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Pregnancy gingivitis: a survey of 100 antenatal patients
Journal of Dentistry,2, 106-110
Pregnancy gingivitis: a survey of 100 antenatal patients D. Adams, B.Sc.,
M.D.S., Ph.D.
J. S. Carney, B D.S. D. A. Dicks, B.D.S. Department of Oral Biology, Dental School, Cardiff ABSTRACT The incidence and severity of gingivitis were compared in pregnant and non-pregnant women. Gingivitis was increased in the maxillary anterior region during pregnancy though little difference was found around the lower anterior teeth. The presence of soft deposits on the teeth was related to the gingivitis in non-pregnant women to a greater degree than in pregnant women. Pregnant women were found to have less debris and brushed their teeth more frequently than the control group. It was concluded that the results confirm the action of a factor or factors other than debris as a causative agent for gingivitis during pregnancy.
INTRODUCTION THE incidence of gingivitis in pregnancy has been reported as being as low as 30 per cent in one survey (Hasson, 1960) and as high as 100 per cent by Hiiming (1950). The cause of this gingivitis is thought to be hormonal (L~Se, 1965), though an association with local factors has also been suggested (Maier and Orban, 1949; Hilming, 1950; Silness and L/Se, 1964). In order to examine the possible relationship between poor oral hygiene and gingivitis we have looked at both these factors in pregnant and non-pregnant women. Equal numbers of subjects were used. Our survey differs from that of Silness and L/Se (1964) and Hugoson (1970) in that our non-pregnant group was not a follow-up of the pregnant women in the survey and had not been subjected to oral hygiene measures or pressures of any kind beyond what might be expected in the general population.
THE SAMPLE AND EXAMINATION TECHNIQUES The pregnant women examined were attending the antenatal clinics of consultant obstetricians of the Welsh Hospital Board for the first time. The stage of pregnancy varied from the third to the ninth month and the majority of new patients attending the clinics over a 4-week period were seen. Ninety-nine per cent of the patients who were asked to participate in the survey agreed and in all 100 patients were examined. The non-pregnant group comprised 100 women who were attending either postpartum clinics 10 weeks after parturition or contraceptive clinics for the first time. None of this group was having any form of hormone therapy at the time of examination. Each person was examined on one occasion only as it was felt that the examination itself might have some effect on the oral hygiene. Advice on oral hygiene was in fact given when requested during the investigation. Some of the women were edentulous and so could not be included. Some were edentuious in one jaw but were included in relation to the teeth present. The pregnant women were examined in cubicles in the antenatal clinic using Anglepoise lamps for illumination. Only the anterior part of the mouth was scored for gingivitis and debris though a general oral examination was also carried out. For gingivitis a modified gingival index system (LOe and Silness, 1963) was used except that papillae rather than teeth were scored. All the anterior interdental papillae (upper and lower) found between the
Adams et al. : Pregnancy Gingivitis
right and left first premolars were included, thus giving seven papillae in each jaw. The method of scoring was: 0, No inflammation. 1, Slight to moderate redness in papillae. 2, Swollen papillae with redness extending around marginal gingivae. 3, Swollen papillae with blood or pus exuding with gentle pressure. No mobility tests were made, and where there were gaps in the arch the papillae on either side of the gap were scored. Debris was scored as present or absent by running a blunt periodontal probe over the labial gingival margins of the upper and lower canines and incisors. If debris was present on a tooth the score was 1 and if not 0. Thus the maximum score in each jaw was 6. The oral cavity was examined and a report made to the patient if any lesions were noted. Information was also gained by means of a short questionnaire on age, duration of pregnancy, smoking habits, denture wearing and oral hygiene, whether the patient had regular dental treatment, and husband's or own occupation. The examination of the non-pregnant women was conducted in the same manner although the lighting tended to vary from clinic to clinic. In an attempt to standardize the subjective estimation of papillary inflammation prior to the survey, colour transparencies of the anterior region of the mouth of patients with and without gingivitis were examined, discussed, and scored together and separately until agreement was found consistently. The procedure was then repeated on patients attending the Periodontal Department of the Dental Hospital in Cardiff. All the examinations in the survey were carried out by two of us (D.A.D. and J.S.C.), each person examining approximately equal numbers of patients in the groups.
R ES U LTS
The pregnant women as a group were slightly younger than, the non-pregnant group. The age range for the l~regnant:women was 16-39 years and for the non-pregnant group 17-45. years (Table 1).
