Odontology

https://doi.org/10.1007/s10266-018-0356-3

ORIGINAL ARTICLE

Influence of a preventive program on the oral health‑related quality

of life (OHRQoL) of European pregnant women: a cohort study
Yolanda Martínez‑Beneyto1 · Javier Montero‑Martin2 · Francisco Garcia‑Navas1 · Ascension Vicente‑Hernandez1 ·
Antonio Jose Ortiz‑Ruiz1 · Fabio Camacho‑Alonso1

Received: 4 December 2017 / Accepted: 22 March 2018

© The Society of The Nippon Dental University 2018

Abstract
The aim of this study was to compare the impact of oral health on quality of life of a group of pregnant women enrolled in
a program of oral health with respect to a control group of non-pregnant women. A cross-sectional study involving a socio-
dental indicator OHIP-14 and a dental examination was completed to assess pregnant women’s knowledge of oral health,
hygienic habits, periodontal and caries index. Data were collected from 113 pregnant women and 113 non-pregnant women.
Sociodemographic data for both groups were homogeneous. Pregnant women have better values of general and oral health,
even though they have not perceived need for dental treatment, compared with control group. A worse periodontal health
was observed for the control group. Our results showed that quality of life in pregnant women has been influenced with a
statistical significance (p < 0.05) by the variables age, unemployment, level of education, immigration, frequency of brush-
ing, type of dental practice, self-reported general and oral health and perceived treatment needs. The oral quality of life
of pregnant women seems to be positively influenced by the incorporation of preventive oral programs during pregnancy.

Keywords  Pregnant women · OHRQoL · Oral health · OHIP-14

Introduction For decades, both oral physiological and pathological

Pregnant women can, therefore, be considered as patients
with a temporary but higher than normal risk of develop-
ing complications, mainly at a periodontal level [1]. Women
experience metabolic changes with alterations in hormone
levels, increase in pathogenic bacteria in the oral cavity,
changes in the immune response and the cellular metabo-
lism [2]. Gingivitis in pregnant women occurs as a result of
an increase in the circulating levels of progesterone and its
effects on the gingival microvasculature [3]. In fact, gingi-
val changes are most evident from the second trimester of
pregnancy, reaching the highest level in the 8th month [2],
reducing the gingivitis until after delivery being similar to
that during the second month of pregnancy [3].
* Yolanda Martínez‑Beneyto
yolandam@um.es
1
Department of Stomatology, Faculty of Medicine‑Dentistry,
University of Murcia, Murcia, Spain
2
Department of Surgery, University of Salamanca, Salamanca,
Spain
changes that occur in pregnant women have been thoroughly
studied and documented, including both the periodontal con-
dition and those related with hard tissues [4, 5]. Also, the
influence of periodontal diseases on the systemic health of
both the mother and the fetus has been discussed as well as
possible complications, such as low weight babies, preec-
lampsia, and diabetes [6].
There is evidence that prevention programs during preg-
nancy have a very positive impact on the gingival health
of pregnant women even reducing the risk of preterm low
weight babies [8]. There is evidence that prevention pro-
grams during pregnancy have a very positive impact on the
gingival health of pregnant women [7], even reducing the
risk of preterm low weight babies [8, 9] and reducing the
appearance of caries in the baby. This is why it is so impor-
tant to carry out interventions before the birth of the baby
[10]. Thus, the intervention of the government or relevant
political authorities is necessary for the establishment of
preventive programs in this risk group [11].
Sociodental indicators are questionnaires prepared to
address all those dimensions of the oral quality of life that
the authors involved want to study. OHIP-14 is one of the

