Gingivitis is defined as the “Inflammation of the gingiva”.1 Gingivitis is essentially a prudent attempt of the human body to wall-off the destructive aspects of the immunologically mediated mechanisms in response to the presence of a biofilm, which enhances the body to cease such perturbating consequences.
Epidemiological studies extrapolate a three dimensional spatial and temporal relation of the existing diseases and provide a framework to construct a prospective data-driven future-oriented plan. Prevalence studies, time and again, has proven itself as a fundamental weapon to translate research science into applied science. The prevalence reflects the burden of a population in terms of life expectancy, morbidity, quality of life and monetary cost.2 These studies continue to propagate dynamics in the field of research, which play a pivotal role in the synchronization among the constant shifts in epidemiology, marked in different eras.
Mediocre documentation of the prevalence of gingivitis in comparison to periodontitis, advocates the need to address the issue. The charm of the study regarding prevalence of gingivitis lies in the eminence of its reversibility.3 A stern action should be incorporated in the treatment plan to halt the progression of gingivitis into periodontitis. In regard of this context, prevalence study of gingivitis should be emphasized as it directs a foundation for the abrupt successive action and compels the evaluator to surrender to foster multifaceted attention for the implicated disease. Additionally, gingival color, gingival bleeding are indubitably more tangible parameters than periodontal pockets.
The study on pregnant females is, moreover, intriguing by the intensity and complexity of the condition of the woman. The physiological changes in the pregnant female is specifically governed by the fluctuations in the level of progesterone and oestrogen. Such effect, in presence of biofilm, is also apparently visible in the gingiva leading to gingivitis.4 The spectrum of the etiology of gingivitis in pregnancy also includes an altered immune response, altered subgingival flora and relation with stress and anxiety during pregnancy, resulting in inadequate attention to oral hygiene and contributing to the deterioration in a woman’s oral condition.5
Possibility of relationships between periodontitis and pregnancy complications such as premature birth (<37 weeks of gestation), low infant birth weight (<2,500 gm) and pre-eclampsia have been suggested in the periodontal archives.6 The gravity and magnitude of the study can be further deciphered by the profound statement made by Lopez in 2002 “Pregnancy-associated gingivitis is a preventable and easy to treat disease, and any cost-benefit analysis of the administration of periodontal therapy to pregnant women in order to reduce preterm birth rates would show a high direct cost-benefit saving. However, the real cost saving of reduction in the rate of preterm birth due to periodontal treatment is best represented by the lives of children saved from premature death and biological, social, and economic impairment.”7
Most studies have reported that gingival inflammation peaks from the second to the eighth month.8 The second trimester is traditionally considered more comfortable, because nausea and postural issues are not excessive.9 The Obstetric Periodontal Study has also demonstrated that dental treatment is safe when delivered during the second trimester. 10 The risk of pregnancy loss is lower compared to that in first trimester and organogenesis is completed.11 The pregnant uterus is below the umbilicus until 20 weeks gestation and the woman is generally more comfortable than she will be as the pregnancy progresses. 12
In the third trimester, the uterus can press on the inferior vena cava and pelvic veins, which impedes venous return to the heart. This decrease in venous return can cause a decrease in the amount of oxygen delivered to the brain and uterus.13 Postural hypotensive syndrome is a clinical concern and is seen in 15% to 20% of pregnant women when supine.14 Women who are supine may have nausea or vomiting.
The prevalence of gingivitis in pregnant women has reportedly ranged from 30% to 100%.8,15,16 Researches have revealed the percentage of pregnant women with gingivitis to be 89% in Ghana, 86.2% in Thailand, 97.3% in Brazil and over 66.8% in India.17-20 Studies from the Health Care Centers showed the prevalence of gingivitis in pregnant women as 98.0% in Bangkok, 86.3% in Nakornsawan and 98.8% in Yala.19
A systematic review done by Figuero et al. revealed non-pregnant women had lower mean gingival index (GI) values than women in their second or third term of pregnancy and a significantly lower GI in pregnant women in the first term compared with those in their second or third term of pregnancy.21
In context of Nepal, the prevalence was found to be 40% in a study done in Sarlahi district, in which the examination had been performed by community-based oral health workers.22 Nepal has been placed in the 15 percent of countries in the world where periodontal conditions of the population are amongst the worst.23
Regular home care by the patient is very effective in controlling most inflammatory periodontal diseases.24 However, in low socio-economic countries like Nepal, even basic oral hygiene practice becomes difficult because affordability25 and accessibility26 of oral hygiene aids is an issue. More irking is the fact that pregnant women tend to look for other alternatives in case of any oral disease. This includes pharmacy-prescribed allopathic medicine, self-application of clove oil and even jhar fuk, a traditional approach where a healer performs a spell to chase “worms” (germs) out of the teeth.26
Attempts have been made to establish a relationship between gingivitis with age, gravida, parity, education and occupation. Increasing severity of gingivitis may be because of the untreated cumulative effect of the disease process over a period of time which is also applicable in terms of age, gravida and parity.5,27 Multiparity increases the odd’s ratio of developing pregnancy by 2.47.28 The hierarchized analysis of the periodontal risk factors in the pregnant population shows a lower degree of schooling to be the most significant factor followed by low income, single marital status, obesity prior to pregnancy, multiple births, smoking, and poor oral hygiene.29 Unemployment is likewise associated with increased gingival inflammation scores, plaque scores, periodontal pocket depths and periodontal attachment levels.30
To our knowledge, there is paucity of data in the Nepalese population on the prevalence of gingivitis in the second trimester of pregnancy. The purpose of the present study was to evaluate the prevalence of gingivitis in a sample of pregnant Nepalese women in their second trimester assessed with Gingival Index based on full-mouth observation at four sites. It also aimed to reveal the relationship between gingivitis and a series of demographic variables. The study aims to trigger clinicians to offer their undivided attention to the pregnant patient to detect the disease at its initial stage.