RESEARCH PROPOSAL By NSANZIMANA Justin And KANSIIME Oliver Submitted in Partial Fulfillment of the Requirements for the Advanced Diploma in DEPARTMENT OF DENTISTRY FACULTY OF ALLIED HEALTH SCIENCES KIGALI HEALTH INSTITUTE Supervisor: Dr MUMENA Chrispinus ASSESSMENT OF PERIODONTAL STATUS OF PREGNANT WOMEN ATTENDING ANTENATAL CLINIC AT MUHIMA HOSPITAL
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RESEARCH PROPOSAL
By
NSANZIMANA Justin
And
KANSIIME Oliver
Submitted in Partial Fulfillment of the Requirements for the Advanced Diploma in
DEPARTMENT OF DENTISTRY
FACULTY OF ALLIED HEALTH SCIENCES
KIGALI HEALTH INSTITUTE
Supervisor: Dr MUMENA Chrispinus
Kigali August 2009
ASSESSMENT OF PERIODONTAL STATUS OF
PREGNANT WOMEN ATTENDING ANTENATAL
CLINIC AT MUHIMA HOSPITAL
Declaration
We do hereby declare that this Research Proposal submitted in partial fulfillment for the
Advanced Diploma, in Department of DENTISTRY, at KIGALI HEALTH INSTITUTE, is
our original work and has not previously been submitted elsewhere. Also, we do declare that
a complete list of references is provided indicating all the sources of information quoted or
cited.
NSANZIMANA Justin KANSIIME Oliver
Signature Signature
August, 2009
DEDICATION
KANSIIME Oliver
I dedicate this piece of work to the Almighty God, Secondly my family, relatives, my boy
friend and Mr. Joseph Kapkha of ILC consultancy as well as Mr. JEAN Baptist of UN.
DEDICATION
NSANZIMANA Justin
I dedicate this piece of work to the Almighty God, my parents and to my brothers as well as sisters and my relatives.
ACKNOWLEDGEMENT
First of all, the researchers would like to express their special appreciation and gratitude to
their Supervisor Dr MUMENA Chrispinus for his immeasurable assistance, and guidance
during the preparation of this research proposal.
Researchers also exceeding grateful to the staff and all lecturers of Dental Department
including Dr Muhumuza Ibra Head of the department for their piece of advices and
contributions where it seems to be tough.
Finally, the researcher would like to extend their sincere appreciation to Orphans of Rwanda
Inc for both material and financial support during this study. Finally, the researcher cannot
forget to thank all KHI administration in granting the permission to carry out this study in the
sphere of their administration
Almighty GOD blesses you all.
SUMMARY OF THE STUDY
Introduction
Periodontal diseases refer to a group of conditions that cause inflammation and destruction
to the supporting structures of the teeth that is gingival, alveolar bone, periodontal ligaments
and cementum. These chronic oral infections are characterized by the presence of a biofilm
matrix that adheres to the periodontal structures and serves as a reservoir for bacteria.
Periodontal diseases affect the majority of the population either as gingivitis or periodontitis.
Many recent studies have reported that maternal periodontal disease may be an independent
contributor to abnormal pregnancy outcomes such as low birth weight, preterm babies, and
risk for preeclampsia, mortality, as well as growth restriction.
Rationale:
The study will provide the baseline data on periodontal status of pregnant women, and this
information is important for planning and execution of oral health care to pregnant women at
all levels .The findings of the study may help to improve the health status of newborn babies.
Objectives
The main objective of the study is to assess the periodontal status of pregnant women
attending antenatal clinic at Muhima Hospital. Furthermore, the study will determine the
level of oral hygiene and assess the utilization of oral health services among pregnant women
attending antenatal clinic at Muhima Hospital. Nevertheless this study will determine the
proportion of pregnant women affected with gingivitis, periodontitis and characterize the
type of periodontal disease as well as determine the association between gingivitis,
periodontitis and the period of pregnancy.
Methodology
A descriptive cross sectional prospective study will be done at the antenatal clinic in Muhima
hospital over a period of two months. The sample size of 200 subjects will be selected
randomly from the pregnant women. Data collection tools will be a self administered
structured questionnaire followed by clinical examination for the pregnant women.