107
Gingivitis as measured by our technique was found to be more prevalent in pregnant than non-pregnant women. In 54 out of 93 pregnant women the upper anterior papillae had a total score of 7 or over, i.e., equivalent to slight redness on all the papillae, whereas 40 out of 88 non-pregnant women scored 7 or over. Using a %2 test the difference between the scores was only just significant statistically. In the lower arch, however, there was no statistical difference between the two groups. Fifty-five out of 97 pregnant women were scored 7 or over whilst 47 out of 92 nonpregnant women had scores higher than 6
(Table
H).
Table L--Age of subjects Age (yr.)
Pregnant
16-20 21-25 26-30 31-35 36-45
18 44 23 6 5
Non-pregnant 5 21 32 16 15
Table//.--Papillary scores Total scores Upper jaw
0 1-6 7-21 Total
0 Lower jaw 1-6 7-21 Total
No. of patients P r e g n a n t Non-pregnant 9 30 54
15 33 40
93
88
18 24 55
18 27 47
97
92
Only 9 pregnant women and 15 non-pregnant women had no gingivitis in the upper jaw. In the lower jaw 18 cases in each group were free of gingivitis. A statistical analysis of the distribution of inflamed papillae in pregnant and non-pregnant women showed that in pregnancy there was more severe involvement in the upper jaw (;~2=19.02, highly significant), whereas in the lower jaw no such difference was found ( ~ = 1 . 3 3 , not significant). Considering upper and lower papillae together the variation in the upper jaw was enough to
108
Journal of Dentistry, Vol. 2/No. 3
give a highly significant difference (Za= 15.03) between pregnant and non-pregnant women overall (Table/11). The mean scores for the presence of debris tended to be lower in pregnant women than in
non-smokers as compared with 54 per cent of the control group. No statistical differences in scoring were detected when observer 1 was compared with observer 2.
Table IlL--Total numbers of papillae in each category
Table/V.--Total debris scores
Group
0
Gingival index 1 2
3
Group
Upper jaw Pregnant 136 309 158 Non-pregnant 200 247 125 7,==19.02 (highly significant)
33 19
Upper jaw Pregnant Non-pregnant
Lower jaw Pregnant 209 276 Non-pregnant 217 237 7'z=1-33 (not significant)
149 152
34 23
Lower jaw Pregnant Non-pregnant
Upper and lower jaws Pregnant 345 585 307 Non-pregnant 417 484 277 Z==15.03 (highly significant)
67 42
the control group. Of the pregnant group, 22 out of 93 had a maximum score of 6 in the upper jaw and 36 out of 88 non-pregnant women had the maximum score. For the lower jaw 33 out of 97 pregnant women had a score of 6 whilst 46 out of 92 in the controls had soft deposits on each tooth. When the totals for all the anterior teeth in the pregnant group were compared with the totals for the teeth in the control group this difference became much more evident (Table 11,'). In the upper jaw the difference is highly significant (P<0.002), as is also the case in the lower jaw (P<0.002). As could be expected from this result when upper and lower scores are combined in each group the difference is also highly significant ( P < 2 × 10-8). Other interesting results from this study include the finding that 73 pregnant women brushed their teeth twice or more times daily while only 57 out of 100 of the non-pregnant women claimed to use their toothbrushes more than twice a day (Table V). Of the 40 women in both categories who wore any form of denture only one removed her denture habitually at night. Thirty-four per cent of the pregnant women were
+
Debris
_
302 329 7== 10.30, P<0.002
236 169
333 375 7,==14.72, P<0.001
238 164
Upper and lower jaws Pregnant 635 Non-pregnant 704 7,2=25"35, P < 2 × 10 -~
474 333
Table V.--Toothbrushing habits No. of brushings daily
Never Once Twice More than twice
Pregnant
Non-pregnant
3 23 60 13
2 41 52 5
DISCUSSION
This survey was carried out by students during a 4-week elective period project and hence the methods used were designed to give the maximum results in the shortest time, whilst maintaining standards that would render the project meaningful. Thus, the modification of the gingival index was intended to allow for the conditions found in the clinics, where lighting and position of the patient were variable. Since gingivitis is commonly found in the interdental papillae and since there is some difficulty in ascribing the papillary inflammation to either of the adjoining teeth, it was decided to score the papillae rather than the more usual method of using the tooth as the reference point. The anterior segment was chosen in spite of the objections put forward by Wade (1966) since
Adams et al. : Pregnancy Gingivitis
