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Year : 2016  |  Volume : 8  |  Issue : 1  |  Page : 53-58

Prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba

1 Department of Preventive Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
2 Department of Preventive Dentistry, College of Medicine, University of Lagos, Lagos State, Nigeria

Date of Web Publication6-May-2016

Correspondence Address:
Dr. Modupeoluwa Omotunde Soroye
Department of Preventive Dentistry, Faculty of Dentistry, College of Health Sciences, University of Port Harcourt, Port Harcourt, Rivers State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-8844.181930

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Objective: To determine the prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of a tertiary health institution in Lagos State, Nigeria. Materials and Methods: A single-point assessment was conducted using a self-reported questionnaire completed by participants. Information such as patients' age, gestational age, educational status, occupation, and perception of gingival colours was obtained. Furthermore, the participants were examined by trained dentists to determine their gingival colours and the presence and severity of gingival inflammation. The data obtained were processed, and descriptive and comparative analyses were done using Epi info version 3.5.1 (2008). Statistical significance was established at P values <0.05. Results: Four hundred and forty-five pregnant women aged between 18 years and 43 years [mean age: 30.3 (±4.61) years] participated in the study. Gestational age was between 4 weeks and 41 weeks with a mean of 23.49 (±9.53) weeks. The prevalence of gingivitis was 85.2%. Two hundred and thirty (51.7%) participants described their gingival colour as pink, 127 (28.5%) as red, 51 (11.5%) as black, 3 (0.7%) as white, 2 (0.4%) as brown, and 32 (7.2%) could not determine the colour of their gingivae. Two hundred and ten (47.2%) participants knew that pink was the normal colour of a healthy gingiva. From objective clinical examinations by dentists, 344 (77.3%) patients had pink gingivae, 85 (19.1%) had pigmented gingivae, and only 16 (3.6%) had red gingivae. Conclusion: The higher prevalence of gingivitis during pregnancy is well-established and that observation is corroborated by this study. Since a change in gingival colour may be an early indication of gingival inflammation, early detection and prompt treatment could prevent further periodontal deterioration. Hence, there is the need to incorporate and intensify oral health education during antenatal care so that pregnant women are able to identify changes in gingiva colour, especially when it is associated with periodontal inflammatory diseases.

Keywords: Gingival colour, gingivitis, pregnant women

How to cite this article:
Soroye MO, Ayanbadejo PO. Prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba. J Orofac Sci 2016;8:53-8

How to cite this URL:
Soroye MO, Ayanbadejo PO. Prevalence of gingivitis and perception of gingival colour among pregnant women attending the antenatal clinic of Lagos University Teaching Hospital, Idi-Araba. J Orofac Sci [serial online] 2016 [cited 2023 Jun 9];8:53-8. Available from:

  Introduction Top

The periodontium consists of the gingiva (gum), cementum, periodontal ligaments, and the alveolar bone. The gingiva is that part of the oral mucosa, which covers the alveolar process of the jaws and surrounds the neck of the teeth. [1] The colour of the healthy gingiva is generally described as coral pink and is determined by the vascular supply, the thickness and degree of keratinization of the epithelium, and the presence of pigment-containing cells (melanin). [1],[2] It varies according to the individual's complexion, being lighter in those with a fair complexion than in those with a dark complexion in whom a brownish tinge may be imposed by their greater melanin pigment. [1],[2],[3],[4],[5] However, the gum becomes red and swollen when inflamed and it may also assume different colours such as blue, black, or brown with various pigmented lesions of the oral mucosae. [3],[4]

Pregnancy, which is associated with hormonal changes [6],[7],[8] increases the risk of gingivitis (inflammation of the gum), which if not property treated can lead to periodontitis (inflammation of the entire tooth-supporting tissues). It has been known to worsen gingiva diseases as well as cause changes in the gingival colour due to hormonal changes. [3] During pregnancy, the level of progesterone in the body can be 10 times higher than normal, [9] a situation that enhances the growth of certain pathogenic bacteria implicated in gingivitis. Also, the immune system is altered, thereby changing the normal host reaction to bacteria plague and worsening gingivitis. [9] As a result of both the hormonal and immune changes, 40% of gravid women develop pregnancy gingivitis at times during their gestation period. [9],[10],[11] In fact, a study has shown that pregnant women are 2.2 times more likely to have gingivitis than nonpregnant women. [12]

