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.

Keywords: periodontal health; oral hygiene; Libyan pregnant women; socio-economic variables; epidemiology.

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 previous periodontal care. All clinical measurements were recorded by the same examiner using a Williams periodontal probe. The clinical parameters used were the plaque index (Pl. I), gingival index (GI), probing depth (PD). These parameters were repeated at the first, second, and third trimesters. The data was statistically assessed using stepwise analysis (Yalcin et al., 2002). An analysis of the data showed that the mean age was 23.62. The majority of participants had primary and secondary level of education. The predominant professional level was housewife (75.4%). The majority of the population did not receive previous periodontal care (70.5%), and over half of the patients were frequent tooth brushers (52.5%).

The result of the study showed that the plaque index, gingival index, and probing depth scores increased gradually in the first, second, and third trimesters, although oral hygiene instructions were given to the entire study population. When clinical parameters and demographic variables were compared, only education level and periodontal care seemed to be statistically significant. When the education level decreased, the plaque index, gingival index, and probing depths increased significantly. The probing depths increased significantly when the participants had no previous periodontal care (Yalcin et al., 2002). They concluded that the clinical index scores were related to the education level of the study population. When the education level of the study group decreased, the plaque, gingival index, and probing depth scores contrarily increased. Also non-attendance for previous periodontal care increased the scores of plaque index and probing depth (Yalcin et al., 2002). They suggested simple preventive oral hygiene programs to help healthy gingival during pregnancy (Yalcin et al., 2002).

The Periodontal Status of Pregnant Women and its Relationship with Socio-demographic and Clinical Variables

        A case-control study was conducted in Jordan studying the periodontal status of pregnant women and its relationship with socio-demographic and clinical variables (Tanni et al., 2003). The aims of this study were to assess the oral hygiene and periodontal status of pregnant women in comparison with non-pregnant controls and to investigate the effect of socio-demographic and other variables on such periodontal status. A total of 400 women were included in the study, of whom 200 were pregnant and 200 non-pregnant controls. The ages of women ranged from 20 to 40 years of age. These women were chosen at random from four health centers. Women with systemic medical problems such as bronchial asthma, blood disorders, diabetes, immune disorders, those who had recently taken antibiotics, immunosuppressant medications or control subjects with abnormal menstrual cycles or taking oral contraceptives were excluded from this study. Non-pregnant controls who had been pregnant within the previous year were also excluded. Before the clinical examination the participants were interviewed about their age, years of education, occupation, oral habits and history of pregnancy, i.e. stage and number of pregnancies and vomiting. All clinical measurements were done by one examiner using the Michigan O periodontal probe. The clinical parameters used were the Silness and Loe plaque index (Pl. I), Loe and Silness gingival index (GI), probing pocket depth (PPD), probing attachment level (PAL). Any relationship to socio-demographic (age, level of education and professional level) and clinical variables (gestation period, previous pregnancy and vomiting during pregnancy) was evaluated and analyzed by SPSS (Taani et al., 2003). The results showed that almost half of the participants were housewives and more than half of them received over 12 years of formal education. More than one-half of pregnant women were in their third trimester, while the minority were in their first trimester. Multigravidae of this population accounted for 77.5%. About 45% of pregnant women had more frequent vomiting and 24% occasional vomiting, while 31% had experienced no vomiting. 69.5% of pregnant women had not received any iron or vitamin supplement. Pregnant women had significantly higher gingival index (GI) and probing pocket depth (PPD) scores but with no statistically significant differences in probing attachment level (PAL) or plaque index (Pl. I) compared with non-pregnant controls. Increased age, lower level of education and non-employment were associated with significantly higher gingival index (GI) and probing pocket depth (PPD) scores. All these clinical parameters increased in parallel with the increase in the stage of pregnancy, reaching their maximum in the eighth month. Women with previous or multiple pregnancy had statistically significantly higher gingival index (GI), probing pocket depth (PPD) scores than those who were pregnant for the first time, but with no statistically significant differences in plaque index (Pl. I) or probing attachment level (PAL) scores. Pregnant women who took supplements in the form of vitamins and iron demonstrated no statistically significant differences for gingival index (GI) and probing pocket depth (PPD) scores compared with those who did not take such supplements Also, women who vomited during pregnancy had significantly higher gingival index (GI) and probing pocket depth (PPD) scores compared with those who did not vomit (Taani et al., 2003). They concluded that the association of pregnancy is with the inflammatory aspects of the disease rather than with the periodontal attachment loss or the environmental issue of plaque accumulation. Also the gingival inflammatory symptoms are aggravated during pregnancy and are related to increased age, lower level of education and non-employment (Taani et al., 2003). They recommended periodontal preventive programmes for pregnant women (Taani et al., 2003).

Dental Status and its Socio-demographic Influences among Pregnant Women Attending a Maternity Hospital in India

        Dental status of pregnant women and its socio-demographic influences was investigated in India (Tadakamadla et al., 2007). The purpose of this study was to estimate the oral hygiene, gingival and periodontal status in a sample of pregnant women and to explore the association of various socio demographic factors on the oral hygiene status. The target population was pregnant women attending the district maternity hospital at Udaipur city in India. The final sample accounted to 206 women 38 in first trimester, 84 in second and the rest in their third trimester. The women's age ranged from 18 to 35 years of age. The women who were experiencing labor pain, uncooperative or unwilling to give consent were excluded from the study. Clinical examination was done by a single examiner based on the WHO criteria for periodontal assessment using the CPI probe. For clinical evaluation they used simplified oral hygiene index to determine debris score and calculus score also they used Loe and Silness gingival index to evaluate gingival status. Before the clinical examination socio-demographic information regarding age, trimester, family income, occupation and education of the subject and their spouses was obtained. The collected data was analyzed by SPSS (Tadakamadla et al., 2007). The analyzed data show that there was a significant increase in mean gingival score with increase in trimester and age. There was a rise in the prevalence of shallow periodontal pockets from the first to the second trimester. Pocket depths of 6-8 mm were only prevalent (8.7%) in the 3rd trimester. Stepwise multiple linear regression analysis revealed that the best predictors in the descending order for oral hygiene index were occupation of husband, trimester, income, occupation, age, whereas occupation of husband, age and income provided a variance of 19.7% in debris level. Occupation of husband was the predictor for all the components of oral hygiene index (Tadakamadla et al., 2007). They concluded that gingival and periodontal statuses deteriorated as the trimesters of pregnancy proceed and various sociodemographic factors in addition to trimester significantly influenced oral hygiene status (Tadakamadla et al., 2007). At the end they recommended oral health intervention programs to these risk groups (Tadakamadla et al., 2007).

