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Periodontal Health of Libyan Pregnant Women

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Abstract

Background: Pregnancy-related changes are most severe on gingival tissue; those observed changes have been the object of interest for a long time. A number of researchers reported the association between periodontal health of pregnant women and socio-economic status. No study on such subject has been performed so far in Libya. The aims of the present study are to evaluate the periodontal status in a sample of Libyan pregnant women and to identify the association between various socio-economic variables (education, occupation and income) and women's periodontal status. Pregnant women's age, stage of pregnancy and number of pregnancies were particularly considered in the analysis of the data. The obtained data could be helpful in planning oral health promotion and periodontal disease prevention programs for pregnant women. Materials and Methods: A total of 34 Libyan pregnant women in varying stage of pregnancy attending the gynecology department at the policlinics in Benghazi-Libya constituted the target population. After the participants filled in a questionnaire, their periodontal status was assessed by the researcher using the Community Periodontal Index (CPI), any relationship to socio-economic variables (educational level, occupational status and income) and women's age, stage of pregnancy and number of pregnancies was evaluated. Data-entry and analysis were performed with the help of SPSS. Results: The results showed that the CPI scores tends to increase as socio-economic status decrease. Furthermore, the CPI scores tends to increase as women's age, stage of pregnancy and number of pregnancies increase. Discussion: The CPI scores of pregnant women were high indicating a moderate to severe periodontal disease. Such finding may be related to the fact that the majority of pregnant women were relatively old, in their third trimester, multigravidae, with primary level of education and house wives. Conclusion: The results revealed that periodontal health of Libyan pregnant women tends to associate with socio-economic status, women's age, stage of pregnancy and number of pregnancies. Therefore oral health promotion and periodontal disease prevention programs should target the identified risk groups.

Introduction

        The introduction will give a description of the context within which the study took place, statement of the problem, description of the country in which the study took place and the policlinics in which the study was undertaken. Also the introduction will provide information on the motivation and objective of this study and the study question.

Background

        Sex-specific medicine is medicine tailored to meet the specific needs of men and women, based on the results of scientific research. Clearly, more research is needed, particularly as it relates to women. Studies are under way and more are being designed to answer specific questions and determine specific strategies to prevent and treat diseases that have particular impact on women (Krejci & Bissada, 2002). Women's health issues have come to the forefront of medical research only within the last decade. This came about only after significant pressure was exerted by physicians and activist groups that recognized that the majority of clinical trials involved men primarily and that sex differences were not being addressed (Angell, 1993). These inequities prompted the Institutes of Health to begin funding research focused on sex differences. This, in turn, triggered other investigations into a variety of women's health issues, and an increasing body of sex-specific scientific literature has emerged (Krejci & Bissada, 2002). The prevailing medical viewpoint relates to biological functions in the male as the norm, while the female is considered to be exactly the same except for reproductive functions. This has lead to a lack of awareness of the need to study the implications of gender differences in periodontal tissues (Covington, 1996). Although teeth are gender free, the supporting tissues of the periodontium are vulnerable to the physiological variations in the levels of circulating steroid hormones in males and females (Tilakaratne et al., 2000).

        One of the enduring puzzles of public health is why some populations are healthier than others.

For years dentists and periodontists have been aware of the effects of pregnancy on the oral health of expectant mothers.

        Pregnancy is associated with great anatomical and physiological changes of varying kinds (Herman, 1923). Pregnancy-related changes are most severe on gingival tissue; those observed changes have been the object of interest for a long time. Many investigators have stated that bleeding on probing and increased periodontal pocket are more common in pregnancy. The severity of the gingival inflammation in pregnant women is greater when compared to gingival inflammation in normal women (Hiling, 1950). All the studies show a high prevalence and an increasing severity of gingivitis during pregnancy. In an effort to determine the nature of this increased inflammation, many more studies have since been carried out.

Three main schools of thought have prevailed in regard to its etiology. Some believe in a local etiology (Monash, 1931), others in vitamin C as a primary factor (Hiling, 1950), and others in the importance of the hormonal factors (Ziskin & Nesse, 1946).

        Socio-economic status is associated with a variety of health-related behaviors. Epidemiological studies indicate that lower SES is associated with poorer health outcomes. A multitude of disease conditions are associated with socioeconomic status, and cause/effect (e.g., social stress as a contributory cause of heart disease) is plausible (Marmot & Wilkinson, 1999) Generally, those who are better educated, wealthier, and live in more desirable circumstances enjoy better health status than the less educated and poorer segments of society. Periodontal disease is a common disease in humans that may be affected by the socio-economic status. The effects of the socio-economic status on periodontal conditions in pregnant women have been reported by a number of researchers and there has been speculation as to whether hormonal changes during pregnancy or pre-existing conditions of general, oral health and socio-economic status have a greater effect on the development of periodontal disease during pregnancy. Dentistry can be vital in improving prenatal outcome and maternal or fetal dental health through screening, referral and education of pregnant patients.

Statement of the Problem

        Relevant topic in pregnant women concern. No study on such subject is being recorded so far in Libya. Given the possible association between periodontal disease and severe systemic conditions such as cardiovascular disease, periodontal status may itself be a risk factor for mortality (Beck et al., 1996). What has come to the forefront of recent periodontal investigations, however, is the relationship between periodontitis and adverse pregnancy outcomes (Krejci & Bissada, 2002). A recent report (Jeffcoat et al., 2001) indicated that the risk of preterm birth was directly related to the severity of periodontitis in the mother. Pregnancy affects the initiation and progression of gingivitis and periodontitis (Brian & Perry, 2002) and this disease if left untreated, can lead to teeth loss. Periodontal disease is a chronic condition with an infectious origin. Person-to-person transmission of periodontal pathogens occurs via saliva, and increased frequency of exposure to infectious saliva increases the likelihood of bacterial colonization (Asikainen et al., 1997). Periodontal pathogens can be transmitted among family members (Asikainen et al., 1997), and familial transmission may be a risk factor for progression to periodontal disease (Zambon, 1994). Periodontal disease was chosen because its prevention and treatment provide a second major part of the workload of practicing dentists. Both dental caries and destructive periodontal diseases are highly prevalent and create much morbidity all over the world because they are very expensive to treat, requiring skilled personnel and considerable amounts of professional time.