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most internationalized instruments in this respect and it has
been validated in Spanish for adults [12, 13].
There are, up to our knowledge, no published papers
about oral quality of life in pregnant women undergoing an
oral preventive program and assuming that pregnant women
have a poorer quality of oral health; the aim of this study was
to compare the impact on oral health-related quality of life
(OHRQoL) in a group of pregnant women enrolled in a pro-
gram of specific dental cares during pregnancy, compared
with a group of non-pregnant women.
Materials and methods
This cohort study followed the STROBE recommendations
for observational studies [14]. It was conducted with 226
women attending a Primary Health Care Center in Murcia,
Spain. 113 participants (study group) were third trimester
pregnant women included in an oral preventive program.
During this third trimester, women have a greater tendency
to have bleeding gum and periodontal disease. Pregnant
women were found out through the midwife, and referred
to the dentist of the Public Dental Health Service during the
first or second trimester of pregnancy. During pregnancy,
women included in an oral preventive program have to attend
three times to the dentist surgery: first during the second tri-
mester of pregnancy, second the third trimester and the final
ones after delivery. Depending on caries and periodontal
risk, they were treated with different alternatives among the
preventive programs such as fluoride (toothpastes and var-
nishes), chlorhexidine 0.12%, oral hygiene techniques and
tartrectomies if necessary. In our study, pregnant women
were interviewed at the end of the treatment included on the
preventive program during the third trimester.
The control group comprised 113 non-pregnant women
with the same age range, randomly selected from women
attending the same health centre. Inclusion criteria to form
part of the study group were: gestation period more than
6 months, a screening test without genetic anomalies, and
non-risk pregnancy. According to KREJCIE et al. [15], it is
necessary to compile information on a total of 63 women to
attain 95% confidence for a finite population of 450 women,
included in oral health program with a gestation period
between 16 and 31 weeks and a negative screening test for
genetic anomalies, and non-risk pregnancy.
For the control group, the inclusion criteria were to be
of fertile age and not pregnant, to have no disease and who
were attending the centre to accompany a patient.
Patients were informed of the characteristics of the study
and gave their written consent to be included in the inves-
tigation. The study protocol was previously approved by
the Institutional Committee of Ethics, University of Murcia
13
(Spain) in accordance with the ethical principles of Declara-
tion of Helsinki.
Women answered questions related with their sociode-
mographic data. The data collected also included past den-
tal attendance by the pregnant women, hygiene habits, and
smoking habits. Oral Health Impact Profile-14 (OHIP-14)
Spanish version [12] was included in the questionnaire as
a measure of the impact of the oral health in disrupting the
psychological, physical and social performances. The partic-
ipants responded to each item according to the frequency of
the impact on a 5-point Likert Scale (0–4), from never (0) to
almost always [12]. The impact on OHQoL was estimated by
counting the number of items recording as occasionally or
more frequently (≥ 2 in the Likert scale) within the domains
and in summary (OHIP total).
The second interview included a clinical examination at
the Oral Health Clinic of the Primary Health Care Centre
under standardized conditions. The intra-examiner agree-
ment was > 0.63 according to the Kappa test. Dental decay
was evaluated with the Decayed, Missing and Filled Teeth
(DMFT) index [16]. A single, independent, calibrated dentist
examined all participants with a scribe in attendance. The
periodontal index registered was the Community Periodontal
Index (CPI) [16]. General and oral health was self-evaluated
on a Likert scale ranging from 0 (bad) to 5 (very good).
The analysis of the results was carried out using the SPSS
version 19.0 Statistical Package for Social Science ­(SPSS®,
Inc., Chicago, IL, USA). A descriptive study was made of
each variable. Scores were expressed as percentages of the
maximum mark obtainable. The associations between dif-
ferent parameters were assessed using the Student’s t test for
quantitative variables. A Chi squared Pearson test was used
to evaluate the differences among the qualitative variables.
A stepwise linear regression model was calculated to predict
the impact on OHQoL based on the predictors found in the
bivariate analyses. For all the analyses, the level of statistical
significance was established at p < 0.05.
Results
The mean age was 32.99 (SD 4.91) years for the pregnant
women and 32.13 (SD 5.89) years for the control group.
Both groups were homogeneous (Table 1).
As regards to beliefs and knowledge of the pregnant par-
ticipants concerning oral health, 7.1% thought dental treat-
ment during pregnancy was harmful for the fetus, that X-rays
were totally prohibited (63.71%) and would not authorize
them (66.41%), although they considered that poor oral
hygiene would have a negative affect (74.3%).
9.74% of the pregnant women smoked 3–10 cigarettes
a day compared with 20.35% of non-pregnant group.
Body mass index (BMI) during gestation was normal
Odontology

Table 1  Sociodemographic description of the subsample of pregnant Table 2  Description and comparison of the behavioral variables
women and controls among pregnant women and controls (Chi squared Pearson test)
Sociodemograpic Pregnant Controls p value Conductual variables Pregnant Controls p value
predictors women (n = 113) Statistical test women (n = 113)
(n = 113) (n = 113)
Mean SD Mean SD N % N %

