Background: Oral health is a concern in pregnancy because of local oral effects such as gingivitis and the potential to have an adverse effect on pregnancy outcomes. In Kuwait, evidence suggests that expectant mothers have poor oral health, are fearful of dentistry, have little awareness of oral health and are in need of dental health education (DHE). In order to design an intervention aiming to change the oral health behaviours of pregnant Kuwaiti women, it was important to have contemporary evidence on the relationship between periodontal disease (PD) and adverse birth outcomes (ABOs), and an understanding of the social and cultural context in Kuwait in which oral health behaviours take place.
Aim: The aim of the thesis was to design, implement and evaluate a DHE intervention for Kuwaiti pregnant women. In order to achieve the aim of the thesis three studies were undertaken: 1) A systematic review and meta-analysis to assess the association between PD and ABO, and the efficacy and the safety of non-surgical periodontal treatment (NSPT) during pregnancy to prevent ABOs. 2) A qualitative study amongst Kuwaiti women to investigate perceptions, beliefs, attitudes and expectations about oral health and maintaining and improving oral health during pregnancy. The data were also used to identify social cognition constructs which might be helpful to promote oral health behaviour in this group of women. 3) A randomised controlled trial to assess the efficacy of dental health education (DHE) with or without a planning intervention on adherence to dental health related behaviours amongst Kuwaiti pregnant women.
Results: Study 1) The majority of individual cohort studies support an association between ABOs and PD, the meta-analyses support the association [(PTB: RR1.63 (95% CI: 1.06, 2.50, P=0.03), LBW: RR 2.35 (95% CI: 1.21-4.57, P=0.01) and PLBW: RR 3.53 (95% CI: 1.51 -8.20, P=0.003)] but are compromised by high levels of heterogeneity associated with the insecurity of definition of periodontal disease. The meta-analyses of 13 RCTs found that NSPT during pregnancy did not prevent PTB and PLBW but may prevent LBW (RR 0.75 (95% CI: 0.56-0.99, P=0.05) and stillbirth (RR 0.48 (95% CI: 0.25-0.90, P=0.02). The meta-analyses for PTB, LBW and PLBW were characterised by high levels of heterogeneity also attributable to uncertainty about definition of periodontal disease. None of the RCTs assessed robustly the safety of the periodontal treatment during pregnancy, though no significant adverse events were reported. There remains uncertainty in relation to the efficacy and safety of NSPT to prevent ABOS.
Study 2) The qualitative study found that women had low levels of oral health knowledge and information. They had unhelpful cultural beliefs concerning oral health during pregnancy, and were unaware of the effect of pregnancy on oral health. Pregnant women lacked motivation to seek dental care even when they considered dental treatment safe during pregnancy. Dentists, unhelpful cultural beliefs, and lack of motivation were identified as barriers to accessing oral health care and seeking oral health knowledge. A number of social cognition constructs were identified from the qualitative study: knowledge; attitudes; subjective norms; barriers; and intentions. These together with the findings from the first study were used to frame, inform and design the intervention reported upon in study 3).
Study 3) At T1 154 women were eligible and randomly allocated to the three groups respectively: Treatment as Usual (TAU) =53; DHE=53; DHE & Planning=48. At T2 the number of women in each group completing the intervention (N=90) was respectively: TAU=28; DHE=30; DHE&P=32. SCM constructs and self-report of behaviours were assessed at T1 and T2 through a questionnaire assessing knowledge, attitudes, subjective norms, barriers, intentions and self-report of oral health behaviours in relation to oral hygiene. Plaque scores (PI ) and gingival scores (GI) were recorded by a trained and calibrated examiner blind to group allocation.
There were no demographic differences between the groups at baseline. The mean age of women was 27.80±SD 5.40, 43% (n=38) had a high school level education and 10% no formal education. Twenty eight per cent were in their first pregnancy, the remainder had 2.06±1.98 or more children. A mixed factor ANOVA analysis demonstrated that all women improved their PI (F=94.343 df=1 p=0.001) and GI (F=73.138 df=1 p=0.001) scores. There were no differences in self-reported oral hygiene and PI and GI by intervention group. The SCM constructs changed over time in all women (N=90) except barriers to attendance (F=1.067 df=1 p=0.305). There were no differences in SCM constructs by intervention group at T2. All women reported increasing the frequency of tooth brushing and flossing.
Conclusion: Providing a basic oral hygiene leaflet was sufficient to motivate women to change their behaviour in relation to tooth-brushing and dental flossing resulting in improved PI and GI scores. In this study where women had very limited oral health knowledge, information giving was as efficacious as an intervention underpinned by SCMs in influencing behaviour change, but these results must be interpreted with caution given the high attrition rates and possible influence of a Hawthorne effect.