        Understanding socioeconomic influences on periodontal health in pregnant women is important for planning and implementing effective prevention strategies against periodontal disease since many studies have shown that the periodontal disease in pregnant women not only influences their own oral health status but also may increase their risk of other diseases such as atherosclerosis (Slade et al., 2003), rheumatoid arthritis (Mercado et al., 2000), diabetes (Thorstensson et al., 1996), impact pregnancy outcome (Offenbacher et al., 1996; Jeffcoat et al., 2001), and their offspring's risk of developing early and severe dental caries (Caufield et al., 1993; Kohler et al., 1983).

Libya

        This study took place in Libya, officially known as the Great Socialist People's Libyan Arab Jamahiriya. Located in North Africa and bordering the Mediterranean Sea to the north, Libya lies between Egypt to the east, Sudan to the southeast, Ghad and Niger to the south, and Algeria and Tunisia to the west and has a coastline of around 1900 kilometers along the Mediterranean Sea (World Health Organization [WHO], 2007). With an area of almost 1.8 million square kilometers, Libya is the 17th largest country in the world by area (United Nations [UN], 2003). The climate is mostly dry and desert like in nature. However, the northern regions enjoy a milder Mediterranean climate. Tripoli is the capital. The main language spoken in Libya is Arabic, which is also the official language. The religion in Libya is Islam. Libya is culturally similar to its neighboring Maghrebian states. Libyans consider themselves very much a part of a wider Arab community. The flag of Libya consists of a green field with no other characteristics. It is the only national flag in the world with just one color and no design, insignia, or other details.

        The main cities are concentrated in the northern part of the country along the coastal area. The six largest cities are Tripoli, Benghazi, Alzawia, Musrata, Derna and Sirte. The total population in 2007 was 6.16 million people (United Nations Population Division [UNPD], 2007). About 85% of the population is urban (UNPD, 2007), mostly concentrated in the two largest cities, Tripoli and Benghazi. The total life expectancy in 2007 was 74 (female 76.5, males 71.3) (UNPD, 2007). Libya is witnessing an increase in the adolescent age group with 32% of the population below 15 years old in 2006 (WHO, 2007). As a result, the country's population is fairly young, and the proportion of Libyans aged 65 years and over was 5% in 2006 (WHO, 2007).

        Libya is an oil-producing country, with its main income coming from oil revenue, as well as some petrochemical industry and agricultural activities. Libya receives no external funds as development aid from any source of any kind (WHO, 2007).

Health care, including preventive, curative and rehabilitation services, is provided to all citizens free of charge by the Government. Health expenditure as a percentage of GDP in Libya is about 3.3% (WHO, 2007) and health expenditure per capita in Libya is US $222 (WHO, 2007). The Government spends 60 million Libyan dinars (1$ =1.256LD) annually for the medical treatment of Libyan citizens abroad (WHO, 2007).

        Population with access to health services (urban and rural) is 100% (WHO, 2007). Major hospitals are located in urban areas. It should be noted that the country has achieved high coverage in most basic health areas (United Nations Development Programme [UNDP], 2002). The mortality rate for children aged less than 5 years fell from 160 per 1000 live births in 1970 to 18 in 2007(United Nations International Children's Emergency Fund [UNICEF], 2007). In 2007, 99% of one-year-old children were vaccinated against tuberculosis and 98% against measles (UNICEF, 2007). All payments in the private sector come directly as an out-of-pocket payment with the exception of some banks, private companies and the oil sector, which subsidize their employees' medical coverage in the private sector.

Some communicable diseases still pose a problem, such as AIDS, hepatitis, measles and tuberculosis. Noncommunicable diseases have become a major cause of mortality and morbidity. The prevalence and incidence of noncommunicable diseases has increased dramatically over the past 20 years (WHO, 2007). Contributing factors include ageing, injuries and lifestyle habits. Cardiovascular diseases, hypertension, diabetes and cancer account for significant mortality and morbidity rates and have put considerable strain on health expenditure (WHO, 2007).

The main causes of death are cardiovascular diseases 37%, cancer 13%, road traffic injuries (RTI) 11% and diabetes 5% (WHO, 2007).Tobacco use among youths of school age (13-15 years) is alarming, 15% of students currently use some form of tobacco products and 6% of students currently smoke cigarettes(WHO, 2007). Obesity is also emerging as a major health problem. Road traffic accidents (RTA), which result in 4-5 deaths per day and even higher figures for disability, are a major burden of disease (WHO, 2007). It is fair to say that Libya has, overall, made a very good job of providing comprehensive healthcare to all Libyan citizens whatever their regional domicile in the country (Otman & Karlberg, 2007).

2nd March and Ibn-Zohr Policlinics

        The policlinics in Libya perform a key role in maintaining health in Libya's population. Anyone in Libya can use the policlinics. It serves the Libyan people free of charge .There are 39 policlinics in Libya, with the capacity of handling approximately 50.000 to 60.000 patients. They are out-patient clinic for all medical specialties staffed by specialty physicians in most areas of medicine.

This study was undertaken at the 2nd March and Ibn-Zohr Policlinics.

        The 2nd March policlinic is located at Al-Hadaek area in Benghazi-Libya, well connected to other parts of the city and can be reached within 15-20 minutes by car from any part of the city. Open from 8 am to 3:30 pm, six days a week. This policlinic has a variety of different healthcare services staffed by specialized physicians and excellent nursing staff. It comprises eight different departments, namely, dental department, gynecology department, internal medicine department, pediatrics department, public health department, ophthalmology department, first aid department and pharmacy. The dental department provides diagnosis, extraction, scaling and radiological services. The internal medicine department provides chronic disease management, acute illness treatment and follow-up of patients discharged from hospitals. The gynecology department provides family planning to prevent unwanted pregnancies, to manage gynecological disorders and to provide contraceptive information and services and also antenatal and postnatal care. The pediatrics department provides management of common childhood illnesses. The public health department provides access to the national immunization programme which is a major part of policlinic services, and growth monitoring for babies. The ophthalmology department provides ophthalmological disorders management. The First aid department provides first aid services, bandage changing and minor surgery procedures like dressing and removal of stitches. The outpatient pharmacy provides the medication for the Libyan people free of charge. The typical patient visit flow starts with registering at the reception; then the patient is referred to the clinic according to his/her complain, takes a number and waits for his/her turn, sees the doctor, goes to laboratory or X-ray (if required), sees the doctor again then drops the prescription at the pharmacy and takes the medication or is further referred to the hospital.