Age (years) 33.0 4.9 32.1 5.9 0.242T Time since last visit to the dentist
Age interval N % N % 0.009C  < 6 months 31 27.4 29 25.7 0.371
 ≤ 25 years 9 8.0 19 16.8  6–12 months 25 22.1 30 26.5
 26–35 years 76 67.3 54 47.8  13–24 months 36 31.9 26 23.0
 ≥ 36 years 28 24.8 40 35.4  > 24 months 21 18.6 28 24.8
Educational level Usual motivation for dental visits
 None 0 0.0 2 1.8 0.479C  Regular check-ups 54 47.8 33 29.2 0.006
 Basic 28 24.8 29 25.7  Problem-based visits 59 52.2 80 70.8
 High School 53 46.9 55 48.7 Brushing habits
 University 32 28.3 27 23.9  Once/twice a day 10 8.8 19 16.8 0.112
Civil Status  3–4 times a day 103 91.2 94 83.2
 Married 84 74.3 60 53.1 0.001C Uses of mouth rinses
 Single 29 25.7 53 46.9  Yes 62 54.9 74 65.5 0.143
Employment status  No 51 45.1 39 34.5
 Active worker 80 70.8 75 66.4 0.474C Use of dental floss
 Unemployed 33 29.2 38 33.6  Yes 41 36.3 47 41.6 0.501
Nationality  No 72 63.7 66 58.4
 Spanish 93 82.3 97 85.8 0.573C Use of interproximal brush
 Foreign 20 17.7 16 14.2  Yes 20 17.7 23 20.4 0.732
T
 No 93 82.3 90 79.6
  Student test
C
  Chi squared Pearson test

(18.50–24.99) in 71.75% of cases. It was their first preg-
nancy for 62.79% of the study group, while 22.12% had
suffered a previous abortion. Premature babies had been
born to 9.5%.
Concerning oral hygiene habits, the results showed that
91.2% of the pregnant women reported brushing their teeth
three times a day, changing toothbrush more regularly than
the control group, using fluorinated toothpaste (83.18%),
although the use of dental floss was low (36.29%). Of the
study group, 27.4% visited the dentist every 6 months,
which is a lightly higher figure than that for the control
group (25.7%) (Table 2). Approximately, a tenth (8%) of
total women had private dental insurance.
Table 3 shows the oral health status of the pregnant and
control groups. The members of the first group had higher
values (p < 0.05) of decayed teeth, DMFT and standing
teeth and a higher number of missing teeth (p = 0.001).
Of the pregnant women, 88.5% showed some gingivitis,
which rose to 95.6% in the control group. Pregnant women
showed a higher rate of bleeding gums (code 1 periodontal
index) than control group, nevertheless a lower rate on
code 2 (calculus) (p < 0.05) (Table 3).
84.1% of pregnant women assumed good self-rated
general health compared with 72.6% of the control group
(p < 0.05) and there was good self-rated oral health also
(16.8%) for the pregnant group (p < 0.001).
Related to the perceived needs for dental treatment,
44.2% of the pregnant group though that they did not need
dental treatment (p = 0.01).
The control group had significantly higher values for
the impact on the OHQoL according to the OHIP for pain,
psychological discomfort, physical disability and psycho-
logical disability sub-scales. According to the OHIP, for
their impact on OHQoL, the control group gave signifi-
cantly higher values to pain, psychological discomfort,
physical disability and psychological disability sub-scales
(p < 0.001), same for total value of OHIP-14 (Table 4).
A correlation analysis investigated the relationship
between sociodemographic predictors, conductual, clini-
cal and subjective variables. Table 5 demonstrates that the
impact on oral health-related quality of life increased pro-
portionally with the number of decayed teeth, perceived
poor general health, the pattern for dental attendance and
among non-Spanish participants.

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 Odontology

Table 3  Description and comparison of the oral health status among pregnant women and controls (Student’s test)
Dental disease Pregnant women (n = 113) Controls (n = 113) p value

Number of decayed teeth 1.4 2.0 0.8 1.9 0.018

Number of filled teeth 4.4 3.1 4.7 3.8 0.481
Number of missing teeth 0.9 1.6 1.8 2.4 0.001
DMFT 6.8 4.1 7.2 4.9 0.462
Standing teeth 26.8 2.4 25.2 5.2 0.004
Periodontal disease Mean SD Mean SD p value

Number of healthy sextants (PCI = 0) 2.3 2.1 2.0 2.1 0.172

Number of bleeding sextants (PCI = 1) 2.2 1.8 1.8 1.5 0.044
Number of tartaric sextants (PCI = 2) 1.3 1.8 2.0 1.7 0.002
Number of sextants with pockets (PCI = 3) 0.1 0.5 0.3 0.8 0.101

Table 4  Description and comparison of the wellbeing-related variables among pregnant women and controls
Pregnant women (n = 113) Controls (n = 113) p value
Chi squared
N % N % Pearson test

