth emerge (American Academy of
Pediatric Dentistry, 2011). Women who have a high caries rate will convey those oral germs to
their babies, and the bacteria can live in an infant's mouth and cause caries when teeth emerge
(American Academy of Pediatric Dentistry, 2011). Bacteria are easily transmitted from mother to
newborn through saliva-sharing behaviors (e.g., sharing utensils, washing the pacifier with the
mother's saliva, prechewing food for the kid). Parental education and encouragement will aid in
the prevention of childhood caries.

The postpartum appointment is an excellent time to review the newborn's dental health.
Before the emergence of infant teeth, it is advised that a newborn's mouth be wiped out each day
with a piece of moist cotton gauze or a clean soft cloth (Clark et al., 2012). This is best done
before going to bed, when germs thrive. It is critical to dissuade parents from putting their infants
to bed with a bottle or a breast in their mouth. Fluoride products, as well as a low-sugar diet,
should be promoted. Saliva-sharing activities (food, pacifiers, bottles, etc.) should be avoided at
all costs. Dental appointments should begin at a young age. The American Academy of Pediatric
Dentistry recommends "initial visit by the first birthday" (2011). Awareness of excellent oral
practices has the ability to influence each child's future health.

Section 3. Methodology

The data came from the 2019 annual report of the Field Health Service Information
System (FHSIS) and the Oral Health Form (OHF) of the local Department of Health in Region
XI, particularly in Davao Oriental. The Department of Health's Field Health Services
Information System (FHSIS) Annual Report is a region-wide collection of data from health
institutions via city, municipality, and provincial health offices. The duties, performances, and
successes of health workers and officials in carrying out health thrusts and improved health
outcomes that are anchored via the strategic framework with the goal of healthier people in
Region XI are gathered, evaluated, and quantified in this public record. This yearly report
produces local sensible data that is crucial in establishing responsive health policies for
progressive development of cities, municipalities, and provinces, which is one of the finest
investments that partner agencies and stakeholders can have. This data is critical for achieving an
equitable impact in the formulation of helpful policies, initiatives, and projects, as well as
efficiency and effectiveness in rationalizing health spending.

Mothers or Pregnant Women would receive the Basic Oral Health Care Package under
the Oral Health Program for Public Health Services (AO 2007-0007), which includes the
following: (1) Oral Examination; (2) Oral Prophylaxis (scaling); (3) Permanent fillings; (4) Gum
treatment; and (5) Health instruction. The proportion of pregnant women receiving Basic Oral
Health Care is one of the key performance indicators used to determine program
accomplishment/status (BOHC). The formula for calculating the eligible population/target is as
follows: Total Population (TP) x 2.7%. The Provincial DOH Oral Healthcare department
frequently collects information on oral and dental health status as part of their vital statistics or
disease surveillance activities. As a result, information on oral health must be gathered in its
entirety or in part for this purpose.
 It is intended that the annual report would continue to aid legislators, program managers,
and health executives in the efficient and successful planning, implementation, monitoring, and
assessment of the key health innovations and efforts.

Section 4. Results and Discussion

Table 1 – 2019 FHSIS ANNUAL DENTAL REPORT: PREGNANT WOMEN GIVEN

BASIC ORAL HEALTH CARE BY BARANGAY, MUNICIPALITIES OF PROVINCE
OF DAVAO ORIENTAL, DAVAO REGION (REGION XI)
 The 2019 FHSIS annual dental report showed the following: The municipality of
Taraggona displayed the highest percentage of target to be accomplished with 45.7%, followed
by the municipality of Banaybanay with 38.8%, followed by the municipality of Boston with
34.6%, followed by municipality of Lupon with 32.9%, followed by the City of Mati and
municipality of Governor Genoroso with 28.3%, followed by the municipality of Caraga with
26.1%, followed by the municipality of San Isidro with 24.6%. The lowest percentage were
garnered by the municipalities of Cateel, Baganga, and Manay with 17.5%, 12.3%, and 8.5%
respectively.

Table 2 – ORAL HEALTH FORM 2 PREGNANT WOMEN GIVEN BASIC ORAL

HEALTH CARE IN OF DAVAO ORIENTAL, DAVAO REGION (REGION XI)
 Table 2 showed the Oral Health Form 2 (OHF 2) that is composed of the activities and
the services rendered by the Department of Health – Province of Davao Oriental in the year
2019. In its annual report there were 4206 Pregnant Women who attended and there were only
4200 who were examined. Furthermore, the oral health status of these pregnant women shows
that there were 3696 who have Dental Caries, 1888 who have Gingivitis/Perio-Disease, 3547
who have Oral Debris, 2897 who have Calculus and 40 who have Dento-Facial Anomalies.
Furthermore, the total DMF (Decayed, Missing, Filled) tooth account sums to 12,466. There
were 5748 Total Missing and 1507 Total Filled.

In the second part of the report, it displayed the services rendered. There were 3507 who
were given the OP/Scaling, 703 who were given Permanent Filling, 202 who were given
Temporary Filling, 70 who were given Extractions, 1681 who were given Gum Treatment, 26
who were given Post-Operative Treatment, 89 who availed of the Oral Abscess Draining, 340
who were given other services, 1043 who were referred, and 3908 who were given
Counseling/Education on Tobacco OH diet.

Section 5. Conclusion

The findings revealed that there is still considerable work to be done to reduce the
prevalence rate of dental caries and periodontal disorders in the general population, as well as to
enhance the oral health conditions of pregnant women by 20%. Regular dental care is essential
for excellent oral and overall health. Improved maternal dental health may prevent the transfer of
possibly cariogenic germs to newborns and the risk of caries in children in the future (Meyer
et.al, 2010). Obstetrician–gynecologists are the most commonly accessible health care
practitioner for many women, creating a unique opportunity to educate women about the
significance of dental care and excellent oral hygiene throughout their lives, especially during
pregnancy.

Recommendations

Based on the current review and literature the following could be recommended to the
local health authorities:
1. Concentrate on public health intervention and local implementations via preventative
initiatives. Engage academia and other educational establishments in growing the workforce of
dentists and other oral health ancillaries, and developing their capabilities aimed toward
prevention rather than cure. Consider the important responsibilities of midwives, obstetricians,
pediatricians, school administrators, primary school teachers, and barangay health workers
(BHWs), to mention a few, in preventive and health promotion. Because dental caries is a
behavioral illness, prevention should begin during pregnancy through mother and child care
programs.

2. Generate enough funding for the long-term viability of national oral health initiatives.
Consider imposing an excise charge on sugary drinks and cigarettes.

3. Form a technical working group to further debate the implementation specifics of proposed
policies that are on the verge of being operationalized.

4. Inform women that maintaining good oral health throughout their lives enhances their overall
health and may minimize the spread of potentially carious mouth germs from mothers to their
infants. Conduct an oral health assessment during the first prenatal visit.

5. Be knowledgeable of the patients' health coverage for dental care during pregnancy so that you
may refer them to the proper dental practitioner.

6. Establish a working relationship with a local dentist. Refer patients for dental health
treatment using a written letter or phone call, just as you would for any medical expert.
7. Women's dental health coverage should be expanded before, during, and after pregnancy,
according to advocates. Pregnancy is a special moment for women to obtain dental health
coverage.

8. Encourage basic oral health maintenance, such as reducing sugary foods and beverages,
brushing twice a day with fluoridated toothpaste, flossing once daily, and seeing the dentist twice
a year.
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