        The Ibn-Zohr policlinic is located at El-Berka area in Benghazi-Libya, and can be reached within 10 minutes by car from any part of the city having the same functioning system as other policlinics in Libya. It comprises four different departments, namely, dental department, gynecology department, public health department and dermatology department.

Hypothesis

        For this study it was assumed that periodontal disease is common in Libyan women and may be influenced by pregnancy and socio-economic status.

This study was conducted based on a quantitative approach to the association between socioeconomic status and periodontal health condition of pregnant women, considering 34 Libyan married pregnant women, varying in age from 20 to 41 years old, living in Benghazi-Libya. To avoid confounders, the participants for this study were recruited at random and from two policlinics in different geographic areas in Benghazi-Libya .The participants were recruited from the gynecology clinic at both 2nd March and Ibn-Zohr policlinics, during June 2009. After filing in a questionnaire by the participants about socio-economic status, the participants received an oral examination by the researcher to evaluate their periodontal health status. All socioeconomic components will be discussed in relation to their impact on the periodontal health of pregnant women. The socio-economic components that were considered in this study were: education, occupation and income. The women's age, number of pregnancy and stage of pregnancy were particularly considered in the analysis.

Objectives

        The aims of this study were to evaluate the periodontal status in a sample of pregnant Libyan women and to investigate the relationship between various socio-economic variables (education, occupation and income) and the identified periodontal status.

        It will be interesting to compare and to investigate the different components of SES and periodontal condition of Libyan pregnant women and see if some have more influence than others. To analyze and discuss the data in the light of a possible influence of socio-economic status related factors on periodontitis in pregnant women, information about pregnant women's age, stage of pregnancy and number of pregnancies was obtained and particularly considered in the analysis of the data. The data thus obtained could be helpful in planning oral health promotion and periodontal disease prevention programs for pregnant women.

The Study Question

        This paper focused on the association between Libyan pregnant women's socioeconomic status and their periodontal health condition in Benghazi-Libya. This study seeks to answer the following research question: Is there an association between Libyan pregnant women's socioeconomic status and their periodontal health status?

Literature Review

        This section contains what is known on the most important aspects related to the research question. It will show the past work done on the stated study question and what is known about the problem that is being studied. The literature section provides in-depth information on the socio-economic status history in Libya including a section specifically for Libyan women, and will give in-depth information on the periodontal health, periodontal health and socio-economic status, periodontal health and pregnancy, and on periodontal health, pregnancy and socio-economic status.

Methods and Search Strategy

        Different methods and strategies to search for information on periodontal health, pregnancy and socioeconomic status were used. Search of the literature for review papers published in medical electronic databases such as PubMed and bibliographies were undertaken using a set of predetermined keywords. The search strategy was initially developed and implemented for PubMed but revised appropriately to suite the other database. Furthermore different individual journals were searched such as the Journal of American Dental Association and others included on the BioMed Central and the Springer Link websites. Additionally, official Libyan websites concerning general information about Libya and socio-economic status history in Libya were searched such as www.gpc.gov.ly. No restriction was placed on the year of publication.

        The search strategy involved using a combination of terms relating to periodontal health, pregnancy and socio-economic status to identify relevant articles. For periodontal health, the following keywords were used: periodontal health, periodontal disease, periodontal status, dental status, oral health, oral disease, periodontitis, gingivitis, periodontal destruction, periodontal condition, and peridontium. For pregnancy, the following keywords were used: pregnancy, pregnant, gestation, reproductive, and gravid. For socio-economic status, the following keywords were used: socio-economic, socio-demographic, and socio-cultural, social class, social factors, education, occupation, employment, income and finance.

        The titles and abstracts of the studies identified by the search were screened for possible inclusion in the review. All potentially relevant articles were thoroughly reviewed. Their reference lists were searched for any related articles.

        The initial search revealed approximately 630 studies. After review of the abstract and / or complete text and after discarding the duplicates, around 125 collected articles served to identify potential articles that related to this study.

The studies were grouped into categories; periodontal health, pregnancy, socio-economic status, periodontal health and pregnancy, periodontal health and socio-economic status, and periodontal health, pregnancy and socio-economic status (relevant studies).

Socio-economic Status (SES) History in Libya

        The living standards of Libyans have improved significantly since the 1970s, ranking the country among the ones with the highest quality of life in Africa. Urbanization, developmental projects, and high oil revenues have enabled the Libyan government to elevate its people's living standards. The social and economic status of women has particularly improved. Various subsidized or free services (health, education, housing, and basic food products) have ensured basic necessities. Many direct and indirect subsidies and free services have helped raise the economic status of low-income families, a policy which has prevented extreme poverty. Libya is not a highly polarized society divided between extremes of wealth and poverty (CIA World Factbook, 2001).

        Regarding the growing role of women in Libyan society, undoubtedly impressive amount of legislation dealing with women's equality has been developed recently (Otman & Karlberg, 2007).

Socio-economic Status (SES) Components

        Socio-economic status (SES) is a complex phenomenon predicted by a broad spectrum of variables that is often conceptualized as a combination of financial, occupational, and educational influences (Mueller & Parcel, 1981).

Socio-economic status may be defined as any measure which attempts to classify individuals, families, or households in terms of indicators such as occupation, income, and education (Marshall, 1998). The social and economic conditions in an individual's life are important determinants of its overall health situation. Most crucial factors are hereby education, employment and income (WHO, 2005). One of the strongest and most consistent predictors of a person's morbidity and mortality experience is that person's socioeconomic status (Marmot et al., 1987). Socioeconomic status is typically divided into three categories, high SES, middle SES, and low SES to describe the three areas a family or an individual may fall into. When placing a family or individual into one of these categories any or all of the three variables (education, occupation, and income) can be assessed.