Socio-demographic Factors Related to Periodontal Status and Tooth Loss of Pregnant Women in Mbale District, Uganda

        (Wandera et al., 2009) have conducted a study in Uganda studying the socio-demographic factors related to periodontal status and tooth loss of pregnant women in Mbale district, Uganda. The objective of this study was to examine periodontal status and tooth loss in pregnant Ugandan women and assess the relationship with socio-demographics factors, gestational age, parity, dental care utilization and oral hygiene behavior. Mothers were participants of a multicentre cluster-randomized behavioral intervention study (PROMISE-EBF Safety and Efficacy of Exclusive Breast feeding Promotion in the Era of HIV in Sub-Saharan Africa). In Uganda, the pregnant women resident in Mbale district were recruited into the PROMISE EBF study between January 2006 and June 2008. There were a total of 6 interviews and one oral examination scheduled for each participant; a recruitment interview, oral health interview and a clinical oral examination during pregnancy, followed by interviews at 3-, 6-, 12-, and 24 weeks post partum. Women who did not intend to breastfeed and infants born with serious diseases or deformities that prevent breastfeeding were excluded from participation. A total of 886 women were eligible to participate of whom information became available for 877 women who participated in the recruitment interview and 713 women who got a clinical oral examination. Periodontal status was assessed by using the Community Periodontal Index of Treatment Needs probe (CPITN probe) by a trained and calibrated dentist. Data was analyzed using SPSS. The results showed 73.3% of the participants were from the rural areas of Mbale district. The majority were in or beyond their 7 month of gestation. Urban women were younger, had higher level of education, were less poor, more often dental visitors, used bed nets more frequently and presented less often with bad oral hygiene as compared to their rural counterparts (Wandera et al., 2009). The result showed sociodemographics variables in terms of age, number of members in household, use of bed net and parity were statistically significantly associated with having CPI score >0. Prevalence of toothloss was statistically significantly associated with place of residence, wealth index, age, size of household, parity, use of bed nets, dental visits and breast problems (Wandera et al., 2009). Size of household, parity, dental visits and breast problems remained statistically significantly associated with tooth loss. The prevalence of tooth loss was 35.7%, 0.6% presented with pockets shallow pockets (4-5 mm), whereas 3.3% displayed bleeding and 63.4% displayed calculus. A total of 32.7% were without any sign of periodontal disease (Wandera et al., 2009). Binary logistic regression analyses revealed that older women, women from larger households and those presenting with microbial plaque were respectively, 3.4, 1.4 and 2.5 times more likely to have CPI score >0. Rural women and those who never visited a dentist were less likely, whereas women from larger households were more likely to have lost at least one tooth. The prevalence of subjects with high CPI score and the prevalence of tooth loss increased with increasing age (Wandera et al., 2009). They concluded that oral condition of pregnant women was characterized by low prevalence of bleeding and moderate prevalence of tooth loss, high prevalence of calculus, low prevalence of pockets 4-5 mm. Age, social status, oral hygiene and parity might be potential risk factors for chronic periodontal disease in this study population (Wandera et al., 2009). They concluded disparity in pregnant women's oral health related to parity suggests that education of maternity care providers concerning oral health in pregnancy is needed (Wandera et al., 2009).

Materials and Methods

        This section gives information about all materials and methods used in this study, by describing the study approach and the research instruments used to examine the study question. It will describe the study design, how participants were recruited and the criteria of selection. It includes the instruments used for data collection and data analysis. Also it will discuss the limitations and strengths of the methods used. This section explains what precautions were taken to ensure that this study is ethically acceptable.

Study Approach

Study Design

        A cross-sectional descriptive study takes place at a single point in time. For this research project a survey was conducted in order to evaluate the periodontal status in a representative sample of Libyan pregnant women and to investigate the relationship between various socio-economic variables (education, occupation and income) and periodontal status. The overall findings will be then extrapolated to the general population of Libyan pregnant women, assuming the sample to be typical of the whole population .Also it will provide a snapshot of the frequency and characteristics of periodontitis in Libyan pregnant women at a particular point in time. This study is conducted based on a quantitative approach to the association between socioeconomic status and periodontal health condition of Libyan pregnant women.

34 Libyan married pregnant women, varying in age from 20 to 41 years old, living in Benghazi-Libya were considered in the study. To avoid confounders, the participants were recruited at random from two policlinics in different geographic areas in Benghazi-Libya .The participants were recruited from the gynecology department at both the 2nd March and Ibn-Zohr policlinics during June 2009. A socio-economic questionnaire was filled in by the participants and an oral examination to evaluate the periodontal health condition was performed by the researcher for each participant. All socioeconomic component in relation with the periodontal health of the pregnant women will be discussed, those that were considered in this study were: education, occupation and income. The pregnant women's age, number of pregnancy and stage of pregnancy were particularly considered in the analysis.

Time Frame and Study Settings

        The study was conducted in Benghazi, Libya. The data collection took place during the internship component of the master study program “Health and Society: International Gender Studies Berlin" from June 7 to July 5 2009. To avoid bias, data was collected from two policlinics located in two different geographic areas in Benghazi-Libya. 2nd March policlinic located at Al-Hadaek area near the apartment buildings and Ibn-Zohr policlinic located at Al-Berka area near the villas. Data was obtained in both settings in different time lengths. The data collection in the 2nd March policlinic was performed in eight steps, one needed for distributing the questionnaire and seven for the clinical oral examination and questionnaire data acquisition. The survey was conducted with 25 questionnaires and Oral clinical examination was performed to the participants on average of examine two women each time. While the data collection in Ibn-Zohr policlinic was performed in ten steps, one needed for distributing the questionnaire and nine for the clinical oral examination and questionnaire data collection. The survey was conducted with 25 questionnaires and Oral clinical examination was performed to the participants on average of examine two women each time. Data collection for oral examination in both clinics had to be performed in accordance to appointment times determined by the participants and the researcher. The workload in the dental department in both clinics regarding the patient's appointments was not too high, and this contributed to a substantially faster data collection procedure. The data gathering procedure was successfully performed in four weeks since the full time length of the internship was dedicated to intensive data acquisition.

Pre-test

        Prior to starting the study, the pre-test was conducted with the socio-economic questionnaire by the researcher. It was performed with around 9 women from the target population who were waiting in the gynaecology department's waiting room in Ibn-Zohr policlinic in Benghazi-Libya. The women were also asked about their opinion after reading the questionnaire, whether it was clear and understandable or not. The result was positive response and acceptance by the targeted women with an exception, namely for the income question. Whereas it was decided with the first supervisor to ask about the exact average monthly income or group it into categories, this was unaccepted from the Libyan population's culture. To avoid losing participants in the study or miss important data because of the income question, with the underlying thought that many are unwilling to give out their income level, it was decided after taking advice from a Libyan sociologist to change the income question in such a way by asking about the average monthly income in comparison with average monthly gross income per capita in Libya. The sociologist's suggestion regarding the income question modification was taken into account, and the question was then changed with the agreement of the first supervisor. With this approach, the access to the study population was substantially improved.

Research Instruments

        For the purpose of this research project, data was collected with a self- administered questionnaire filled in by the participants and a clinical oral examination performed by the researcher.

Questionnaire

        Data regarding the socio-economic status of Libyan pregnant women was collected with a self- administered questionnaire. The questionnaire was developed in English, translated into the Arabic language and back translated into English and double- checked by a professional translator. Social professionals reviewed the questionnaire for semantic, experiential and conceptual equivalence. Cultural sensitivity and selection of appropriate words were considered. Self-administered structured questionnaire, researcher's contact data and informed consent in Arabic language explaining the need for the study and the procedure for responding to the study were enclosed as a cover sheet. Those sheets were distributed to the Libyan pregnant women attending the gynecology department in 2nd March and Ibn-Zohr policlinics. The distribution of the questionnaire was done by the researcher who was guest doctor at both 2nd March and Ibn-Zohr policlinics, and was present until its completion in order to explain the objective of the study and to clarify any possible questions participants might have had. The questionnaires were filled out in the waiting room of the gynecology department, in June 2009. It took the majority of the participants 5 min to complete the questionnaires. After filling in the questionnaire, the participants were asked to contact the nurse in the dental department; in order to arrange an appointment for a clinical oral examination, with instructions to return the filled in questionnaire on the day of the oral examination appointment.

        The questionnaire contains 10 main questions with categorical answers, and where detailed information is required open answers were allowed. Six open questions (age, place of residence, occupation, husband's occupation, months of pregnancy, and number of children) and four categorical questions (level of education, number of pregnancy, presence of other member in the family, and monthly gross income) were included in the survey instrument.