Pregnancy gingivitis is the swelling and inflammation of the gums of pregnant women due to bacterial plague, especially early in their pregnancy. In this state, plaque irritates the gum tissue more, making it tender, bright red, swollen, sensitive, and easily bleed. [11],[12],[13] Usually, the peak occurrence is between the second month and eighth month of gestation and tapers off after delivery. [12] The earliest clinical signs could be changes in gingival colour from the usual coral pink of healthy gingiva to red and progressing to bleeding on tooth brushing and then to spontaneous bleeding from the swollen gum. The most common site is the front of the mouth. [12] Tooth brushing twice daily, dental flossing once daily, and the use of antimicrobial mouth rinses have been known to reduce the risk of pregnancy gingivitis. [14]

A number of studies [15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] have demonstrated a link between periodontal disease and premature birth and low birth weight. Consequently, it has been recommended that all pregnant women have periodontal examination as part of prenatal care, even as statistics have shown that up to 50% of them do not receive proper dental care. [14],[15],[16] It is the authors' opinion that women who are properly informed of this risk and trained to identify changes in gingival colour might be able to detect early signs of pregnancy gingivitis and quickly seek periodontal health care. Hence, this study is a pioneer effort in our environment to assess the knowledge and perception of pregnant women about the colour of the gingiva in a healthy and nongravid state and in pregnancy. It is also a further attempt to quantify the prevalence of pregnancy gingivitis among expecting mothers in Nigeria.

  Materials and Methods Top

This is a cross-sectional study conducted at the antenatal clinic of Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos State, Nigeria. Participants were drawn from women who attended the clinic between September 1, 2011 and October 31, 2011. All consecutive patients who signed a written informed consent were recruited.

A self-reported questionnaire was used to obtain information such as the participant's age, gestational age, ethnicity, educational status and occupation, perception of self-gingival colour, and opinion on normal gingival colour. Furthermore, the participant's medical and dental histories were taken and extraoral and intraoral examinations were performed on each participant by a qualified dentist to determine the existence of gingivitis. Four dentists participated in the exercise. The questionnaire was pretested among pregnant women attending an antenatal clinic in another government hospital to determine its validity and reliability and necessary adjustments made.

The examinations were performed in the antenatal clinic using an artificial light source. Each patient's mouth was examined using disposable latex gloves, disposable facemasks, and sterile dental mouth mirrors ( Adequate infection control was ensured before the examinations as examiners had to scrub their hands with soap after which antiseptic lotion (hibitane in methylated spirit) was applied and the hands were dried with a sterile towel. The protocol was observed in between every consecutive subject.

To ensure reliability and consistency, the standard criteria for diagnosis were defined and the examiners were calibrated using the statistical test of reliability of Cohen's kappa. The criteria for diagnosis include the presence of changes in gingival colour, gingival swelling, and gingival bleeding on probing estimated using the gingival index (GI) of Loe and Silness, 1963. [30] The index scores the marginal and interproximal tissues separately on a scale of 0-3 as follows: 0 = normal gingiva; 1 = mild inflammation - slight change in colour and slight edema but no bleeding on probing; 2 = moderate inflammation - redness, edema and glazing, bleeding on probing; 3 = severe inflammation - marked redness and edema, ulceration with tendency for spontaneous bleeding.

Bleeding was assessed by probing gently along the wall of soft tissue of the gingival sulcus. The scores of the four areas [mesial, distal, buccal (facial) and lingual (palatal)] of the tooth was summed and divided by 4 to give the GI for each tooth. The GI of the individual was obtained by adding the values for each tooth and dividing by the number of teeth examined. The GI was scored for all surfaces of all teeth as follows:

0.1-1.0 = mild inflammation

1.1-2.0 = moderate inflammation

2.1-3.0 = severe inflammation

The study protocol was approved by the Health Research and Ethics Committee (HREC) of LUTH, Idi-Araba, Lagos State, Nigeria.

Data analysis was performed using Epi Info version 3.5.1 ( (August 2008) statistical software. Descriptive analyses were done and statistical comparison was accomplished with the chi-square test, taking P values <0.05 to be statistically significant.

  Results Top

Interrater reliability analysis using the Cohen's kappa statistics was performed to determine the coherence among raters. K value of 0.8 for was obtained (note that K > 0.7 is generally considered satisfactory). [Table 1] shows the sociodemographic characteristics of the participants. There were four hundred and forty-five pregnant women with an age range of 18-43 years and mean age of 30.3 [Standard Deviation (SD) ±4.61] years who participated in the study. Gestational age was between 4 weeks and 41weeks with a mean value of 23.49 (SD ±9.53) weeks. This study comprised mostly educated women. Overall, 221 (49.7%) had at least a tertiary level of education while only 4 (0.9%) had no formal education.
Table 1: Demographic data of participants

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Multiple Nigerian ethnic groups were represented with the Igbos (45.8%) constituting the majority.