Nearly all epidemiological studies use SES as an explanatory or a control variable, or for the selection of subjects or matching criteria (Wnkleby et al., 1992).

Education

        A person's educational attainment is considered to be the highest level (grade or degree) of education they have completed. Education is an important factor contributing to better job opportunities and a higher income, which can again impact an individual's health in a positive manner. Many studies have documented strong inverse associations between education and all-cause mortality (Feldman et al., 1989) as well as life expectancy (Sagan, 1987). Education may facilitate the acquisition of positive social, psychological, and economic skills and assets, and may provide insulation from adverse influences (Wnkleby et al., 1992). Higher education enhances furthermore the access to health information and improves the health seeking behaviour, whereas a low educational level bears a higher risk of inadequate coping with stress, depression, and hostility (WHO, 2005). The most plausible hypothesis is that education may protect against disease by influencing life-style behaviors, problem-solving abilities, and values (Liberatos et al., 1988).Education is available for all individuals regardless of employment status, has high reliability and validity (Liberatos et al., 1988).

        Over time, education has become the most commonly used measure of SES (Liberatos et al., 1988). Educational level is generally stable after early adulthood, easily reported, and can be collected as a continuous variable (Wnkleby et al., 1992). It is may be the most judicious SES measure for use in epidemiological studies (Wnkleby et al., 1992). In studies that have a cost or time restraint but need a measure of SES as a potential confounding variable, education is an expeditious choice (Wnkleby et al., 1992).

        Education in Libya is free for all citizens. The 1969 Libyan Constitutional Declaration states,“Education is a right and a duty for all Libyans. It is compulsory until the end of primary school”. Libya boasts of the highest literacy and educational enrolment rates in North Africa (WHO, 2007). The adult literacy rate is 86.8% (male 94.5%, female 78.4%) (United Nations Educational, Scientific and Cultural Organization [UNESCO], 2007). The main universities in Libya are: Al Fateh University (Tripoli) and Garyounis University (Benghazi). Significant numbers of Libyans attend university abroad, mainly in the United States of America and Europe (WHO, 2007).

        During the late 1960s, the percentage of females in elementary education was between 11 and 19%. By early 1970 the rate shot up to 37% and by 1990 it had escalated to 48%. The percentage of women at university level developed from 3% in 1961 to 8% in 1966, 20% in 1981 and then to 43% in 1996. By the early 1990 the number of females at all levels of education became equal to the number of males (Otman & Karlberg, 2007).

Occupation

        Occupational status as one component of SES encompasses both income and educational attainment. Occupational status reflects the educational attainment required to obtain the job and income levels that vary with different jobs and within ranks of occupations. Additionally, it shows achievement in skills required for the job. Occupational status measures social position by describing job characteristics, decision making ability and control, and psychological demands on the job. Occupation measures prestige, responsibility, physical activity, and work exposures (Susser et al., 1985).

        In Libya, commencing with the Constitutional Declaration of 1969, which asserted the equality of all citizens before the law, and the Declaration of the Establishment of the Authority of the people in 1977, which asserted, “Women and men are equal as human beings. Discrimination between men and women is a flagrant act of oppression without any justification”.

        The legal position of women was reinforced by a series of important enactments through the 1980s and 1990s, for example women can become judges since 1991, while many work as doctors and engineers in the oil industry (Otman & Karlberg, 2007). Women were mobilized in the military and in the political system in the late 1970. There are also women lawyers and pilots. The percentage of women in the workforce is 32% (WHO, 2007).

Income

        Income refers to wages, salaries, profits, rents, and any flow of earnings received. Income can also come in the form of unemployment or workers compensation, social security, pensions, interests or dividends, royalties, trusts, alimony, or other governmental, public, or family financial assistance. Income reflects spending power, housing, diet, and medical care (Susser et al., 1985). That better health is associated with higher income is well established.

        Income is related to health in three ways: through the gross national product of countries, the income of individuals, and the income inequalities among rich nations and among geographic areas (Marmot, 2002).

The income measure of SES can be used as a quantitative measure but is often grouped into categories due to people's reluctance and/ or inability to report their exact income. The sensitivity of this information is often problematic since many are unwilling to give out their income level, even in broad categories. Further complications with this measure include that it is relatively unstable over time and is age dependent since income tend to rise throughout one's career and then drop after retirement.(Loue & Sajatovic, 2004)

        The gross national income per capita (PPP international $) in Libya is US$ 14 710 (WHO, 2009). Approximately 7.4% of the Libyan population live below the poverty line (CIA, 2005 est.).

In Libya, opportunities for upward social movement have increased; and petroleum wealth and the development plans of the revolutionary government have made many new kinds of employment available, thus opening up more well paid jobs for women especially among the educated young.

Periodontal Health

        This section deals with the normal features of the tissues of the periodontium, knowledge of which is necessary for an understanding of periodontal disease.

A section specifically for periodontitis epidemiology, etiology, pathophysiology and its main signs and symptoms is included.

Normal Periodontal Anatomy

        The tissues that surround and support the teeth for normal function form the periodontium (Greek peri- “around”; odont-, “tooth”). The periodontium consists of the gingiva, periodontal ligament, cementum and alveolar bone.