Level of Education was assessed with regard to the highest obtained school certification by means of the following five categories: illiteracy, primary, secondary, diploma, and university or higher. Number of pregnancy was categorized as “yes” if women had been pregnant before and “no” if they had not. The presence of other member in the family was categorized as “yes” or “no”. The income was categorized in comparison with the average monthly gross income per capita in Libya as “below this level”, “at this level”, or “above this level”.

Clinical Oral Examination

        Libyan pregnant women who were recruited for the study had to sign the informed consent, fill in the socio-economic questionnaire, arrange an appointment and give verbal informed consent prior to the clinical oral examination. Arrangement of the appointments was performed according to participant's time and time schedule of the dental department, whereas the researcher who will perform the clinical oral examination was always available from June 7 to July 5 2009, which is the internship period.

        All of the examinations were carried out at the dental department of 2nd March and Ibn-Zohr policlinics with the participant seated in a dental chair in a semi recumbent position under a standard dental examination lamp. Examination of the periodontal status was done by a single examiner who is the researcher based on the WHO criteria for periodontal assessment using mouth mirror, explorer and CPI probe. Direct data entry was used for performing the clinical oral examination by the examiner on a prepared record chart.

        The Community Periodontal Index probe (CPI probe) is a specially designed lightweight probe with a 0.5 mm ball tip and gradations corresponding to shallow and deep pockets, with a black band between 3.5 and 5.5 mm and rings at 8.5 and 11.5 mm from the ball tip.

The evaluation of the periodontal status of the participants was done by using the epidemiological part of the Community Periodontal Index (CPI) which was developed by the World Health Organization (WHO) in 1982 for the evaluation of periodontal disease in population surveys. It can be used to recommend the kind of treatment needed to prevent periodontal disease. The Community Periodontal Index (CPI) with 10 index teeth defined by tooth number (17, 16, 11, 26, 27, 47, 46, 31, 36, and 37) and 6 sextants (17-14, 13-23, 24-27, 38-34, 33-43, and 44-47).

        A sextant was examined only if there were two or more teeth present and not indicated for extraction. Three indicators of periodontal status were used for this assessment; gingival bleeding, calculus and periodontal pockets. Probing pocket depth is one of the most commonly used surrogate markers of periodontal disease and most effectively evaluated over time in order to assess the extent of disease that has occurred. Probing pocket depths were measured from the gingival margin to the apical extent of the probe tip penetration and reported in millimeters.

        An index tooth was probed, by using the CPI probe as a “sensing” instrument to determine pocket depth and to detect subgingival calculus and bleeding response. The sensing force used was no more than 20 grams. A practical test for establishing this force was done by the researcher many times prior the examination, by placing the probe point under the thumb nail and press until blanching occurs. For sensing subgingival calculus, the lightest force that allowed movement of the probe ball tip along the tooth surface was used.

        When the probe was inserted, the ball tip followed the anatomical configuration of the surface of the tooth root. If the patient felt pain during probing, this was an indicative of the use of too much force. The probe tip was inserted gently into the gingival sulcus or pocket and the total extent of the sulcus or pocket explored. For example, the probe was placed in the pocket at the disto-buccal surface of the second molar, as close as possible to the contact point with the third molar, keeping the probe parallel to the long axis of the tooth. The probe was then moved gently, with short upward and downward movements, along the buccal sulcus or pocket to the mesial surface of the second molar, and from the disto-buccal surface of the first molar towards the contact area with the premolar. A similar procedure was carried out for the lingual surfaces, starting distolingually to the second molar.

        The periodontal pocket and bleeding on probing were recorded on the mesio-facial, mid-facial, disto-facial, disto-lingual and mesio-lingual aspects of each index tooth, and each sextant was scored according to its highest CPI score. If no index tooth was present in a sextant, all the remaining teeth in that sextant were examined and the highest score was recorded as the score for that sextant. The problem of a questionable diagnosis was avoided by the rule that when in doubt, assign the lower score.

        Only index teeth were examined according to the following criteria: healthy periodontal status (code 0), bleeding observed, directly or by using mouth mirror, after probing (code 1), calculus and bleeding detected during probing, but all the black band on the probe is visible (code 2), shallow periodontal pocket 4 to 5 millimetres, gingival margin within the black band on the probe (code 3) and deep periodontal pocket 6 millimetres or more, black band on the probe not visible (code 4), excluded sextant, less than two teeth present (code X). The maximum code for the entire mouth was used for evaluation the periodontal status and the treatment recommendation.

        No formal treatment was conducted during the study, except supra gingival scaling for pregnant women who were in the second trimester (safe period for pregnant women to receive dental treatment) and this was done by request of the participant, but all the participants received standard oral hygiene examination, oral health education and motivation, new dental brush and written information about oral hygiene practices.

Accessibility and Recruitment Procedure

        As health facilities in Benghazi-Libya serving the largest Libyan pregnant women population, policlinics have been chosen to be the site for recruitment. Regarding the Libyan traditions and culture, the researcher was a Libyan female and this made the accessibility to Libyan pregnant women easier. Access to the patients in Benghazi-Libya to perform dental procedures by the researcher was allowed, as the researcher is a Libyan dentist and has been employed as a dentist since March 2003 by the Libyan Ministry of Health. To recruit as much participants as possible in four weeks and to avoid bias, two policlinics located in two different geographic areas were selected. The main and the only policlinics in Benghazi-Libya where participants were recruited from, were the 2nd March and Ibn-Zohr policlinics, especially from the gynecology department. In order to recruit as much participants as possible in four weeks, the gynecology department appointment schedule for both policlinics was reviewed to identify the day with the highest number of pregnant women appointments and choose it as the day for the questionnaire distribution.

        A questionnaire about socio-economic status; studying educational level, income level and the professional level was distributed at both policlinics. The volunteers were asked, after filling in the questionnaire, to contact the nurse at the dental department in the same policlinic to arrange an appointment for periodontal status examination. Volunteers were offered oral prophylaxis as needed (supra gingival scaling), oral health education and motivation, written information about oral hygiene practices, and new tooth brush, all free of charge.

The voluntary nature of participation was emphasized. It was made explicit that the decision to participate had no bearing on clinical care and could be ended at any point.

This source of recruitment was regarded to be appropriate for the purpose of this study, since the range of women attending these policlinics was high, varying from illiterate women to highly educated women, and from the very poor to wealthy women, representing the ethnical and cultural heterogeneity of Benghazi's population.

Study Populations

        The participants of this study were chosen at random and recruited in June 2009 from the gynaecology department in two policlinics located in two different geographic areas in Benghazi-Libya, the target population included Libyan pregnant women. For reason of limited time to finish the study, a sample size of a minimum of n=25 for the study population has been recommended by the first supervisor to be sufficient to produce reliable results for this pilot study. The study population was Libyan females representing the socio-economic characteristics of Libya. The Libyan pregnant women who sought prenatal care at the 2nd March or Ibn- Zohr policlinics at the day of distribution of the questionnaire were invited to participate in the study.

Inclusion and Exclusion Criteria

        The definition of the study population was performed on the basis of the following criteria

Inclusion Criteria

        All healthy Libyan pregnant women present on the day of distribution of the questionnaire at the 2nd March and Ibn-Zohr policlinics were included in the study.