all regions show similar patterns of involvement according to the figures of Hugoson (1970). Alexander (1970) has pointed out that the method of assessing gingivitis should be related purposefully to the information required, and since we wanted a simple method to compare two populations this seemed to have the merit of simplicity and speed. Revision of the criteria for gingivitis was carried out at regular intervals in art attempt to minimize observer variability. Plaque and debris scores involving the whole crown of the tooth have been criticized on the grounds that plaque on the coronal part of the tooth probably does not contribute much to disease. For this reason and because it was impracticable to use disclosing solution it was decided to follow the pattern adopted by Swallow and Adams (1967) and score debris in contact with the gingivae as present or absent. There would appear to be a discrepancy between scoring the papillary condition and attempting to relate this to the presence of debris on the labial surface, but in practice the scoring included debris in contact with the papillae. That gingivitis was more frequent in the upper anterior papillae of the pregnant group compared with the non-pregnant group confirms the observations of, among others, Hilming (1950), L/Se and Silness (1963), Silness and L/Se (1964), L/Se (1965), and Hugoson (1970). Where the present study differs from most previous ones is in the comparison of upper and lower jaws. In the only other report found which does make a comparison (Cohen, Friedman, Shapiro, and Kyle, 1969) the findings were similar to those reported here, with greater differences occurring in the maxilla than the mandible. No increase in incidence or severity of gingivitis was detected in the lower jaw during pregnancy. It is difficult to compare the incidence of gingivitis in our groups with those of other surveys because of the different criteria involved. Most authors use a gingival index which may not be strictly comparable to that used here. However, the high incidence of some form of gingivitis in both control ayd pregnant groups is in keeping with 'the epidemiological studies of the general population (Gray, Todd, Slack,
109
and Bulman, 1970) a.nd suggests that our sample was not an unusual one. The debris scores in the pregnant group were lower both when indices of individual patients were considered and even more so when total numbers of teeth with debris were compared with the non-pregnant group (Table IV). It is difficult to explain this finding. Although the non-pregnant women were slightly older than the pregnant group it would seem unlikely that the slight difference in age could have made this difference. Further, since the non-pregnant group was made up of individuals who either had recently been pregnant or were seeking advice on contraception it would appear that there would be no obvious difference in motivation towards oral hygiene measures. It is possible that conditions in the mouth are different during pregnancy or that pregnant women have more time or motivation in attending to all health matters. This decrease in the soft-deposit scores is similar to the decrease in plaque scores noted by Silness artd L~Se (1964) and Hugoson (1970) and may perhaps be related to the apparent increased frequency of toothbrushing found in the pregnant group. The scores for frequency of toothbrushing do not lend themselves easily to statistical examination as they rely on information given by the patient. The patient may feel that she should brush her teeth more often and be ashamed to admit that she does not. On the other hand, the lower debris scores in pregnancy may be related to alterations in the composition of the saliva or gingival fluid. In order to examine the relationship between the debris score on each tooth and the papillary index a new index was computed. First, the scores on the papilla on either side of the tooth were added together to represent the score for that particular tooth. The total papillary score for all the teeth with debris was then divided by the total number of teeth with debris. In addition, the total papillary score for all the teeth without debris was divided by the total number of teeth without debris. For pregnant women the index for teeth with debris was 2.48 and for those without debris was 1.82. For the non-pregnant
110
Journal of Dentistry, Vol. 2/No. 3
group the index for teeth with debris was 2.46 and for those without debris was 0.74 (Table VI). Thus there would appear to be a closer relationship between debris and papillary inflammation in the non-pregnant group. This suggests that there is an additional factor, possibly the systemic one of hormonal changes as postulated by L/Se (1965), who also noted a poor correlation between plaque and gingivitis in pregnancy. Table V/.--Debris and papillary inflammation Group Pregnant Non-pregnant
Debris + -+ --
No. of Papillary Index teeth scores 613 460 680 333
1523.87 833.3 1671.05 248.03
2.48 1.82 2.46 0.74
The number of persons in both groups who wore dentures and who kept these in at night is very high. This shows either a lack of communication between dental surgeon and patient or an Unwillingness on the pfirt of the patient to be without her dentures. Perhaps this is all indication of the importance of the dentition in making a person socially desirable.