Conclusion
This project will cost a total of 3.123.500Rfw
Contents
Table of ContentsTABLES OF CONTENTS Page Declaration…………………………………………………………………ii Dedication…………………………………………………………………..iii Acknowledgement……………………………………………………….....iv Summary……………………………………………………………………v Tables of contents…………………………………………………………..vi Abbreviations and acronyms………………………………………………viii List of tables…………………………………………………………………ix List of figures………………………………………………………………..x
CHAPTER 1.INTRODUCTION…………………………………………… 1.1. Definitions of key terms pertinent to the study…………………………. 1.2. Background to the study ………………………………………………… 1.3 Problem statement……………………………………………………….. 1.4. Main objective………………………………………………………….. 1.5. Specific objectives………………………………………………………. 1.6. Study questions/Hypothesis……………………………………………… 1.7. Significance of the study………………………………………………… 1.8. Subdivision of the Project: Mention the main parts of the proposal
CHAPTER 2.LITERATURE REVIEW
CHAPTER 3.METHODOLOGY
CHAPTER 4.PRESENTATION OF THE RESULTS
LIST OF ABBREVIATIONS
Dr: Doctor Mr: Mister WHO: World health organization KHI : Kigali Health Institute LOA: Loss of attachment CEJ: Cemento-enamel junction HIV: Human Immune Virus AIDS: Acquired Immune Deficiency Syndrome UN: United Nation ILC: International limited Company MM: Millimeters LGE: Linear Gingival Erythema CPTIN: Community periodontal Index of Treatment Need %: Percentages
1:0 INTRODUCTION
1.1 DEFINITIONS OF THE KEY TERMS/CONCEPTS
Antenatal clinics:
These are clinics that take care for the health of pregnant women by and their new born
babies.
Plaque:
This refers to the soft; sticky accumulation that occurs on the teeth and various other intra-
oral surfaces around the tooth .it is the host to a complex micro-system of micro-organisms
whose pathogenicity and virulence cause inflammatory diseases of the gingival and other
periodontal tissues and also can be removed by direct brushing or polishing from tooth
surfaces.
Pocket probing depth;
Refers to the distance from the gingival margin to the base of the pocket. Pocket depth refers
to the abnormal space developing between the tooth and the gum.
Gingiva recession
A condition when edge of the gum moves apically along the root surface of the tooth
resulting in exposure of the roots.
Gingivitis;
This is a superficial inflammation of gum tissue (gingival). The clinical feature of gingivitis
varies as they reflect the type and extend of inflammation present which may be either acute
or chronic.
Any or all of the following signs may be noted:
Discolouration of the gingival tissue from pink to bluish red.
Swelling of the gums and loss of stippling.
Retraction of the gingiva.
Bleeding: this is the most common symptom of the inflammation of the gum tissues.
Calculus;
refers to the calcified deposits on the teeth ;formed by the continuous mineralization of
presence of dental plaque ,and also its surface provides an ideal medium for the further
plaque formation and threatening the health of the gingiva.
Root planning;
This refers to the procedure used to treat periodontal condition by scaling the roots of the
teeth to establish a smooth area and send calculus free from teeth surface and usually requires
local anesthesia to prevent pain during procedure and to avoid trauma to the client.
Gingiva (Gum):
This is a portion of the soft tissue that lines the oral cavity, covering and attaching to the
alveolar bone and cervical regional of the teeth. Normally it is salmon pink, stippled and
generally terminates coronally in a knife-edge relationship with the tooth surface. Apiccaly it
extends to the mucogingival line of the vestibular fornix and floor of the mouth. It is firmly
and well attached to the tooth. That part of the gum which forms a point between the teeth is
called the gingiva papilla.
Collagen fibres:
The major portion of the connective tissue of the free and attached gingiva consists of dense
net working of collagen fibres which interdependently fulfil numerous functions and provide
firmness to the gingiva and to the attachement of the gingiva to the underlying cementum and
alveolar bone.
The collagen fibres go in various directions and intimately blended
They are classified into groups based on their functions, location and insertion.
The periodontal ligament:
These connect the tooth with surrounding alveolar bone and it is consequently situated in the
narrow space normally between 0.1mm to 0.25mm in width and it is visual through
radiograph as radioluscent line surrounds the root. The width depends on the age and the
functioning of the tooth,mobility may occur if the width is increase ligaments are partially
lost
The cementum:
This covers the surface of the root; fibers of the periodontal ligaments are attached to this
layer. The thickness of the cementum at the cemento-enamo junction is about 5mm in the age
group and its deposition continues periodically throughout the life
Alveolar bone;
Alveolar processes are the parts of the maxilla and mandible providing the housing for the
roots of the teeth, they develop in accordance with tooth formation and eruption and they are
subjected to atrophy if the teeth are lost
Periodontitis;
Refers to both inflammation and destruction of the supportive tissues around the teeth
(periodontium)
Periodontium;
refers to periodontal tissues and it includes:gingiva(gums),periodontal ligaments,cementum
and alveolar bone.