Exclusion Criteria

        Exclusion criteria include women with systemic medical problems such as bronchial asthma, blood disorders, diabetes and immune disorders. Women who required prophylactic antibiotics before dental procedures, those who taking immunosuppressant medications, attended the policlinics for dental treatment at the time of participation in the study, received periodontal therapy for four months preceding their participation in the study, experiencing labor pain, gave birth to an infant with a major congenital abnormality, had a perinatal death, and refused to give informed consent were also excluded.

Data Collection

        This study was a field study. When collecting data in the field, the researcher was assisted by the nurse of the dental department of the study settings, who was well instructed and arranged the appointment for clinical oral examinations with the participants. The socio- economic data of the study sample were collected by using a questionnaire, whilst measurement of the clinical parameters to record CPI was performed by the researcher. The questionnaires were kept by the participants and they were only seen by the researcher after completing the clinical oral examination and recording the measures. The record chart of the clinical oral examination was fill in immediately after the consultation and was attached to the questionnaire of the same participant.

Data Analysis

Data-entry Procedure and Data Clearing

        For the purpose of this study data was collected with 34 questionnaires and oral clinical examinations. During the data clearing procedure none of the questionnaires or the clinical oral examinations was excluded. Data were merged with participant identification number, entered into a personal computer using Microsoft Office Excel 2003 database and proofed for entry errors. Then, data-entry was performed with the statistics software programme SPSS version 17 (Statistical Package for Social Sciences) by the researcher and a skilled statistician. During the data-entry procedure, the questionnaires and the clinical oral examination results were screened for plausibility and accuracy. After the data were entered into the statistical programme, their correctness was again tested with validity and consistency checks. After a repeated inspection of suspect values in the questionnaires and clinical oral examinations, there was neither missing nor non-plausible data. The frequency tables were then exported again into Microsoft Office Excel 2007, where they processed to obtain a more synthetic set of data, which were graphically as charts presented in the result section.

Statistical Analysis

        Data analysis focused on possible association between periodontitis in Libyan pregnant women and their socio-economic status. Statistical analysis was performed with the Pearson Chi-square-test (two-sided) for the critical analysis of the findings in the sample in bivariate relationships (cross tabulation), where appropriate. Descriptive statistics including mean, standard deviations and frequency distributions that describe characteristics of the population and prevalence of periodontitis were performed.

Redefinition of Variables into New Categories

        For the better interpretation of data in the statistical analysis the following variables have been redefined in new categories before entering into statistical analysis:

Age Distribution

        The participants of this study were all aged between 20 to 41 years old. For a better comparability of the age distribution in the sample; four age groups were defined:

1 = 20-25 years old

2 = 26-30 years old

3 = 31-35 years old

4 = 36-41 years old

Stage of Pregnancy

        For better comparability of the stage of pregnancy in the sample; the months of pregnancy were grouped into the following three categories:

1 = first trimester (Month 1 through months 3 of the pregnancy)

2 = second trimester (Months 4 through months 6 of the pregnancy)

3 = third trimester (Months 7 through months 9 of the pregnancy)

Number of Pregnancies

        Number of pregnancy was assessed by asking “Is this your first pregnancy?” in a ranking 1=Yes and 2=No. The values were grouped into the following two categories:

1 = First gravidae

2 = Multi gravidae

Educational Level

        The educational status was assessed by obtained school certification in a ranking from 1= illiteracy up to 5=university or higher. The values were categorized according to the highest completed school education as follows:

1 = illiteracy

2 = primary school degree

3 = secondary school degree

4 = Diploma degree

5 = University degree or higher

Occupational Status

        For better comparability of the occupational status in the sample; it was into the following five categories:

1 = Teacher

2 = Employee

3 = Technician

4 = Nurse

5 = Housewife

Income Level

        The income level was assessed by comparison with the average monthly gross income per capita in Libya in a ranking from 1 = below this level up to 3 = above this level. The income level was categorized as follows:

1 = below this level

2 = at this level

3 = above this level

Husband's Occupational Status

        For better comparability of the husband's occupational status in the sample; it was grouped into the following five categories:

1 = Teacher

2 = Employee

3 = Technician

4 = Businessman

5 = Unemployed

Periodontal Health

        The periodontal health was assessed by Community Periodontal Index (CPI) in a ranking from 0 = no sign of periodontal disease up to 4= deep pocket 6 mm or more. The values were categorized according to the CPI score of the entire mouth as follows:

0 = healthy periodontal status.

1 = bleeding observed, directly or by using mouth mirror, after probing.

2 = calculus and bleeding detected during probing, but all the black band on the probe is visible.

3 = shallow periodontal pocket 4 to 5 millimetres, gingival margin within the black band on the probe.

4 = deep periodontal pocket 6 millimetres or more, black band on the probe not visible.

Data Safety and Ethical Considerations

        Before the implementation of the research project, the study protocol was approved by the Ethical Committee of the policlinics in Benghazi-Libya.

Corresponding to the preconditions of data safety of all study participants, administrations of 2nd March and Ibn-Zohr, and the staff of both dental and gynaecology departments in both clinics were informed about content and aim of the study verbally. Additionally, a written hand-out including information about the study and researcher's contact data was distributed with the questionnaire. All the participants entered the study voluntarily, following an explanation of its purpose and objectives. An informed written consent was obtained from all participants in the study and verbal consent prior to each clinical oral examination. In case of a withdrawal of the given agreement by the participant, the questionnaire and the clinical oral examination would have been excluded from the study, in this study this case did not occur. Additionally, the collected data contains no information about names and addresses of participants, thus this approach was regarded to be appropriate. Another important aspect which became evident during data collection was that the study populations were rarely familiar with scientific research approaches. Some of the participants were worried to sign a written consent because they have a fear of misuse of their signature.

        The questionnaire and the data of the clinical oral examination do not contain names or addresses of study participants, thus procedures for anonymous data entry to software were not required. The researcher is bound to confidentiality in dealing with collected data and to its utilization only for scientific research. Precautions are taken to guarantee that no person other than the researcher has access to data archives. This study contains no risk or harm for the study participants.

Limitation

        Biases may have been introduced through the researcher simultaneously acting as examiner for the clinical oral examination. This study is cross-sectional in nature, therfore the cause-effect relationships can not be reliably established. Additionally, it gives only a snapshot, whereas the situation may provide differing results if another time-frame had been chosen. Furthermore, there is no control group to study, how the socio-economic status affects the periodontal health of non-pregnant Libyan women.

        Probing pocket depth measurements should be interpreted with caution, due to inherent errors related to the technique and the inflammatory state of the periodontal tissues. Furthermore, variables such as probing force, angulation and position of probing and contour of the tooth or root impacts on accuracy and reproducibility of the measurements.

Due to time constraints, whereas this study had to be finished in a limited time, only a small sample size could be recruited.

Reliability

        All clinical measurements were carried out by one examiner who is the researcher. The method of examination and scoring was standardized in this study.

An intra-examiner reproducibility study was performed. Seven participants, with a range of severity of periodontal disease were reexamined approximately one hour after they were periodontally assessed for the study. The examiner was blind to the clinical data recorded at the first examination. By comparison, there was no difference between the first and the second records.

Results

        This section will present the data that has been collected and the results that have been obtained from analyzing these data in examining the study question.

The result section is divided into the following two parts: The first part presents the descriptive analysis of participants' demographic information, clinical variables related to pregnancy, socio-economic factors and periodontal health. The second part presents the association between periodontal health of the participants and their demographics, clinical variables related to pregnancy and socio-economic status. For the purpose of this research 34 questionnaires and clinical oral examinations collected from 2nd March and Ibn-Zohr policlinics in Benghazi-Libya were included into the study. Exact numbers of all considered variables are given in the presentation of the results in the corresponding figures.