Self-rated general health

 Bad 7 6.2 4 3.5 0.014
 Regular 11 9.7 27 23.9
 Good 95 84.1 82 72.6
Self-rated oral health
 Bad 23 20.4 44 38.9 < 0.001
 Regular 71 62.8 67 59.3
 Good 19 16.8 2 1.8
Perceived dental treatment needs
 Yes 63 55.8 81 72.3 0.013
 No 50 44.2 31 27.7
Impact on the OHQoL according to the Mean SD Mean SD p value
OHIP Student’s test

Functional limitation 0.2 0.5 0.2 0.5 0.782

Physical pain 0.8 0.9 1.2 0.8 < 0.001
Psychological discomfort 0.7 0.7 1.1 0.8 < 0.001
Physical disability 0.2 0.6 0.4 0.7 0.021
Psychological disability 0.3 0.6 0.5 0.8 0.016
Social disability 0.2 0.6 0.3 0.6 0.212
Handicap 0.3 0.6 0.4 0.7 0.061
Overall OHIP-14 score 2.7 3.6 4.2 3.6 0.002

Discussion experience among a group of pregnant women included

Illness in general has been related not only with clinically
detectable biological factors, but also with other factors
such as style of life, and behavioral and psychological fac-
tors [12]. No studies have been conducted on oral quality
of life and its relationship with oral sociodemographic
status, oral hygiene habits, dental decay and periodontal
in an oral preventive program, with regular visits, use of
fluoride, chlorhexidine, improving oral hygienic habit and
mechanical removing of plaque.
Information and preventive measures on the part of pro-
fessionals on good oral hygiene habits during pregnancy can
help avoid gingival problems and their effect on the fetus,
while increasing both objectively and subjectively the con-
ception of oral health.