The structure below summarises the different parts of the tooth mentioned above and
their location
1:2: Background of the study
Periodontal diseases refer to a group of conditions that cause inflammation and destruction
to the pe r iodon t ium/ supporting structures of the teeth that is gingival, alveolar bone,
periodontal ligaments and cementum. These chronic oral infections are characterized by the
presence of a biofilm matrix that adheres to the periodontal structures and serves as a
reservoir for bacteria. Periodontal diseases affect the majority of the population either as
gingivitis or periodontitis. Recently there have been many studies that link or seek to find a
relationship between periodontal disease and other systemic dis- eases including,
cardiovascular disease, diabetes, stroke, and adverse pregnancy outcomes (compend contin
Educ Dent Suppl 2000)). The disease affects all ages and sexes without ratio or sex
predilection (ref).
Many recent studies have reported that maternal periodontal disease may be an independent
contributor to abnormal pregnancy outcomes including preterm birth, low birth weight,
risk for preeclampsia, mortality, and growth restriction. However, the causality of how
periodontitis influences pregnancy outcomes has not been established.(Bogges et al. 2006,
Lopez et al. 2002, Dosanayake et al. 1996, Offenbacher et al. 2001, Offenbacher et al. 1996)
Preterm birth has been identified as one of the most important perinatal health problems in
both un developed and developing countries (ref). The rate of preterm birth has not changed
despite improvement in health delivery systems in many countries (ref). Preterm birth is the
leading cause of mortality in neonates (ref). There is about 56.2% of infant mortality
reported
1.3 PROBLEM STATEMENT
The association of periodontal diseases in pregnant women with the bad health status of
newborn has been observed and reported worldwide (Bogges et al. 2006, Lopez et al. 2002,
Dosanayake et al. 1996, Offenbacher et al. 2001, Offenbacher et al. 1996). There is available
literature from developed countries that documents the high prevalence of periodontal
diseases in pregnant women (Bogges et al. 2006, Lopez et al. 2002, Dosanayake et al. 1996,
Offenbacher et al. 2001, Offenbacher et al. 1996). This has increased the emphasis of
integrating the oral health care in antenatal clinics so as to prevent the complications of
periodontal diseases in the newborn babies. The periodontal status of pregnant women in
Rwanda remains unknown, whether oral health care should be integrated in antenatal clinics
or not has never been considered. Nevertheless, a high proportion of pregnant women with
dental problems including periodontitis were observed during the period of clinical
placement at Muhima Hospital in 2008.
There is no available literature documenting magnitude of periodontal diseases of pregnant
women in Rwanda.
1.4 STUDY OBJECTIVES
I. MAIN OBJECTIVE
To assess the periodontal status of pregnant women attending antenatal clinic at
Muhima Hospital.
II. SPECIFIC OBJECTIVES
To determine the level of oral hygiene among pregnant women attending
antenatal clinic at Muhima Hospital.
To assess the utilization of oral health services among pregnant women
attending Muhima Hospital.
To determine the proportion of pregnant women affected with gingivitis
To determine the proportion of pregnant women affected with periodontitis
at Muhima Hospital
To characterize the type of periodontal disease affecting the pregnant
women Muhima hospital
To determine the association between gingivitis and the period of
pregnancy
To determine the relationship between periodontitis and the period of
pregnancy
1:5: STUDY QUESTIONS/HYPOTHESIS
I. Alternative hypothesis
There is a high proportion of pregnant women affected with periodontal disease in Rwanda.
II. Null hypothesis of the study
Periodontal disease in pregnant women is not a serious problem in Rwanda
1.6 SIGNIFICANCE/RATIONALE OF A STUDY
This study will provide the baseline information about the periodontal status among pregnant
women attending at Muhima Hospital. This information is important for planning and
execution of oral health care to pregnant women at all levels. The findings of the study may
help the policy makers on how better to improve the health status of newborn babies.
CHAP 2. LITERATURE REVIEW:
Clinical presentation of periodontal diseases:
Two major categories of periodontal diseases (Gingivitis and periodontitis) have been
described (American Dental Association 1986 )and more than that within each category
there are specific types of diseases that have been identified. The severity, the predisposing
factors and the clinical presentation of these forms differ widely.