Results of Recruitment Procedure

        The data collection took place at 2nd March and Ibn-Zohr policlinics in Benghazi-Libya, from June 7 to July 5 2009. Out of 50 women, 41 recruited to the study and signed the informed consent form and 9 refused to participate. Reasons given for not participating were: not interested, felt nauseous, time unavailability for filling out the questionnaire and/or oral examination, unable to attend dental appointment; due to employment, due to travel, dental fear, some women believed that poor oral health status during pregnancy is normal, and other women believed that they or their fetus could be harmed by the clinical examination.

Of 41 women recruited to the study, 7 withdrew, leaving 34 women enrolled. The main form of withdrawal was non-attendance at the dental appointment.

Description of the Study Population

        This part presents the results of the descriptive analysis of participants' demographics, clinical variables related to pregnancy, socio-economic factors and periodontal health.

Age Distribution

        All women (n= 34) included in the study population were between 20 and 41 years old at the time of data acquisition. For a better comparability of the age distribution in the sample; four age groups were defined:

1 = 20-25 years old

2 = 26-30 years old

3 = 31-35 years old

4 = 36-41 years old

The age distribution of study participants shows that the proportion of women in the age group of 31 to 35 years was the highest (18 out of 34). The lowest proportion of women was in the age group of 20 to 25 years (3 out of 34). The mean age was 31.65 (SD 4.348).

Stage of Pregnancy

        Stage of pregnancy was assessed regarding the months of pregnancy in the following 3 categories:

1 = Month 1 through months 3 of the pregnancy

2 = Months 4 through months 6 of the pregnancy

3 = Months 7 through months 9 of the pregnancy

More than half of the pregnant women (19 out of 34) were in their third trimester, while the minority (3 out of 34) were in their first trimester.

Number of Pregnancies

        The participants were asked whether this was their first pregnancy or not. Number of pregnancy was assessed in the following two categories:

Yes = First gravidae

No = Multi gravidae

Of the 34 pregnant women, 13 were primigravidae, while 21 were multigravidae.

Educational Level

        The educational status was assessed regarding the highest obtained school certification in the following five categories: illiteracy, primary, secondary, diploma, and university or higher.

The majority of participants had primary level education (11out of 34), and only very few participants were illiterate (2 out of 34). The proportion of participants with secondary level education was equal to those with diploma (8 participants in each category).

Occupational Status

        Occupational status has been grouped into the following five categories:

1 = Teacher

2 = Employee

3 = Technician

4 = Nurse

5 = Housewife

The predominant occupational status in the study sample at the time of data collection was housewife (14 out of 34) followed by employee (9 out of 34). The lowest proportion were technicians (3 out of 34). Nurse and teacher categories have the same proportion (2 out of 34).

Income Level

        The income level was categorized in comparison with the average monthly gross income per capita in Libya as “below this level”, “at this level”, or “above this level”.

According to this classification, the great majority of the participants live at a median income level (15 out of 34), while the minority (6 out of 34) live at low income level.

Husband's Occupational Status

        Husband's occupational status has been grouped into the following five categories:

1 = Teacher

2 = Employee

3 = Technician

4 = Businessman

5 = unemployed

The predominant husband's occupational status in the study sample at the time of data collection was employee (20 out of 34) followed by technician (7 out of 34).

While the minority of the husbands were unemployed (3 out of 34). The teacher category accounted for 4 out of 34 of the husband's occupation.

Number of Children

        Number of children ranged from one to five. The great majority of the participants had two children, followed by either one or three children, while only one woman had five children.

Presence of other Member in the Family

        Of 34 participants, only 1 woman had one other member in the family (her father in-law).

Place of Residence

        All the participants were living in Benghazi city.

Periodontal Health Evaluation

        The periodontal health was assessed by Community Periodontal Index (CPI). The values have been categorized according to the CPI score of the entire mouth as follows:

0 = healthy periodontal status.

1 = bleeding observed, directly or by using mouth mirror, after probing.

2 = calculus and bleeding detected during probing, but all the black band on the probe is visible.

3 = shallow periodontal pocket 4 to 5 millimetres, gingival margin within the black band on the probe.

4 = deep periodontal pocket 6 millimetres or more, black band on the probe not visible.

Periodontal disease prevalence was determined by considering participants with CPI scores 1, 2, 3 and 4 as diseased and the participants with CPI score 0 were considered as healthy. None of the participants examined were free of any periodontal disease.

The most prevalent conditions found in the examination of the pregnant women were pockets = > 6 mm (14 cases out of 34) and calculus (11 cases out of 34). Bleeding on probing (score 1) was less prevalent among the examined women, as it was only twice identified. 7 out of 34 participants had at least one 4- to 5-mm pocket (CPI = 3).

Association between Periodontal Health and Demographic Factors, Clinical Variables Related to Pregnancy, and Socio-economic Status

        The variables that were considered in the analysis were: women's age, stage of pregnancy, number of pregnancy, educational level, occupational status and income level.

Periodontal Health and Age Distribution

        In terms of age, a result which raises concern is that the pockets = > 6 mm (score 4) were more often identified in the study participants compared to shallower pocket (score 3), especially among women aged 31 to 35, which is also the age group with the highest general prevalence of periodontal disease. Bleeding on probing (score 1) was only twice identified in the examined women, with a case being recorded for each of the 20-25 and 31-35 age groups. Calculus (score 2) was more prevalent among the women aged 31 to 35 years old, whereas a relatively equal number of cases was recorded among the 26-30 and 36-41 age groups. Patients aged from 20 to 25 years old had a low prevalence of periodontal health problems, with only one case identified for each of bleeding, calculus and pocket of lower severity. The analysis showed CPI score increased with increasing age. Prevalence of calculus and periodontal pockets tends to increase with increasing age.

Periodontal Health and Stage of Pregnancy

        In terms of trimester, periodontal health problems were identified in all patients, irrespective of their pregnancy stage. Periodontal pocket = > 6 mm was more often identified in the patients compared to other periodontal disease, especially among women in their third trimester, which is also the stage of pregnancy with the highest general prevalence of periodontal disease. Bleeding was only twice identified in the examined women, with a case being recorded for each of the first and third trimester. Calculus was more prevalent among the women in their second trimester. Patients in the first trimester had a low prevalence of dental health problems, with only one case identified for each of bleeding, shallow pocket and deep pocket. The analysis showed that CPI score increased with pregnancy stage. Prevalence of calculus and periodontal pockets tends to increase with increasing stage of pregnancy.

Periodontal Health and Number of Pregnancies

        In terms of pregnancies number, pathological periodontal pockets = > 6 mm (score 4) were more often identified in the patients compared to the other periodontal disease, especially among women with previous or multiple pregnancy, which is also the group with the highest general prevalence of periodontal disease. Bleeding on probing (score 1) had a low prevalence in both groups. The analysis showed CPI score increased with increasing number of pregnancies. Prevalence of calculus and periodontal pockets tends to increase in multi gravidae women.

Periodontal Health and Educational Level

        In terms of educational level, bleeding on probing (score 1) was only twice identified in the examined women, both cases in women with secondary level of education. Periodontal pockets = > 6 mm (score 4) were more often identified in the patients compared to the other periodontal diseases with the exception of women with university level of education or higher. The most significant periodontal problem for women with diploma, and university level of education or higher was calculus, with equal number of cases recorded among these two groups. Illiterate women had a low prevalence of periodontal health problems; however when they actually had problems, these were of a higher degree of severity. The analysis disclosed a significant impact of the educational status on the periodontal health, as prevalence of periodontal disease tends to decrease with an increase in educational level.