CONCLUSIONS The incidence of gingivitis ill pregnancy seems to be offset to some degree by a concomitant decrease in debris accumulation at the necks of teeth. The increase in gingivitis in pregnancy ill this group of patients was confined to the upper jaw. It is suggested that the present findings lend further support to the concept that the gingivitis of pregnancy has a systemic cause as a contributory factor. The decrease in debris index noted during pregnancy may be
related to increased frequency of toothbrushing but further investigation of the cause of this reduction is suggested.
Acknowledgements We are grateful to Dr. G. Daniels and Mr. J. G. Lawson and the staff of the Obstetric Department of the University Hospital of Wales for allowing us facilities to examine their patients. We are also grateful to Dr. M. Davies of the Department of Health of Cardiff Corporation for permission to examine the patients attending contraceptive clinics under her control. Mr. P. Zlosnick and Mr. R. Newcombe of the Department of Medical Statistics and Mr. J. N. Swallow of the Dental School, Cardiff, gave invaluable help with the analysis of the results. REFERENCES ALEXANDER,A. G. (1970), Dent. Hlth, 9, 30. COHEN, D. W., FRIEDMAN, L., SHAPIRO, J., and KYLE, G. C. (1969), J. Periodont., 40, 563. GRAY, P. G., TODD, J. E., SLACK, G. L., and BULMAN, J. S. (1970), Adult Dental Health in England and Wales in 1968. London: H.M.S.O. HASSON,E. (1960), Harefuah, 58, 224. HILMING, F. (1950), Gingivitis gravidarum. Dissertation to the Royal Dental College, Copenhagen. HUGOSON, A. (1970), J. periodont. Res., suppl. 5. LSE, H. (1965), J. Periodont., 36, 37. - - - and S[LNESS, J. (1963), Acta odont, scand., 21, 533. MAIER, A. W., and ORBAN, B. (1949), Oral SurE., 2, 334. SILNESS,J., and Li3E, H. (1964), Acta odont, scand., 22, 121. SWALLOW, J. N., and ADAMS, n . (1967), Br. dent. J., 123, 137. WADE, A. B. (1966), J. Periodont., 37, 55.
Pregnancy gingivitis: a survey of 100 antenatal patients D. Adams, B.Sc.,
M.D.S., Ph.D.
J. S. Carney, B D.S. D. A. Dicks, B.D.S. Department of Oral Biology, Dental School, Cardiff ABSTRACT The incidence and severity of gingivitis were compared in pregnant and non-pregnant women. Gingivitis was increased in the maxillary anterior region during pregnancy though little difference was found around the lower anterior teeth. The presence of soft deposits on the teeth was related to the gingivitis in non-pregnant women to a greater degree than in pregnant women. Pregnant women were found to have less debris and brushed their teeth more frequently than the control group. It was concluded that the results confirm the action of a factor or factors other than debris as a causative agent for gingivitis during pregnancy.
INTRODUCTION THE incidence of gingivitis in pregnancy has been reported as being as low as 30 per cent in one survey (Hasson, 1960) and as high as 100 per cent by Hiiming (1950). The cause of this gingivitis is thought to be hormonal (L~Se, 1965), though an association with local factors has also been suggested (Maier and Orban, 1949; Hilming, 1950; Silness and L/Se, 1964). In order to examine the possible relationship between poor oral hygiene and gingivitis we have looked at both these factors in pregnant and non-pregnant women. Equal numbers of subjects were used. Our survey differs from that of Silness and L/Se (1964) and Hugoson (1970) in that our non-pregnant group was not a follow-up of the pregnant women in the survey and had not been subjected to oral hygiene measures or pressures of any kind beyond what might be expected in the general population.
