Abstract

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

Introduction

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

Background

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

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

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

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

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

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

Statement of the Problem

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

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

Libya

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

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

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

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

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

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

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

2nd March and Ibn-Zohr Policlinics

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

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

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

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

Hypothesis

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

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

Objectives

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

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

The Study Question

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

Literature Review

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

Methods and Search Strategy

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

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

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

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

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

Socio-economic Status (SES) History in Libya

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

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

Socio-economic Status (SES) Components

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

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

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

Education

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

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

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

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

Occupation

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

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

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

Income

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

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

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

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

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

Periodontal Health

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

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

Normal Periodontal Anatomy

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

        The gingiva is divided anatomically into the marginal (unattached), attached and interdental gingival. The marginal gingiva is the terminal edge of the gingiva surrounding the teeth like a collar, but is not adherent to it and it can be separated from the tooth surface with a periodontal probe. The cemento-enamel junction (CEJ) is where the enamel of the crown and the cementum of the root meet. The Marginal gingiva in normal periodontal tissues extends approximately 2mm coronal to the CEJ. The space between the marginal gingiva and the external tooth surface is termed the gingival sulcus. The probing depth of a clinically normal gingival sulcus in humans is 2 to 3 mm (Manfra-Maretta, 1990). The attached gingival is continuous with the marginal gingiva. It is firm, resilient, and tightly bound to the underlying alveolar bone. Attached gingiva is bordered coronally by the apical extent of the unattached gingiva, which is in turn defined by the depth of the gingival sulcus. The apical extent of the attache