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Odontology
Table 5  Linear Regression Analysis for predicting the impact on OHQoL (OHIP total Score) after introducing all the potential predictors (soci-
odemographic, conductual, clinical and subjective variables)
Parameter β SE
Number of decayed t­eetha 0.56 0.11
Self-rated general h­ ealthb (good as reference) 1.51 0.39
Pregnancy (pregnant as reference)c 1.52 0.43
Motivation for dental check-upd (regular vs 1.19 0.45
problem-based visits)
Nationality (Spanish vs Foreigner)e 1.19 0.45
a
 F = 31.8; p < 0.001; corrected R2: 0.12
b
 F = 29.7; p < 0.001; corrected R2: 0.20
c
 F = 26.6; p < 0.001; corrected R2: 0.26
d
 F = 22.9; p < 0.001; corrected R2: 0.28
e
 F = 19.4; p < 0.001; corrected R2: 0.29
Few studies have used the OHIP-14 questionnaire with
pregnant women [17–21]. The questionnaire has been used
for the subjective assessment of the impact of given altera-
tions and conditions on the quality of life, and it is used fre-
quently in epidemiological studies to subjectively evaluate
oral health [22]. However, the present study is the first to
describe the oral quality of life in pregnant women in Spain
using the version adapted specifically for this population
[12].
The study was made with women in the third trimester
of pregnancy included in a oral preventive program from
the first–second trimester, while most studies to date have
dealt with women in the first and second trimesters of preg-
nancy [21, 23] when most gingival problems have not yet
developed.
Most participants in our study were Spanish and the mean
age of 33 was slightly higher than that of similar studies
made in other parts of the world [17–21], confirming that
Spanish women have children at an older age than many
other countries. No association between age and quality of
oral life was detected in the study, similar to other studies
conducted in other countries [18] unlike other studies [21].
Numerous studies have mentioned highest values of oral
impacts more frequently among multiparous women [18,
20, 24], although in our study, most of the women who were
pregnant for the first time did not find a significant relation
in this respect.
Our study has shown that the women included in an
oral health program (educational and preventive treatment)
were more motivated in their regular dental revisions com-
pared to the control group. However, the low use of dental
services by pregnant women is a common occurrence [25],
and about three quarters of the participants in a study by
WANDERA et al. [24] had never even visited a dentist. It
seems reasonable to think that being included in a program
Standardized β p value CI 95%_lower CI 95%_
limit upper limit
0.30 < 0.001 0.35 0.78
0.22 < 0.001 0.73 2.29
0.21 < 0.001 0.67 2.36
0.16 0.009 0.31 2.08
0.12 0.042 0.05 2.37
means that it is possible to change important habits such as
the awareness of very frequent dental revisions. However
in Shanghai, where free antenatal health care education
programs are provided, only 1.2% of the pregnant women
followed used dental services for regular dental checkup
[21].
The use of preventive measures such as frequent brush-
ing, using mouthwashes, dental floss and interproximal
brushes did not seem to be greater than that observed in the
control group in our study, despite the program. There are
studies [10, 26] that indicate the need for multilevel inter-
vention activities and not only educational campaigns, pro-
moting activities and preventive programs.
However, the results in terms of oral hygiene habits in our
study were far superior to those detected in other groups of
pregnant women [18, 27]. In our study, the presence of vom-
iting was not associated with oral quality of life, a parameter
that in other studies showed a significant relation [21].
The occupational level and the level of education have
a direct influence on the quality of life of pregnant women
[19]. In our study, most of the pregnant women were
employed, married and with a medium level of education
(high school and university), the same characteristics as in
the control group.
An increase in tooth caries among pregnant women was
detected, although the DMFT index was lower due to a
lower presence of missing teeth. The values of DMFT for
the group of pregnant women were slightly lower for the
same cohort of women of the National Survey of Spanish
Oral Health [10]. In our study, we detected a relationship
between high values of OHIP-14 and active caries in preg-
nant patients. These results are similar to the detected in
India [17, 18] and Brazil [20]; however, with Argentines, no
association was detected with active caries, even with higher
values of DMFT [23].
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 Odontology
Bleeding gums were more frequent among the group of
pregnant women compared to non-pregnant women; how-
ever, a lower level of calculus was detected (CPITN score
of 2) and established periodontal disease (CPITN score of
3 and 4) among pregnant women. These results are very
positive and would be due to the women being included in
the preventive program, where they would have been treated
for gingivitis and periodontal disease, minimizing the risks
of preeclampsia, low weight babies at birth and even ges-
tational diabetes, which are related with advanced stages
of periodontal disease. These results are contradictory to
those published in a similar study in India [18], where the
non-pregnant women had fewer periodontal problems. In
our study, 88.5% of pregnant women showed signs of gingi-
vitis (CPITN 1–4), a very similar situation described in the
national survey of oral health for the group of non-pregnant
Spanish women [28] and lower than that described in other
similar studies (93.75–100%) (18, 23), despite that in our
study they are in the third trimester, when gingivitis in preg-
nancy peaks.
No correlation between periodontal disease and high
values of OHIP-14 were detected, similar to other studies
[23, 24]. This situation is due to the low severity of the peri-
odontal conditions observed among the group of pregnant
women, where the values of CPI ≥ 2 were superior in the
control group.
Few studies have linked “self-rated general health” and
“self-rated oral health” variables and the oral quality of life
(OHRQoL) in pregnant women. In our study, these two
variables showed significant and important differences. The
degree of good self-rated general health was higher among
the pregnant women, particularly so in the case of self-rated
oral health where the difference between groups was signifi-
cantly higher.
In general, dental pain, bleeding gums and changes in
gum color, all of which have been associated with limited
oral life quality in toothed patients. This situation is reflected
in physical pain and psychological discomfort, the two
domains most commonly reported [21].
When there are limitations such as a low number of
teeth, the problems affect the overall quality of life which
is reflected in the OHIP-14 as “functional limitation” and
“physical disability” [21, 24]. However, these problems were
not detected in our study, since, as mentioned above, the
level of oral health among the pregnant women did not differ
much from that of the control group.
In terms of total values of OHIP-14, the group of non-
pregnant women showed much higher values than the group
of pregnant women. These results contradict previously
published results, which associated a poorer OHRQoL with
pregnant women, compared to non-pregnant women [18].
The same research group showed that increased age, multi-
parity, dental caries and periodontal disease were associated
13
with poorer OHRQoL in pregnant women. However, our
results demonstrate that the impact on oral health-related
quality of life increases proportionally among non-Spanish
participants, when habits are not very favorable, such as
low attendance for dental revisions, when dental caries is
active and, in general, when the perceived general health
and oral health is poor. These variables could be a predictor
for OHRQoL.
An important limitation of our study is that our data
has not been compared with a group of pregnant women
not included in an oral preventive program. We decided to
choose as a control group non-pregnant women, because
their periodontal status should be better than pregnant
women. However, the results obtained have been encourag-
ing and positive.
In summary, in two homogeneous groups of women in
terms of sociodemographic data, an average educational
level and acceptable oral hygiene habits, the group of women
in the final stage gestation had a better perception of oral
quality of life and general health compared to a control
group of non-pregnant women.
This lead us to suggest that behavioral intervention to
promote oral health-related changes during pregnancy
seems to be beneficial in limiting periodontal illness and
could increase their positive perception of oral and general
quality of life.
Compliance with ethical standards 
Conflict of interest  The author(s) declares that they have no conflict
of interests.
Funding None.
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