THE SAMPLE AND EXAMINATION TECHNIQUES The pregnant women examined were attending the antenatal clinics of consultant obstetricians of the Welsh Hospital Board for the first time. The stage of pregnancy varied from the third to the ninth month and the majority of new patients attending the clinics over a 4-week period were seen. Ninety-nine per cent of the patients who were asked to participate in the survey agreed and in all 100 patients were examined. The non-pregnant group comprised 100 women who were attending either postpartum clinics 10 weeks after parturition or contraceptive clinics for the first time. None of this group was having any form of hormone therapy at the time of examination. Each person was examined on one occasion only as it was felt that the examination itself might have some effect on the oral hygiene. Advice on oral hygiene was in fact given when requested during the investigation. Some of the women were edentulous and so could not be included. Some were edentuious in one jaw but were included in relation to the teeth present. The pregnant women were examined in cubicles in the antenatal clinic using Anglepoise lamps for illumination. Only the anterior part of the mouth was scored for gingivitis and debris though a general oral examination was also carried out. For gingivitis a modified gingival index system (LOe and Silness, 1963) was used except that papillae rather than teeth were scored. All the anterior interdental papillae (upper and lower) found between the
Adams et al. : Pregnancy Gingivitis
right and left first premolars were included, thus giving seven papillae in each jaw. The method of scoring was: 0, No inflammation. 1, Slight to moderate redness in papillae. 2, Swollen papillae with redness extending around marginal gingivae. 3, Swollen papillae with blood or pus exuding with gentle pressure. No mobility tests were made, and where there were gaps in the arch the papillae on either side of the gap were scored. Debris was scored as present or absent by running a blunt periodontal probe over the labial gingival margins of the upper and lower canines and incisors. If debris was present on a tooth the score was 1 and if not 0. Thus the maximum score in each jaw was 6. The oral cavity was examined and a report made to the patient if any lesions were noted. Information was also gained by means of a short questionnaire on age, duration of pregnancy, smoking habits, denture wearing and oral hygiene, whether the patient had regular dental treatment, and husband's or own occupation. The examination of the non-pregnant women was conducted in the same manner although the lighting tended to vary from clinic to clinic. In an attempt to standardize the subjective estimation of papillary inflammation prior to the survey, colour transparencies of the anterior region of the mouth of patients with and without gingivitis were examined, discussed, and scored together and separately until agreement was found consistently. The procedure was then repeated on patients attending the Periodontal Department of the Dental Hospital in Cardiff. All the examinations in the survey were carried out by two of us (D.A.D. and J.S.C.), each person examining approximately equal numbers of patients in the groups.
R ES U LTS
The pregnant women as a group were slightly younger than, the non-pregnant group. The age range for the l~regnant:women was 16-39 years and for the non-pregnant group 17-45. years (Table 1).
107
Gingivitis as measured by our technique was found to be more prevalent in pregnant than non-pregnant women. In 54 out of 93 pregnant women the upper anterior papillae had a total score of 7 or over, i.e., equivalent to slight redness on all the papillae, whereas 40 out of 88 non-pregnant women scored 7 or over. Using a %2 test the difference between the scores was only just significant statistically. In the lower arch, however, there was no statistical difference between the two groups. Fifty-five out of 97 pregnant women were scored 7 or over whilst 47 out of 92 nonpregnant women had scores higher than 6
(Table
H).
Table L--Age of subjects Age (yr.)
Pregnant
16-20 21-25 26-30 31-35 36-45
18 44 23 6 5
Non-pregnant 5 21 32 16 15
Table//.--Papillary scores Total scores Upper jaw
0 1-6 7-21 Total
0 Lower jaw 1-6 7-21 Total
No. of patients P r e g n a n t Non-pregnant 9 30 54
15 33 40
93
88
18 24 55
18 27 47
97
92
Only 9 pregnant women and 15 non-pregnant women had no gingivitis in the upper jaw. In the lower jaw 18 cases in each group were free of gingivitis. A statistical analysis of the distribution of inflamed papillae in pregnant and non-pregnant women showed that in pregnancy there was more severe involvement in the upper jaw (;~2=19.02, highly significant), whereas in the lower jaw no such difference was found ( ~ = 1 . 3 3 , not significant). Considering upper and lower papillae together the variation in the upper jaw was enough to
108
Journal of Dentistry, Vol. 2/No. 3
give a highly significant difference (Za= 15.03) between pregnant and non-pregnant women overall (Table/11). The mean scores for the presence of debris tended to be lower in pregnant women than in
non-smokers as compared with 54 per cent of the control group. No statistical differences in scoring were detected when observer 1 was compared with observer 2.