Periodontal Health and Occupational Status

        In terms of occupational status, periodontal pockets = > 6 mm were more often identified than other periodontal diseases, especially among housewives, which is also the occupational group with the highest general prevalence of periodontal disease. Bleeding on probing (score 1) was only twice identified in the examined women, with a case being recorded for each of “the employee” and “housewife” groups. 4-5 mm periodontal pockets were only identified in “the employee” and “housewife” groups, with a relatively equal number of cases. Calculus was most prevalent among teachers, employees and nurses, with an equal number of cases. The analysis disclosed a significant impact of occupational status on periodontal health, as periodontal diseases are most prevalent among housewives.

Periodontal Health and Income Level

        In terms of income level, bleeding on probing (score 1) was only twice identified in the examined women, both cases recorded among women at high income level, which is also the income group with the highest prevalence of calculus (score 2). Periodontal pockets were more prevalent among women with a median income level, whereas a relatively equal number of cases was recorded among the low and high income level groups. The proportion of periodontal pockets tends to decrease as income level increases.

Discussion

        The discussion section will present the interpretation of the results and analyze the implications of the findings. Furthermore, part of the discussion will highlight similarities and differences in the findings of others who have investigated the topic. Also, this section will discuss the strengths and limitations of methodology and results.

Analysis of Central Themes

        The aim of this study was to evaluate the periodontal status in a sample of Libyan pregnant women (n=34), aged 20 to 41 years old, and to investigate the relationship between various socio-economic variables (education, occupation and income) and periodontal status. It was emphasized to discuss the data in the light of a possible influence of socio-economic status on the periodontal health of Libyan pregnant women and to reflect how they might be explained and related to each other. Information about pregnant women's age, stage of pregnancy and number of pregnancies were particularly considered in this context.

For the purpose of this study the following research question has been developed: Is there an association between Libyan pregnant women's socioeconomic status and their periodontal health status?

        The key findings of this study are that periodontal health of Libyan pregnant women's manifest by bleeding on probing, calculus and periodontal pocket, tends to associate with their socioeconomic status. Women with low socio-economic status were more likely to have periodontal disease. Furthermore, periodontal health tends to be impacted by women's age, stage of pregnancy and number of pregnancy. As these factors increase, the severity of periodontal disease tends to increase.

        The periodontal tissue has shown to be affected by pregnancy. The effect of pregnancy on the periodontal tissue is clinically exhibited by bleeding, calculus and pathological periodontal pocket. Periodontal tissue changes may be the result of an altered immune response or it may be triggered of the stress and anxiety during pregnancy, which may lead to a neglect of oral hygiene and contribute to the deterioration of the periodontal condition. A possible reason for the increased probing periodontal pockets is the swelling and loosening of the gingival tissues around the teeth caused by inflammation so allowing the probe to penetrate deeper within the tissues (Socransky & Haffajee, 1992). The CPI scores of pregnant women reported in this study were high, indicating a moderate to severe periodontal disease. Such findings 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 housewives. This low socio-economic status had a considerable influence on this study.

        Prevalence of periodontal disease tends to increase with increasing age. A pattern of positive correlation between periodontal disease and age has been found in numerous studies globally.

The analysis of the results revealed that the prevalence of periodontal disease tends to increase with increasing stage of pregnancy. Willerhausen et al. (1991) showed that progesterone concentrations corresponding to those seen in the third trimester of pregnancy, caused decreased synthesis of all glycosaminoglycans by human gingival fibroblasts, contributing to the inflammatory changes observed in the gingivae at this stage.

        It was demonstrated in this study that prevalence of periodontal disease tends to associate with being multi gravidae; the relationship could be interpreted as accumulated tissue destruction across time rather than an intrinsic parity related abnormality. In this sense, it is argued that women who had already experienced a dental disease in their previous pregnancies did not receive treatment for this disease and thus carried these dental disease into their current pregnancy.

Furthermore, pregnant women with better education continue to show better condition of periodontal tissues. This would seem to indicate that something in the lifestyle of this group, beyond relative mouth cleanliness tends to hold periodontal disease in check. Severity of periodontal disease tends to increase with lower levels of education. This inverse relationship is possibly the result of poor or low awareness about the importance of maintaining oral hygiene.

        The analysis of the results showed that as the income level decreased, the prevalence of CPI high score tends to increase. The most likely explanations for this result are that costs of dental care have an impact on the dental care seeking behaviors of pregnant women in Libya and failure to attend a dentist on a regular basis.

In Libya, patients must have insurance or be prepared to pay to cover private dental treatment or be placed on a waiting list to seek free treatment in the public system. Because of all these reasons women simply cannot afford regular dental visits.

The analysis of the results showed that the prevalence of periodontal disease tends to be high among housewives. The most probable explanation for this result is housewives usually have low educational levels and low income levels; and that might lead to negligence of their oral hygiene.

These analyses demonstrated the important role of socio-economic status in the etiology of periodontal diseases in Libyan pregnant women.

Characteristics of the Study Sample

        All women in the study sample were between 20-41 years old, with the majority in the 31 to 35 age group; the strongest explanation is that the marriage age for women in Libya has increased in the recent decades and reach about 29 years old in 1995 (UN world marriage patterns, 2000). Since in Libya as in any other Arabic country, the norm is to have many children, most of the pregnant women were multigravidae.

The majority were in their third trimester; the best explanation is that older and multigravidae women tended to seek prenatal care in their last trimester.

Education in Libya is compulsory until the end of primary school, which might explain the fact that most participants had a primary level of education, which in turn might explain the higher proportion of housewives in this sample.

Most Libyan people live within the middle income level; this might explain the fact that most participants had a median income level.

Comparison to Previous Studies

        There has been no study assessing the association between periodontal health and socio-economic status among pregnant women in Libya.

A range of various definitions of periodontal disease in terms of gingival bleeding, probing pocket depths, loss of attachment and radiographic bone loss have been utilized to study periodontal health in pregnant women (Baelum & Scheutz, 2002). Moreover, there are considerable variations in the number of sites per tooth and number of teeth examined (Gjermo, 2005). This inconsistency in methodology and use of disease parameters influences results and limits valid comparisons between studies. Many studies have shown that prevalence and severity estimates, as well as the distributional characteristics of periodontal condition vary depending on the method used for recording (Gursoy et al., 2008).

        The study design used for this study and previous studies was cross-sectional in nature, except Taani et al. (2003) which was a case-control study. The required information for this study was obtained from participants by means of a self- administrated questionnaire, while in previous studies participants were interviewed.

The most frequent stage of pregnancy category in this study was third trimester, similar to that reported by Machuca et al. (1999), Taani et al. (2003), Tadakamadla et al. (2007) and Wandera et al. (2009).

In this study the majority of women were multigravidae, same observation reported by Taani et al. (2003).

Primary level of education was the predominant level of education for the sample of Libyan women sample, similar to the finding of the study of Machuca et al. (1999).

The most frequent occupational status in this study was housewife, similar to that reported by Machuca et al. (1999), Yalcin et al. (2002) and Taani et al. (2003).

Most participants of this study live within the middle income level, while in the previous relevant studies the income level was often not taken into account.

The periodontal probe used for this study was CPI probe, similar to the probe used by Tadakamadla et al. (2007) and Wandera et al. (2009).

For periodontal health evaluation CPI index was used in this study and in Wandera et al. (2009).

The present study showed that prevalence of periodontal disease tends to increase with increasing age. This observation is in agreement with other investigators ((Machuca et al., 1999; Taani et al., 2003; Tadakamadla. et al., 2007; Wandera et al., 2009) who reported a similar association.