        The gingiva is divided anatomically into the marginal (unattached), attached and interdental gingival. The marginal gingiva is the terminal edge of the gingiva surrounding the teeth like a collar, but is not adherent to it and it can be separated from the tooth surface with a periodontal probe. The cemento-enamel junction (CEJ) is where the enamel of the crown and the cementum of the root meet. The Marginal gingiva in normal periodontal tissues extends approximately 2mm coronal to the CEJ. The space between the marginal gingiva and the external tooth surface is termed the gingival sulcus. The probing depth of a clinically normal gingival sulcus in humans is 2 to 3 mm (Manfra-Maretta, 1990). The attached gingival is continuous with the marginal gingiva. It is firm, resilient, and tightly bound to the underlying alveolar bone. Attached gingiva is bordered coronally by the apical extent of the unattached gingiva, which is in turn defined by the depth of the gingival sulcus. The apical extent of the attached gingiva is the mucogingival junction on the facial aspect of the mandible and maxilla, and the lingual aspect of the mandibular attached gingiva. The palatal attached gingiva blends indistinctly with the similarly textured palatal mucosa. Interdental gingiva occupies the interproximal space beneath the area of tooth contact. It consists of a facial and a lingual papilla and the col. The col is a depression between the papillae which conforms to the shape of the interproximal contact area (Newman et al., 2002). It is sometimes absent when adjacent teeth are not in contact. If a diastema is present, the gingiva is firmly bound over the interdental bone and forms a smooth, rounded surface without interdental papillae.

        The periodontal ligament (PDL) surrounds the normal tooth root and forms the connective tissue attachment from the root to the alveolar bone. The functions of the periodontal ligament are attachment of the teeth to the alveolar bone, maintenance of the gingival tissues in their proper relationship to the teeth, provision of a soft tissue to protect the vessels and nerves from injury by mechanical forces, transmission of occlusal forces to the bone, resistance to the impact of occlusal forces by shock absorption, contribution to the formation and resorption of cementum and bone. It is also supplies nutrients to the cementum, bone, and gingival through the blood vessels and provides lymphatic drainage.

        Cementum is the hard tissue that forms the outer covering of the tooth roots. It has a laminated arrangement and its' intercellular matrix is calcified. As cementum is formed, the fibers of the PDL are incorporated into it as Sharpey's fibers. There are two main types of cementum: acellular (primary) and cellular (secondary). Acellular cementum does not contain cells, it is the first to be formed and covers approximately the cervical third or half of the root. This cementum is formed before the tooth reaches the occlusal plane. Cellular cementum contains cells (cementocytes); it is most abundant at the apex of the tooth and formed after the tooth reaches the occlusal plane. Unlike bone, cementum does not remodel. Its growth is by apposition. Cementum resorption is very common and may alternate with periods of regeneration (Newman et al., 2002). Cementum resorption may be due to local or systemic causes or may occur without apparent etiology. Among the local conditions in which cementum resorption occurs is periodontal disease.

        The alveolar process is the portion of the maxilla and the mandible that forms and supports the tooth sockets (alveoli). It forms when the tooth erupts and disappears gradually after the tooth is lost. The alveolar process consists of external plate of cortical bone formed by haversian bone and compacted bone lamellae, alveolar bone proper (cribriform plate) and the supporting alveolar bone. The components of the alveolar bone do not differ from bone elsewhere in the body. The alveolar bone proper consists of a thin layer of dense compact bone into which the Sharpey's fibers of the PDL insert deeply. The suppporting alveolar bone is comprised of the facial and lingual plates of the compact bone and cancellous trabeculae.

Periodontitis

        Periodontitis is the most common type of periodontal disease. The term periodontal disease has been given different meanings and is used rather ambiguously. It is used to define any inherited or acquired disorder of the tissues surrounding and supporting the teeth (periodontium). These diseases may be of developmental, inflammatory, traumatic, neoplastic, genetic, or metabolic origin (Armitage, 2004). Traditionally, periodontal diseases have been divided into two types: gingival disease and periodontal disease. Gingival disease includes diseases that attack only the gingiva, whereas periodontal disease includes diseases that involve the tooth supporting structure. However, the term periodontal disease usually refers to the common inflammatory disorders of gingivitis and periodontitis. The focus of this section will be on periodontitis as it is the periodontal disease that has a relation with pregnancy and is affected by socio-economic status.

Epidemiology

        Progress in the study of the epidemiology of periodontal diseases has been slower than that achieved in the study of dental caries because of several important factors that do not exist in the study of dental caries. The pathological changes of dental caries involve hard, calcified tissues, whereas periodontal disease involves soft and hard tissues. Unlike dental caries, periodontal disease does not lend itself easily to objective measurement, because the signs of periodontal pathologic alteration involve color changes in the soft tissues, swelling, bleeding, and bone changes that are reflected in crevice depth changes or pathologic pockets, as well as loss of tooth function because of tooth mobility. Therefore, examining the tooth for signs of dental caries is far easier than evaluating the pathologic variables used to define periodontal disease (Newman et al., 2002).

        The periodontal diseases are highly prevalent and can affect up to 90% of the worldwide population (Bruce et al., 2005). Gingivitis, the mildest form of periodontal disease, is highly prevalent and affects 50-90% of adults worldwide, depending on its precise definition (Albandar & Rams, 2002).

The prevalence of periodontal disease increases with age (Oliver et al., 1991) and as more people are living longer and retaining more teeth, the number of people developing periodontal disease will increase in the next decades. in a study for periodontal disease in adults 30years of age and older in the United States conducted from 1988 to 1994, it was found that about 50% of the adult population had gingivitis, 30% had periodontitis as defined by the presence of three or more teeth with pockets of 4 mm (Albandar et al., 1999). Between 5and 15% of those with periodontitis have advanced forms with pockets of 6 mm (Papapanou, 1996). Another 3to 4% of individuals will develop an aggressive form of periodontal disease between the ages of 14and 35years. These prevalences suggest about two million Americans younger than 35years and another four million older than 35years may have a form of periodontal disease that requires professional intervention (Loesche & Grossman, 2001).

        Studies carried out in different communities have revealed that about 10-15% of individuals are particularly susceptible to periodontitis (Baelum et al., 1988; Brown et al., 1990) .In addition, about 10% of the population seem to be completely resistant to periodontitis. Very little information has been collected on these individuals to establish why they are so resistant, despite the presence of any amount of dental plaque. The remaining 75-80% of individuals have varying degrees of susceptibility, which may be influenced by a number of factors, such as levels of oral hygiene, tobacco smoking, diabetes and possibly also psychological stress (Brown et al., 1990).