Table IlL--Total numbers of papillae in each category
Table/V.--Total debris scores
Group
0
Gingival index 1 2
3
Group
Upper jaw Pregnant 136 309 158 Non-pregnant 200 247 125 7,==19.02 (highly significant)
33 19
Upper jaw Pregnant Non-pregnant
Lower jaw Pregnant 209 276 Non-pregnant 217 237 7'z=1-33 (not significant)
149 152
34 23
Lower jaw Pregnant Non-pregnant
Upper and lower jaws Pregnant 345 585 307 Non-pregnant 417 484 277 Z==15.03 (highly significant)
67 42
the control group. Of the pregnant group, 22 out of 93 had a maximum score of 6 in the upper jaw and 36 out of 88 non-pregnant women had the maximum score. For the lower jaw 33 out of 97 pregnant women had a score of 6 whilst 46 out of 92 in the controls had soft deposits on each tooth. When the totals for all the anterior teeth in the pregnant group were compared with the totals for the teeth in the control group this difference became much more evident (Table 11,'). In the upper jaw the difference is highly significant (P<0.002), as is also the case in the lower jaw (P<0.002). As could be expected from this result when upper and lower scores are combined in each group the difference is also highly significant ( P < 2 × 10-8). Other interesting results from this study include the finding that 73 pregnant women brushed their teeth twice or more times daily while only 57 out of 100 of the non-pregnant women claimed to use their toothbrushes more than twice a day (Table V). Of the 40 women in both categories who wore any form of denture only one removed her denture habitually at night. Thirty-four per cent of the pregnant women were
+
Debris
_
302 329 7== 10.30, P<0.002
236 169
333 375 7,==14.72, P<0.001
238 164
Upper and lower jaws Pregnant 635 Non-pregnant 704 7,2=25"35, P < 2 × 10 -~
474 333
Table V.--Toothbrushing habits No. of brushings daily
Never Once Twice More than twice
Pregnant
Non-pregnant
3 23 60 13
2 41 52 5
DISCUSSION
This survey was carried out by students during a 4-week elective period project and hence the methods used were designed to give the maximum results in the shortest time, whilst maintaining standards that would render the project meaningful. Thus, the modification of the gingival index was intended to allow for the conditions found in the clinics, where lighting and position of the patient were variable. Since gingivitis is commonly found in the interdental papillae and since there is some difficulty in ascribing the papillary inflammation to either of the adjoining teeth, it was decided to score the papillae rather than the more usual method of using the tooth as the reference point. The anterior segment was chosen in spite of the objections put forward by Wade (1966) since
Adams et al. : Pregnancy Gingivitis
all regions show similar patterns of involvement according to the figures of Hugoson (1970). Alexander (1970) has pointed out that the method of assessing gingivitis should be related purposefully to the information required, and since we wanted a simple method to compare two populations this seemed to have the merit of simplicity and speed. Revision of the criteria for gingivitis was carried out at regular intervals in art attempt to minimize observer variability. Plaque and debris scores involving the whole crown of the tooth have been criticized on the grounds that plaque on the coronal part of the tooth probably does not contribute much to disease. For this reason and because it was impracticable to use disclosing solution it was decided to follow the pattern adopted by Swallow and Adams (1967) and score debris in contact with the gingivae as present or absent. There would appear to be a discrepancy between scoring the papillary condition and attempting to relate this to the presence of debris on the labial surface, but in practice the scoring included debris in contact with the papillae. That gingivitis was more frequent in the upper anterior papillae of the pregnant group compared with the non-pregnant group confirms the observations of, among others, Hilming (1950), L/Se and Silness (1963), Silness and L/Se (1964), L/Se (1965), and Hugoson (1970). Where the present study differs from most previous ones is in the comparison of upper and lower jaws. In the only other report found which does make a comparison (Cohen, Friedman, Shapiro, and Kyle, 1969) the findings were similar to those reported here, with greater differences occurring in the maxilla than the mandible. No increase in incidence or severity of gingivitis was detected in the lower jaw during pregnancy. It is difficult to compare the incidence of gingivitis in our groups with those of other surveys because of the different criteria involved. Most authors use a gingival index which may not be strictly comparable to that used here. However, the high incidence of some form of gingivitis in both control ayd pregnant groups is in keeping with 'the epidemiological studies of the general population (Gray, Todd, Slack,
109