Gingivitis is the earliest form of the disease usually present in a variety of forms depending
the causes and the associated predisposing conditions. Five forms have been documented as
commonly occurring and may all present in pregnant women depending on the accompanied
systemic condition (ref).
Plaque-Associated Gingivitis: This is the commonly and simplest form of the disease
caused by poor oral hygiene, but it can be modified by a number of factors therefore
enhancing speed and severity. Normally this form clinically will appear with bleeding of the
gums on probing without loss attachment.
Necrotizing Ulcerative Gingivitis: This is a special type of periodontal disease also known
as “trench mouth” or “Vincent’s infection”. It may be mild or severe, acute or chronic. It is
seen in people of all ages; young people of 15-30 years seem to develop the disease most
easily. It has been found that when emotional tension increases, the infection gets worse. If
the destruction extends into the soft tissues, then it is called Noma or Cancrum Oris. This
condition has been described mostly in tropical African countries where the disease has been
associated with predisposing systemic diseases such as meascles, small pox, malaria and
secondary anemia. These observations strongly suggest that while the initiating factors are
bacterial in origin, the resultant severity and extent of the disease is markedly affected by the
resistance of the host. Patients diagnosed with Necrotizing Ulcerative Gingivitis may present
with the following clinical findings: Papillary necrosis, bleeding, pain and fetor oris (odor).
No any study reported this in pregnant women.
Hormone-Induced Gingival Inflammation (pregnancy gingivitis or epulis):
This form occurs commonly due to changes in the circulating level of hormones such as
estrogen and progesterone. Such hormonal changes induce gingival hyperplasia, this can
occur at puberty or during pregnancy. Clinically this form present with the following features
gingival redness, bleeding upon probing, edema and gingival enlargement associated with
proliferation of blood vessels.
Drug-Influenced Gingivitis: This is another form of gingivitis but occurs in patients on
systemic medications for treatment of other systemic medical conditions such as epilepsy.
The use of some antibiotics is also associated with such changes. Medications known to
bring gingivitis are such as Dilantin, Cyclosporine or Procardia often present with gingival
overgrowth.
Clinical findings in this form include: Fibrotic gingival response, pseudo pockets and
bleeding upon probing.
Linear Gingival Erythema (LGE):
A form of gingivitis occurring in Patients that have HIV/AIDS. In this form there is a linear
band or fiery red band 2 to 3 mm along the gingival margin, and less plaque. This form of
gingivitis is reported to be associated with candidal infection.
Periodontitis is the progression of gingivitis that has not been adequately treated or not
completely treated. This involves the chronic inflammation and destruction of the supporting
bone and parts of the periodontal membrane. As the fibres of the periodontal membrane are
destroyed and the margin of the gums detaches from the tooth, pockets are formed. Pockets
are spaces between the teeth and the surrounding tissues where formerly the attachment was
situated. From pockets pus sometimes can be discharged. As the pockets get deeper, the teeth
get looser. Teeth frequently become abscessed and eventually can even fall out. The clinical
picture of periodontitis therefore in addition to the above mentioned signs of gingivitis,
include pocketing and loosening of teeth. Several forms of periodontits are well known
depending on the aetiological factors, the age of the affected invidividual and the severity.
Aggressive periodontitis : This is a form of the periodontitis that occurs in the patients who
are clinically healthy and common features include rapid attachment loss ,bone destruction
and facial aggression
Chronic periodontitis: This is a form of the periodontal disease resulting in inflammation
with in the supporting tissues of the teeth, progressive attachment loss and bone loss and also
it is characterized by pocket formation, recession of the gingiva. .It is recognized as the most
frequently occurring form of periodontitis which is prevalent in adults but can occur in any
age.
Necrotizing periodontal diseases: an infection characterized by necrosis of gingival tissues,
periodontal ligaments and alveolar bone. These lesions most commonly observed in
individual with systemic conditions including but not limited to HIV infection, malnutrition
and immunosuppressant
Juvenile periodontitis: A common form with onset in adolescence and puberty and
relatively well defined clinical features.
Adult Periodontitis: This is the most common chronic form of periodontitis. The presence
of local factors such as plaque is usually comparable with the disease progression. Usually it
is the progression of simple plaque induced gingivitis.