Previous reports considering the profile of periodontal status globally have concluded that the distribution of advanced periodontal destruction in adults is quite similar across populations in Africa (Kenya), Asia (Japan and China) America (Mexico) and Norway (Baelum et al., 1996) Recently, it was recognized that Black people are twice as likely as White people to have chronic periodontal problems, with males being most severely affected (Albandar & Tinoco, 2002).

There is no data being recorded or published regarding periodontitis prevalence in the Libyan population.

Etiology and Pathophysiology

        Periodontitis (Greek peri- “around”; odont-, “tooth”; -itis - “inflammation”) refers to a number of inflammatory disease affecting the elements of the periodontium and includes progressive loss of the alveolar bone around the teeth, and if left untreated, can ultimately lead to the loosening and subsequent loss of teeth.

Gingivitis is the inflammatory condition of the gingiva in which the junctional epithelium remains attached to the tooth root at its normal anatomical level. There are pathologic changes present, but no loss of periodontal attachment. Periodontitis occurs when pathologic changes progress to include the destruction of the periodontal ligament and the migration of the junctional epithelium apical to the CEJ (Pontoriero et al., 1988). Periodontitis is always preceded by gingivitis, but gingivitis does not always progress to periodontitis.

        The most common cause of periodontal diseases is poor oral hygiene which leads to an accumulation of plaque and calculus, and the proliferation of pathogenic organisms subgingivally within the sulcus. Periodontal disease requires pathogenic bacteria, a susceptible host, and a conducive environment (Rose, 2004). The bacteria attributed to the etiology of periodontal disease are typically Gram negative, facultative or anaerobic organisms.

        While the primary etiology of periodontal disease is considered to be bacterial in origin, there are many contributing or modifying factors that may affect the extent and severity of this disease, such as genetics, tobacco use, systemic diseases, hormonal changes, oral hygiene practices, medications, and stress (Newman, 2002).

Periodontitis is initiated by specific bacteria. These bacteria are known to stimulate the host response, which plays an important role in the recruitment of leukocytes and the subsequent release of inflammatory mediators and cytokines. The immune inflammatory reaction that develops in the gingival and periodontal tissues in response to the chronic presence of plaque bacteria results in the destruction of structural components of the periodontium leading, ultimately, to clinical signs of periodontitis. Both the host and bacteria in the periodontal biofilm release proteolytic enzymes that damage tissue. Increased levels of inflammatory mediators and cytokines are involved in periodontal tissue destruction (Genco, 1992).

Loss of the periodontal attachment and pathologic deepening of the gingival sulcus clinically manifests as periodontal pocket formation (Becker et al., 1988).

        True periodontal pockets are classified as suprabony (supracrestal) or infrabony pockets (intra-bony, subcrestal, intra-alveolar). The pockets are lined by plaque covered cementum and enamel on one side, while the soft tissue walls and floor of the pocket are covered by a micro ulcerated layer of junctional epithelium, which is attatched to the root at the base of the pocket (Caffesse et al., 1991). Increased sulcular depth may result from coronal displacement of the gingival margin due to enlargement of gingival tissue, apical migration of the junctional epithelium, or a combination of both. The process begins with inflammation of the connective tissues within the wall of the gingival sulcus (Becker et al., 1988). As the normal sulcus progresses to a diseased periodontal pocket, the proportion of the pathogenic microorganisms increases (Lindhe et al., 1995). The microorganisms produce toxic products and cause inflammation, which results in tissue destruction and deepening of the sulcus (Becker et al., 1988). With inflammation, the junctional epithelium lining the floor of the pocket is infiltrated with polymorphonuclear cells. When they reach more than 60% of the volume, the integrity of the junctional epithelium is disrupted. Cellular enzymes degrade cellular junctions and the epithelium detaches from the tooth, causing further recession of the pocket (Becker et al., 1988). Bony destruction is caused by microorganisms and their products, as well as the destructive effects of the immune products, such as prostaglandins and complement of the host, and substances from inflamed gingival. Plaque derived products are also thought to contribute to bone loss by direct and indirect means (Wikesjo et al., 1991). Histotlogical studies have found that a greater degree of inflammation of the periodontal tissues correlates with a greater depth to which the tip of the periodontal probe will penetrate apically (Fowler et al., 1982).

Signs and Symptoms

        Gingival inflammation and bone destruction are painless. In the early stages, periodontitis has very few symptoms and in many individuals the disease has progressed significantly before they seek treatment. Signs and Symptoms of periodontitis are red, swollen or tender gums; bleeding of gums while brushing teeth, using dental floss or biting into hard food; gums that have pulled away from the teeth; halitosis mouth, or bad breath, and a persistent metallic taste in the mouth; deep pockets and pus between the teeth and gums; gingival recession, resulting in apparent lengthening of teeth and loss of teeth in the later stages.

People may wrongly assume that painless bleeding after teeth cleaning is insignificant, although this may be a symptom of progressing periodontitis in that patient (Newman et al., 2002).

Periodontal Health and Socio-economic Status

        The development of healthy public policies, a cornerstone of health promotion, is based on the premise that there is sufficient evidence identifying many of the key social and societal variables that if improved would elevate population health (Tarlov, 1999). Tarlov, for example, has outlined certain societal features that would at a minimum improve the general quality of living overall, but would most likely improve population health as well (Johnson, 1999). These features include improved opportunities for the following: successful child development, strengthened community cohesion, enhanced self-fulfillment, increased socioeconomic well-being, and modulated hierarchical structuring (Tarlov, 1999). Central to much contemporary research on society and health is the concept that the establishment of social hierarchies within both human and animal groups creates levels of psycho-social stress which are manifest in health gradients between those at the top of the hierarchy and those at the bottom (Manuck et al., 1995; Francis et al., 1999). In particular the quest is to define the biological pathways in which social phenomena translate into differences in levels of health (McEwen & Seeman, 1999; Hindle et al., 2000). Factors such as socioeconomic class, race and sex are not commonly reflected in medical journals, which leads to biases in both the content and the process of research (Östlin et al., 2004). Comparisons between populations should be based upon groups equivalent in socioeconomic status. Socioeconomic status (SES) has shown to be strong predictors of a range of health problems. Better health is associated with having more income, more years of education, and a more prestigious job.