The analysis of the results revealed that the prevalence of periodontal disease tends to increase with increasing stage of pregnancy. This finding is in agreement with studies of Machuca et al. (1999), Taani et al. (2003) and Tadakamadla et al. (2007) who found a similar result.

It was demonstrated in this study that prevalence of periodontal disease tends to associate with being multi gravidae. Such observation is in agreement with that of Taani et al. (2003) who demonstrated a similar finding.

Severity of periodontal disease was found to increase with the decrease in educational level. This agrees with the results of Machuca et al. (1999), Yalcin et al. (2002) and Taani et al. (2003).

Results showed that the prevalence of periodontal disease tends to be more prevalent among housewives, similar to what Machuca et al. (1999) and Taani et al. (2003) reported.

The present study showed that as the income level decreased, the prevalence of periodontal disease tends to increase; a similar result was found by the study of Tadakamadla et al. (2007).

Discussion of Limitations

        Limitations to the materials and methods were already mentioned. Some limitations arising directly through the study will be discussed at this point.

Materials and Methods

Study Design

        The cross-sectional nature of the study precluded establishing any cause-effect relationships among variables. This study did not include a comparison group and the findings are to be interpreted with caution. Nonetheless, most of the results were positive and suggest the need for a broader scientific study of the effects of the socio-economic status on periodontal health of Libyan pregnant women.

Additionally, it gives only a snapshot of the population at a certain point in time, whereas the research may provide differing results if another time-frame had been chosen.

Selection Bias

        Although the survey took place at two policlinics located in two different geographic areas in Benghazi-Libya, selection bias is still possible. These policlinics serve Libyan people free of charge, that might be a reason why women from lower socio-economic groups were over represented in the study. If the participants had been recruited also from a private clinic, the analysis might shown different results.

Recruitment Bias

        Recruitment bias was less important than selection bias; because the symptoms of periodontal disease are usually silent and not apparent to the patient in the manner of dental caries. Furthermore, the presence of periodontal disease and dental caries are not related. Hence, even if a subject were aware of dental problems, they may not necessarily be periodontal in origin.

Assessment Bias

        Bias in the assessment of periodontal disease was minimized because all clinical measurements were carried out by one examiner who is the researcher, and was unaware of the participants' socio-economic status. Furthermore, the method of examination and scoring was standardized in this study.

Examiner Bias

        Examiner bias that may have been introduced through the researcher simultaneously acting as examiner for the clinical oral examination was reduced because the questionnaire was kept by the participant and only seen by the researcher after recording the clinical oral examination measures.

Research Instruments

Questionnaire

        The questionnaire included questions asking for husband's occupation, number of children and their age, presence of other member in the family and their age, with the aim to analyze the income regarding to these factors and later classify the participants as low, middle or high income level. Since the exact average monthly income could not be collected by means of the questionnaire, these factors were no more analyzed in studying the association with periodontal disease.

The questionnaire did not collect information on dental insurance coverage; therefore, it was impossible to assess the impact of dental health care coverage. The ability to examine lifestyle determinants and oral health behaviors like; frequency of tooth brushing and previous periodontal maintenance, were limited.

Clinical Oral Examination

        Probing pocket depth (PPD) measurement error may have been introduced because of the inflammation of the periodontal tissue which could affect the resistance to the tip of a periodontal probe. Additionally, other sources of error such as intra examiner reproducibility, probing force, angulation and position of probing and contour of the tooth or root may have confounded the results.

        CPI includes all periodontal disease indicators from bleeding on probing (code 1) to advanced periodontal disease (code 4) and has been used extensively in various populations. This index does not make a distinction between gingival inflammation and periodontal destruction due to its hierarchical scoring principle.

Teeth with calculus do not represent bleeding and that teeth with deep pockets do not present with calculus. CPI scores 1 and 2 reflect gingival inflammation and poor oral hygiene, conditions that are common but do not necessarily progress to periodontal destruction (Gjermo, 2005). Other shortcomings are that measures of clinical attachment loss and tooth mobility are not considered.

Keeping in mind the limitations associated with CPI and that this method does not constitute a complete measure of periodontal conditions. The use of index teeth, instead of a full mouth recording may have resulted in an underestimate of the level of periodontal disease (Agerholm & Ashley, 1996) in this study.

Using number of subjects with bleeding, calculus and pockets as periodontal outcome variables instead of for instance alveolar bone and attachment loss focuses on the extent of the infection at the time of the survey rather than on consequences of past disease processes.

        Despite its methodological limitations, the epidemiological part of the CPITN, the CPI, was deemed to be an appropriate screening system for the pilot study (WHO, 1997). Due to time limitation extra-examiner reproducibility of the clinical examination could not be performed. No clinical test was carried out to identify the part played by hormonal changes during pregnancy, but a full review of the pertinent literature has been included.

Results

        Although the present study aimed to estimate the oral hygiene, gingival and periodontal status and to explore the association of various socio-economic factors on the oral hygiene status of Libyan pregnant women, the results are limited as they do not represent the whole pregnant population of the country.

The study was conducted in only two public policlinics and socio-economic data collected was based on participants' information.

        Due to time constraints, since this study had to be finished in a limited time, only small sample size could be attained. The small sample size of the survey was considered as the main limitation of this research project, despite its comprising from illiterate to highly educated women, and from the very poor to wealthy women, representing the ethnical and cultural heterogeneity of Benghazi's population.

        The limited sample size reduced the likelihood that the studied group will represent good cross sections from the targeted population, and thus do not allow generalizing the findings of this study to the larger population from which the samples are drawn (Atkinson & Flint, 2001). As a result of small sample size, some indicators which would have been needed to adequately answer the research question; could not be measured. Furthermore, the result could not be expressed in percentage, as the sample comprised only 34 participants. The frequencies of distribution were expressed as absolute figures; computing percentages was considered to be logically incorrect.

Strengths

        Although the sample size of the survey was very small, it comprised all socio-economic status levels, representing the ethnical and cultural heterogeneity of Benghazi's population.

An intra-examiner reproducibility study was performed to seven participants, with a range of severity of periodontal disease. Those participants were reexamined approximately one hour after assessing their periodontal health. The examiner was blind to the records of the first examination. The results of the intra-examiner reproducibility study indicated a strong agreement in the measurements of the periodontal variables among study subjects.

Since an association has been found, a cross-sectional study can be very suggestive of a possible risk factor such as low socio-economic status for a periodontal disease in Libyan pregnant women.

Despite the mentioned methodological and results limitations of this pilot study, it could be considered as a good study, since the initially obtained data give important hints and impulses for a more comprehensive analysis and further in-depth research on this topic, particularly as it relates to salient health outcomes of pregnancy.

Researcher Issue

        During the clinical examination, there were some conversations between the examiner and the participants. From these conversations, it was concluded that most participants had limited periodontal health knowledge. All of them had no knowledge about risk of preterm delivery and low birth weight in women with periodontal disease. The majority had never thought about the possibility of an association between periodontal disease and socio-economic status. Many participants had received no instructions on oral health care during their pregnancy. Some participants were apathetic towards dental examinations, particularly those with poor oral health and those who were examined more than once. A Couple of pregnant women said that they notice bleeding on brushing, but their dentist was unwilling to treat them during their pregnancy. This unfortunate attitude from some profession also shows a complete lack of understanding that the periodontal therapy may reduce the risk of preterm delivery and low birth weight in women with periodontal disease. Many dental problems of participants can be treated in one dental visit.

Oral Health Promotion and Periodontal Disease Prevention Programs

        Most participants suffer from moderate to severe periodontal disease. Since all these diseases are preventable, oral health promotion and prevention programs would be very effective in reducing the prevalence of periodontal disease among Libyan pregnant women.