Picture of Plaque-Associated adult Periodontitis (slowly progressing periodontitis)
Measurement of periodontal disease:
Pathognomic feature of periodontal disease is the destruction of the collagen fibres of the
periodontal ligaments that may result in a loss of bone support of the tooth. Clinically the
condition is defined as measurable loss of attachement (LOA) in relation to cementoenamel
junction (CEJ). This is associated with the presence of an inflammatory reaction which
clinically is recognized as bleeding, erythema, edema, and occasionally suppuration out of
the marginal periodontal tissues. Other commonly identified signs include periodontal pocket
formation, recession of the gingival margin and eventually radiographic bone loss
Prevalence
Epidemiological studies from many countries document that 5 to 20% of the adult population
suffers from severe forms of periodontal disease (periodontitis), depending on the measure of
disease applied (Pilot and Miyazaki 1991, Hugoson et al. 1998, Brown and Loe 1998). In
developing countries such as Thailand the prevalence and severity has been reported to be
generally high. The above findings were obtained by using the WHO community periodontal
index of treatment needs (CPITN), that demonstrated that periodontitis was found in 1.1,
37.2 and 61.6% of subjects aged 15, 35-44 and 60-74 years respectively. Data for child
bearing age was not available therefore not reported.
Causes of periodontal diseases
For many years, it was believed that specific pathogenic bacteria found within dental
plaque biofilm were solely responsible for periodontal diseases. While it is known that
pathogenic bacteria are one facet of the disease process and are consistently present, it is
not the only cause of periodontitis. The host response to the bacterial insult modulates
the severity of the disease by activating the immune system to mediate the disease
process. How well the host responds to the pathogenic bacteria modulates how the
disease is initiated and progresses. This is evidenced by the fact that gingivitis does not
always progress into periodontitis.
Over the years, several risk factors for periodontitis have been identified. For example, stress,
poor dietary habits with high sugar intake, smoking and tobacco use, obesity, age, and poor
dental hygiene all contribute to the development of periodontal disease. Other major risk
factors include clinching or grinding teeth, genetic factors, other family factors, other medical
diseases such as diabetes, cancer, or AIDS, defective dental restorations medication use, and
conditions that change estrogen levels such as puberty, pregnancy, menopause
2.1:1 Ni iki ukuresha mu gusukura amenyo yawe? I. Uburoso bw’amenyo
II. Agati cyangwa umutozoIII. Nta na kimweIV. Niba hari ikindi, kivuge………………………
2.1.2. Ese ni kangahe usukura amenyo yawe nibura ku munsi?
I. Rimwe ku munsiII. Kabiri ku munsi
III. Gatatu ku munsi cyangwa birenzehoIV. Nta na rimwe
2.2 Ese hari ubwo waba warigeze kujya kwa muganga w’amenyo cyangwa uwita ku menyo? 1= Yego 2= Oya (Niba ari oya, jya ku kibazo cya No 2.3) 2:2:1 Niba ari yego, ni iyihe mpamvu yatumye ujyayo?
I. Kubera ububabare bw’amenyoII. Bamunyoherejeho
III. Kwisuzumisha amenyo IV. Ibindi, bivuge_______________________________________ 2.2:2 Ese ni ryari uheruka kwisuzumisha amenyo? 2:3 Ese ujya ubona cyangwa ugacira amaraso igihe usukura mu kanwa?
1= Yego
2= Oya
2:4 Ese ishinya yawe yaba ifite ikibazo cyo kubyimba muri iki gihe utwite? 1= Yego 2= Oya
2:5 Ese ishinya yawe yaba ikubaba muri iki gihe utwite? 1= Yego 2= Oya
2.6. Ese hari ubwo waba ugira ikibazo cy’impumuro idasanzwe mu kanwa muri iki gihe utwite?
1= Yego 2= Oya
2.7 Ese haba hari undi muntu wo mu muryango wanyu waba waragize ikibazo cy’ishinya cyangwa wivujije ikibazo nk’icyo?
1= Yego 2= Oya
2:8 Ese waba unywa itabi muri iki gihe utwite?
1= Yego 2= Oya
2:9 Ese waba unywa inzoga cyangwa warayinyweye muri iki gihe utwite?
1= Yego 2= Oya
2:10 Ese haba hari bumwe muri ubu burwayi waba ufite?
I. HIV/ SIDAII. Indwara z’umutima
III. Indwara ziterwa n’isukaliIV. Indwara z’ubuhumekero V. Igicuri
VI. Izindi, zivuge__________________________________________ 2:11 Ese haba hari imiti ya zimwe mu ndwara zavuzwe haruguru ufata? 1= Yego
2= Oya
2:11:1 Niba ari yego, yivuge__________________________________________