        Many previous studies documenting differences in periodontal health have included SES indicators (i.e., income and education) in their analyses. Some studies have provided cross-tabulations between periodontitis and categories for each SES indicator (Locker & Leake, 1993; Oliver et al., 1998; Elter et al., 1999; Borrell et al., 2002; Gillespie et al., 2002), whereas others have included these indicators as covariates in multivariable analysis approaches. Periodontitis is more common in people of low socioeconomic status (Burt, 2005). The incidence of periodontal disease has been positively correlated with lower educational achievement and lower socio-economic status (Machuca et al., 1990; Gaffield et al., 2001; Gaffield et al., 2003).

        A study conducted in 2003 (Hobdell et al., 2003), which found that SES variables alone account for approximately 50% of the differences in the prevalence of periodontitis at 35-44 years of age is noteworthy. They concluded that there is a discernable association between oral diseases and SES variables. The strength of the association varies. It is strongest for chronic destructive periodontitis and weakest for oral cancer. Dental caries lie in between these two. Chronic destructive periodontal disease would seem to be the oral disease which most clearly reflects differences in SES (Hobdell et al., 2003).

        The 1985-1986 American national survey (U.S. Public Health Service, 1987) found that the widely observed relation between SES levels and gingival health is a function of better oral hygiene among the better educated, more positive attitudes toward oral hygiene, and a greater frequency of dental visits among the more dentally aware and those with dental health care insurance.

Black ethnic groups have more severe periodontal disease than white but these differences often disappear if socioeconomic grouping is taken into account (Genco, 1996).

        The report of the U.S. surgeon general, about Oral Health in America, underscores the disparities in oral health according to income (US Department of Health and Human Services, 2000). U.S. data for 1999 through 2004, from the Third National Health and Nutrition Examination Survey, clearly showed that people with incomes equal to or above twice the poverty line, at ages 20 through 64 years, had an average complete tooth loss of 4.41 percent, as compared with 9.28 percent among those with incomes below the poverty line (Dye et al., 2007). At ages 65 years and older, those with incomes equal to or above twice the poverty line had an average complete tooth loss of 26.9 percent, as compared with an average complete tooth loss of 44.19 percent among people with incomes below this level (Dye et al., 2007).

Access to dental care has been widely studied and generally found to be closely related to socioeconomic disparities (Schwarz, 2006). The groups with the highest incomes and education were three to four times more likely to visit a dentist annually than those with the lowest income and education (Gift & Newman, 1993).

Women with the highest household incomes or with education beyond high school were more likely than women with lower incomes or educational levels to have gone to the dentist during their pregnancies. In general, mothers with lower annual household incomes were significantly less likely to seek dental care than were mothers with higher incomes (Gaffield et al., 2001). The main causes of inequalities in oral health are differences in patterns of consumption of non-milk extrinsic sugars and fluoridated toothpaste. Improvements in oral health that have occurred over the last 30 years have been largely a result of fluoride toothpaste and social, economic and environmental factors (Sheiham et al., 1999).

Periodontal Health and Pregnancy

        Changes in hormone levels such as those that occur during puberty, pregnancy, menstruation and menopause, as well as those that occur with the use of hormone supplements including oral contraceptives, have long been associated with the development of gingivitis and are well documented in the literature (Löe, 1965; Lindhe & Attsfrom, 1967; Nyman, 1971; Sutcliffe, 1972; Sooriyamoorthy & Gower, 1989; Mombelli et al., 1989).

        During pregnancy, the body experiences hormonal changes, which can affect many of the tissues in the body, including the gingiva. Many investigators have reported widely variable prevalence levels of gingivitis during pregnancy ranging from 35 to 100% (Löe & Silness, 1963; Silness & Löe, 1964; Lindhe & Branemark, 1968; Cohen et al., 1969; O'Neil, 1979; Kornman & Loesche, 1980; Sooriyamoorthy & Gower, 1989; Steinberg, 1991; Lapp et al., 1995; Machuca et al., 1999). Pregnant women demonstrate an increased level of gingival inflammation compared to non-pregnant controls (Loe & Silness, 1963; Silness & Loe, 1964; Cohen et al., 1971; Arafat, 1974; Samant et al., 1974; Jago et al., 1984; Miyazaki et al., 1991). There have also been studies that have shown an increased probing depth during pregnancy (Loe & Silness, 1963; Arafat, 1974).

        Mainly because of the effect of oestrogen, the gums become inflamed, oedematous, and sensitive, with a tendency to bleed easily, and existing gingivitis may worsen considerably during pregnancy if the plaque is not removed (Loe & Silness, 1963; Ferris, 1993). Increases in both the rate of estrogen metabolism by the gingiva and in the synthesis of prostaglandins contribute to the gingival changes observed during pregnancy (Lee, 1999). Alterations in progesterone and estrogen levels have been shown to affect the immune system and the rate and pattern of collagen production in the gingiva, thus reducing the body's ability to repair and maintain gingival tissue (Zachariasen, 1993; Lopatin et al., 1980). Recently, the dental community has focused on potential associations between periodontitis and pregnancy outcomes (Offenbacher et al., 1996; Offenbacher et al., 1998; Dasanayake, 1998), the ways in which oral health may contribute to general health outcomes (U.S. Department of Health and Human Services, 2000), strategies for preventing bacteria transmission from mother to child (Caulfield et al., 1993) and, ultimately, early childhood caries. Furthermore, advanced periodontal infections in a pregnant woman may pose a threat to the placenta and uterus and may increase the likelihood of pre-term delivery (Offenbacher et al. 1996, Dasanayake, 1998). Prematurity is the leading cause of neonatal morbidity and mortality in non-anomalous infants (Mathews et al., 2003). There are numerous and heterogeneous factors associated with preterm birth, such as low maternal body mass index, maternal smoking, and maternal infections (Kramer, 2003). It has been estimated that periodontal disease of the mother might cause more than 18% of all pre-term births and low birth weight in infants (Offenbacher et al. 1996). A systematic review of 25 studies (13 case-control, 9 cohort and 3 controlled trials) has demonstrated that periodontal disease may be associated with adverse pregnancy outcomes in humans (Xiong et al., 2006). Consequently, it is obvious that oral health and dental care of women during pregnancy are important for both the mother and the baby. However, many women in a number of countries do not visit a dentist during their pregnancy (Gunay et al., 1991; Rogers, 1991; Mangskau & Arrindell, 1996; Gaffield et al., 2001).