and Bulman, 1970) a.nd suggests that our sample was not an unusual one. The debris scores in the pregnant group were lower both when indices of individual patients were considered and even more so when total numbers of teeth with debris were compared with the non-pregnant group (Table IV). It is difficult to explain this finding. Although the non-pregnant women were slightly older than the pregnant group it would seem unlikely that the slight difference in age could have made this difference. Further, since the non-pregnant group was made up of individuals who either had recently been pregnant or were seeking advice on contraception it would appear that there would be no obvious difference in motivation towards oral hygiene measures. It is possible that conditions in the mouth are different during pregnancy or that pregnant women have more time or motivation in attending to all health matters. This decrease in the soft-deposit scores is similar to the decrease in plaque scores noted by Silness artd L~Se (1964) and Hugoson (1970) and may perhaps be related to the apparent increased frequency of toothbrushing found in the pregnant group. The scores for frequency of toothbrushing do not lend themselves easily to statistical examination as they rely on information given by the patient. The patient may feel that she should brush her teeth more often and be ashamed to admit that she does not. On the other hand, the lower debris scores in pregnancy may be related to alterations in the composition of the saliva or gingival fluid. In order to examine the relationship between the debris score on each tooth and the papillary index a new index was computed. First, the scores on the papilla on either side of the tooth were added together to represent the score for that particular tooth. The total papillary score for all the teeth with debris was then divided by the total number of teeth with debris. In addition, the total papillary score for all the teeth without debris was divided by the total number of teeth without debris. For pregnant women the index for teeth with debris was 2.48 and for those without debris was 1.82. For the non-pregnant
110
Journal of Dentistry, Vol. 2/No. 3
group the index for teeth with debris was 2.46 and for those without debris was 0.74 (Table VI). Thus there would appear to be a closer relationship between debris and papillary inflammation in the non-pregnant group. This suggests that there is an additional factor, possibly the systemic one of hormonal changes as postulated by L/Se (1965), who also noted a poor correlation between plaque and gingivitis in pregnancy. Table V/.--Debris and papillary inflammation Group Pregnant Non-pregnant
Debris + -+ --
No. of Papillary Index teeth scores 613 460 680 333
1523.87 833.3 1671.05 248.03
2.48 1.82 2.46 0.74
The number of persons in both groups who wore dentures and who kept these in at night is very high. This shows either a lack of communication between dental surgeon and patient or an Unwillingness on the pfirt of the patient to be without her dentures. Perhaps this is all indication of the importance of the dentition in making a person socially desirable.
CONCLUSIONS The incidence of gingivitis ill pregnancy seems to be offset to some degree by a concomitant decrease in debris accumulation at the necks of teeth. The increase in gingivitis in pregnancy ill this group of patients was confined to the upper jaw. It is suggested that the present findings lend further support to the concept that the gingivitis of pregnancy has a systemic cause as a contributory factor. The decrease in debris index noted during pregnancy may be
related to increased frequency of toothbrushing but further investigation of the cause of this reduction is suggested.
Acknowledgements We are grateful to Dr. G. Daniels and Mr. J. G. Lawson and the staff of the Obstetric Department of the University Hospital of Wales for allowing us facilities to examine their patients. We are also grateful to Dr. M. Davies of the Department of Health of Cardiff Corporation for permission to examine the patients attending contraceptive clinics under her control. Mr. P. Zlosnick and Mr. R. Newcombe of the Department of Medical Statistics and Mr. J. N. Swallow of the Dental School, Cardiff, gave invaluable help with the analysis of the results. REFERENCES ALEXANDER,A. G. (1970), Dent. Hlth, 9, 30. COHEN, D. W., FRIEDMAN, L., SHAPIRO, J., and KYLE, G. C. (1969), J. Periodont., 40, 563. GRAY, P. G., TODD, J. E., SLACK, G. L., and BULMAN, J. S. (1970), Adult Dental Health in England and Wales in 1968. London: H.M.S.O. HASSON,E. (1960), Harefuah, 58, 224. HILMING, F. (1950), Gingivitis gravidarum. Dissertation to the Royal Dental College, Copenhagen. HUGOSON, A. (1970), J. periodont. Res., suppl. 5. LSE, H. (1965), J. Periodont., 36, 37. - - - and S[LNESS, J. (1963), Acta odont, scand., 21, 533. MAIER, A. W., and ORBAN, B. (1949), Oral SurE., 2, 334. SILNESS,J., and Li3E, H. (1964), Acta odont, scand., 22, 121. SWALLOW, J. N., and ADAMS, n . (1967), Br. dent. J., 123, 137. WADE, A. B. (1966), J. Periodont., 37, 55.