        While many health professionals and educational programs are concerned with numerous aspects of maternal health, periodontal health is usually overlooked.

In planning a preventive periodontal program for pregnant women in the dental public service, interest must first be created by the dental profession at the community, governmental and professional level. This is because support is needed from political, administrative and professional leaders for programs to become feasible (Sheiham, 1983). National political, co-ordinated efforts of the health sector and relevant activities of other social and economic development sectors are needed for successful implementation of preventive programs (WHO, 1981).

        A dental facility at a prenatal care centre can provide a convenient and accessible preventive dental resource for pregnant women (Doust et al., 1985).

The program should aim at developing skills in oral cleansing using practical methods of feedback. The objectives of oral care can be reinforced by methods or tools for home oral hygiene support and assessment, in the form of oral hygiene aids and written literature. This is because tooth brushing is a social norm in most societies today and dental health education should stress the effectiveness of tooth brushing, rather than the frequency (Ainamo, 1984). Moreover, according to Doust, skill deficits are the major problems in oral cleansing in pregnant women (Doust et al., 1985). The results of this study pointed that exist a relationship between various socio-economic variables and periodontal status. Therefore the preventive programs must be processed specifically for this group.

        As mothers play a crucial role in transferring and demonstrating health habits to their children (Blinkhorn, 1981), pregnant women should be a target group for oral health education, especially in a country such as Libya where the population growth is very high. Dental health education programs for expectant mothers could result in children being taught oral hygiene routine which are beneficial to oral health. Preventive periodontal programs directed at expectant mothers, can thus result in highly beneficial outcomes in the long term improvement of periodontal health in the community.

        The main aim of dental health education of expectant mothers should thus be to create the appropriate norms of effective oral health practices, so that the behavior pattern becomes institutionalized in the family (Blinkhorn, 1981).

The aims of these programs should be stated according to short, medium and longer term goals (Wong-Lee & Joyce, 1986). In the short term, the goal would be the prevention of gingivitis during pregnancy with a reduction in the number of bleeding gingival sites as a measurable objective. In the medium term, the oral health of pre-school children would be improved through the benefits of the mothers from program. The oral health status can be assessed according to measurable caries and gingival status. In the longer term, the goal would be an improved oral health status in the primary schoolchildren (Wong-Lee & Joyce, 1986).

The range of preventive activities at prenatal centers can start as a dental health promotion and periodontal disease prevention program, with dental health education as the major activity provided by specially trained dental health educators. Such a program would be supported by an efficient system of referral if dental treatment is required.

        The second stage of the program begins when the dental health education stage is fully operational after a year. Political expediency can be used to facilitate the setting up of dental clinics at these centers to examine and treat pregnant women. Based on the diagnosis and the periodontal treatment needs using CPITN, the dentist can advise and offer treatment to the women. Pregnant women can be appropriately referred to the educators for dental health education and the operating auxiliary for scaling and simple root planning. The dentist would be responsible for the treatment plan and secondary levels of preventive care and exclude surgical interventions.

        A preventive periodontal program for pregnant women can be designed as part of a community's preventive health services. It can be incorporated and be compatible with existing prenatal services, using existing facilities. This would reduce costs and facilitate implementation. Being conveniently located, it will be accessible to all pregnant women seeking prenatal care.

The preventive program can be designed initially as a pilot project at a large prenatal care centre. When fully operational, it can serve as a model for expansion of preventive periodontal disease interventions in the community.

Conclusion and Recommendations

        This section will draw together the various parts of the thesis and discuss the implications of the study. Furthermore, it will provide a summary of the arguments that have developed throughout the work. This section also, will identify recommendations and areas for further research.

Conclusion

This thesis aimed to evaluate the periodontal status in a sample of Libyan pregnant women, to investigate the relationship between various socio-economic variables (education, occupation and income) and periodontal status and to analyze and discuss the data in the light of a possible influence of periodontitis in pregnant women related factors. Information about pregnant women's age, stage of pregnancy and number of pregnancies were obtained and particularly considered in the analysis of the data.

        A pilot study of thirty four Libyan pregnant women was carried out in Benghazi-Libya, and showed that there was a high prevalence of => 6 pockets, low prevalence of bleeding and moderate prevalence of calculus and pockets 4-5 mm in the pregnant women when scored by the Community periodontal Index.

The findings in this study tend to indicate an association between periodontal health of Libyan pregnant women and socio-economic status. As socio-economic status decreases, the prevalence of periodontal disease tends to increase. Furthermore, available data highlights considerable relations between severity of periodontal disease in pregnant women and age, stage of pregnancy and number of pregnancies.

As age, stage of pregnancy and number of pregnancy increased, the prevalence of periodontal disease tended to increase.

        It can be assumed that low educational level, low occupational status, low income level, advanced age, advanced stage of pregnancy and higher number of pregnancies tend to be potential risk factors for periodontal disease in this study population. Therefore, comparisons between populations should be based upon groups equivalent in socioeconomic status.

        It should be noted that participants had low socio-economic status. The majority of participants were housewives and almost all of the participants had primary level of education. Furthermore, most pregnant women were relatively old, in their third trimester and multigravidae. All these conditions had a considerable effect on the results.

Previous studies on periodontal disease in pregnancy have tended to use different methods for measuring periodontal disease. This difference in methodology and use of disease parameters influences findings and limits valid comparisons between studies. However, there are currently several research studies in this area, which support the hypothesis that periodontal disease is associated with low socio-economic status.

        Periodontal diseases are the result of the interplay between plaque bacteria and host responses. Increased periodontal disease has a common occurrence during pregnancy. While the exact cause has not been determined, the condition can be prevented by effective plaque control.

        A great knowledge and awareness of periodontal disease is possible through public health promotion and education campaigns. This must be reinforced by dental health education and motivation. Pregnant women are an important target because they are receptive to health education and as future mothers; they become influential role models for their children in preventive dental disease behavior. Oral health antenatal education is an effective educational approach for developing preventive dental behavior in pregnant women. The provision of a dental team, located at a prenatal centre, will facilitate dental health education and treatment for pregnant women.

This would be an effective strategy for preventive periodontal intervention in the community.

Recommendations

        Being aware of its methodological limitations, however, this pilot study is the first scientific attempt so far to investigate the association between periodontal health of Libyan pregnant women and socio-economic status. The findings in this study may give hints and inspiration for further research in this field and should be verified on bigger samples of Libyan pregnant women. Additional research is needed to determine the nature of this association.

        In view of the results, it might be recommended to women who are pregnant or planning to become pregnant that they have periodontal examinations and subsequent preventive or therapeutic treatment if indicated, to maintain healthy gingiva and prevent development of severe cases. Preventive periodontal therapy may begin early in pregnancy with removal of plaque and calculus, and with patient oral hygiene instructions. Women should be taught tooth brushing and flossing to disrupt subgingival plaque, and professional scaling and prophylaxis could be performed whenever necessary. In this respect, oral health promotion and periodontal disease prevention programs should target these risk groups. Educating and motivating women to maintain good oral hygiene is considered necessary. Improving dental education may need to become a priority in antenatal care to educate women at risk of the importance of maintaining oral health.

Suggestions for future studies:

  • Studies to assess the long-term effect of oral health educational programs in maternity care centers in Libya on dental health knowledge and behavior of pregnant women.
  • Studies are needed in Libya to determine if there is a strong association between periodontal disease and pregnancy outcomes and whether periodontal therapy or prevention can reduce the risk of preterm delivery and low birth weight.