A Chilean study (Lopez et al., 2002), concluded that periodontal therapy significantly reduced the rates of pre-term low birth weight (PLBW) in their population of women with periodontal diseases.

        Periodontal awareness among pregnant women was investigated in a recent study in Jordan (Alwaeli & Al-Jundi, 2005) using 275 out of 300 returned questionnaires. They found that 88% of respondents were aware that bleeding gums indicated the presence of periodontal disease; however 56% did not believe that tooth brushing should be increased during pregnancy and 5% thought that there may be a relationship between gum diseases and premature labour. They concluded that pregnant women need more information about oral health and disease prevention. Therefore, it has been recommended that all women should have a dental examination and appropriate dental hygiene care at least once during their pregnancy (Carl et al., 2000). The American Academy of Periodontology (AAP) recommends that women visit the dentist for a periodontal evaluation before pregnancy and that they maintain oral hygiene during pregnancy (American Academy of Periodontology, 2004). Barriers to dental care may be greater for pregnant women because the window of treatment time has traditionally been restricted to the second trimester. The American Dental Association (ADA) suggests that elective dental care should be avoided, if possible, during the first trimester and the last half of the third trimester (American Dental Association, 2006). This time frame apparently is widely recommended because it includes the periods of greater risk of harm to the developing embryo or fetus (Lee et al., 1999), as well as the least comfort for the mother (Wasylko et al., 1998; Sabatka et al., 2000). During the first trimester, risks of birth defects associated with the use of teratogens are higher than in the other two trimesters (Lee et al., 1999). In addition, a large number of pregnancies undergo spontaneous abortion during the first trimester, and any dental procedures performed around the time of the spontaneous abortion could be perceived as causal (Lee et al., 1999). During the last one-half of the third trimester, the increased sensitivity of the uterus to external stimuli increases the risks associated with premature delivery (American Dental Association, 1995; Lee et al., 1999). That recommendation leaves fewer than 4 months for pregnant women to receive oral health education, preventive care, and treatment of any disease.

Periodontal Health, Pregnancy and Socio-economic Status (Relevant Studies)

        Many epidemiological studies have been conducted in different populations documenting the effects of SES components on health outcomes. A reasonable amount of studies exist describing the effects of socio-economic status components related to periodontal health. Few studies analyzing the effects of socio-economic status on periodontal health in pregnant women exist. No study has been reported so far in Libya concerning the effects of socio-economic status on periodontal health in pregnant women. For the literature review of this paper the following studies will be chosen, as they related to periodontal health in pregnant women and socio-economic status.

The Influence of General Health and Socio-Cultural Variables on the Periodontal Condition of Pregnant Women

        A study conducted in Spain studying the influence of general health and socio-cultural variables on the periodontal condition of pregnant women (Machuca et al., 1999). The purpose of this study was to evaluate the periodontal status in a sample of pregnant Spanish women by measuring the plaque index (PI), bleeding index (BOP), probing depth (PD), and clinical attachment level (CAL). Furthermore the aim was to investigate the relationship between these variables and a series of demographic variables (age, professional level, education level, and place of residence) and clinical variables (gestation period, previous periodontal treatment) in order to determine how these relationships may be modified to improve oral health. 130 pregnant women attending the Escuela de Madres Center at the Department of Obstetrics in the Virgen Macarena University Hospital in Seville were studied over six month period. Prior to the periodontal evaluation the participants were interviewed about socio-cultural background including age, economic and professional category, education, and place of residence (rural or urban) frequency of their dental and periodontal appointments. All clinical measurements were recorded by the same observer using a calibrated periodontal probe (Machuca et al., 1999). They found that the mean age was 30.11 years, and that the predominant economic-professional level was housewife (47.7%). More than half the participants had a primary level of education (54.6%) and more than half (57.7%) lived in rural areas. The great majority of the patients were in the third trimester. There was a low proportion of high-risk pregnancies and also of concomitant medical conditions requiring treatment. More than half of the patient did not receive regular dental care (Machuca et al., 1999). The results showed that the plaque index significantly increased when the professional level was lower, education was lower, previous periodontal maintenance was less frequent and patient lived in rural areas. No significant difference were detected between the categories of age, professional-economic level, gestation period, number of previous live births, presence or absence of medical conditions occurring during pregnancy. The bleeding index was significant in relation to lower professional level, less frequent previous periodontal maintenance and an urban residence. Clinical attachment level was related significantly with age and third trimester of gestation period. The probing depth was related significantly with age, lower professional level, rural residence, two or more previous live births and non attendance for previous periodontal maintenance (Machuca et al., 1999). They concluded that gingivitis due to accumulation of plaque was the most common periodontal condition in this sample and was related to professional level, education level, and previous periodontal maintenance (Machuca et al., 1999). They recommended establishing periodontal preventive measures for pregnant women (Machuca et al., 1999).

The Effect of Sociocultural Status on Periodontal Conditions in Pregnancy

        A study conducted in Turkey studying the effect of sociocultural status on periodontal conditions in pregnancy (Yalcin et al., 2002). The goal of the study was to investigate the periodontal condition in a group of Turkish pregnant women by recording clinical measurements including plaque index, gingival index, and probing depths, and to evaluate the interaction between these parameters and their socio-cultural background at three trimesters. The study population was Caucasian females representing the socio-cultural characteristics of Turkey. A total of 61 pregnant women in their first trimesters reporting to the Department of Reproductive Medicine in the University of Istanbul were chosen for the study. The ages of women ranged from 17 to 36 years of age. First the participants were interviewed about socio-cultural background including age, education, professional level, frequency of tooth brushing, and pre


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