More than half of the participants were professionals including medical doctors, lawyers, engineers, and self-employed elites; 74 participants (16.6%) were full-time homemakers.

The prevalence of pregnancy gingivitis is depicted in [Table 2]. Of the 445 participants, 85.2% (379/445) had pregnancy gingivitis. Among these, 86.3% (327/379) had mild gingivitis, 12.9% (49/379) had moderate gingivitis, and 0.8% (3/379) had severe gingivitis. Participants indicated their opinions regarding the colour of a normal healthy gingiva as follows: 210 (47.2%) indicated pink colour, 112 (25.2%) red, 42 (9.4%) black, 1 (0.9%) white, 4 (0.9%) brown while 76 (17.1%) felt that they did not know the normal colour [Figure 1]. On the other hand, 230 participants (51%) thought the colour of their own gingiva was pink, 127 (28.5%) indicated red, 51 (11.5%) black, 3 (0.7%) white, 2 (0.4%) brown while 32 (7.2%) did not know the colour of their gingiva [Figure 2]. However, upon clinical assessment, 344 (77.3%) patients were noted to have pink gingivae, 85 (19.1%) had physiologic black gingivae while 16 (3.6%) had red gingivae [Figure 3]. Chi-square test conducted to determine the difference between the individual's perception of gingiva colour and clinical observations of the participants' gingiva colour showed a significant statistical difference with a P value of <0.001 [Table 3].
Figure 1: Participants' perception of normal gum colour

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Table 2: Frequency and severity of gingivitis among participants

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Table 3: A cross-tabulation of participants' perception of their gum colour and clinical assessment of their gingival colour

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Figure 2: Participants' perception of their gum colour

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Figure 3: Clinical assessment of participants' gum colour

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  Discussion Top

Pregnancy has been associated with a high prevalence of gingivitis. This observation is corroborated by this study in which we found a prevalence of 85.2%, a value comparable to 86.2% reported in Thailand. [12] Some other authors such as Chanduaykit et al. [31] and Ababneh et al. [32] made similar observations, reporting a prevalence of 86.2% and 97%, respectively. This high prevalence of pregnancy gingivitis has been ascribed to the altered immune response to stress and anxiety as well as hormonal imbalances known to be associated with pregnancy. [10],[11],[12],[13],[14],[15],[16] The altered host physiology tends to accentuate normal inflammatory reaction to plague accumulation, leading to rapid deterioration of the oral condition. [11],[12] However, the degree of severity of pregnancy-related gingivitis appears to be largely determined by the individual's oral hygiene rather than the mere existence of pregnancy. [33] This fact may account for the observation of mild gingivitis in a large majority - about three-fourth of the participants in this study. Compared to a similar study conducted at the antenatal clinic of King Hussein Medical Center in Saudi Arabia where about 70% of the pregnant women had moderately severe gingivitis, our study population presented better oral hygiene. This may not be unconnected to the differential level of literacy and elitism between the two populations of participants in these studies. In our study, a majority of the participants were professionals and individuals of middle to high socioeconomic standings; the former study involved a population of largely illiterate women whose oral health consciousness was predictably lower. Only about 13% of the participants in our study expressed moderate to severe gingivitis.

Gingival colour change is one of the cardinal signs of early gingivitis. A healthy gingiva is generally coral pink in colour, depending on the individual's race and complexion; a variance of physiological pigmentation is accepted for normal gingiva. However, when the gingiva is inflamed, it becomes red and swollen and may also become bluish, blackish, or brownish in various diseased states. It is therefore, important that women are able to recognize the colour of a healthy gingiva so as to be able to detect changes that may indicate the onset of a disease. In this study, barely over half of the population (56.6%) knew the normal colour of a healthy gingiva. One-fourth of the population thought that red was normal while over 17% had no idea of what a normal gingiva colour could be. On the other hand, 63.2% of the participants perceived their own gingiva colour as pink while 28.5% considered their gingivae as red in colour. A few others (7.2%) could not even determine the colour of their own gingivae. These observations have significant implications since the ability of an individual to differentiate normal from inflamed or diseased gingiva could facilitate prompt seeking of periodontal care. Unfortunately, literatures discussing individuals' knowledge and perception of normal or personal gingiva colour are very sparse, and so we were unable to compare these outcomes. In fact, this study is a pioneer effort along this line of interest in periodontal research in the Nigerian environment.

When clinician assessment of gingiva colour among participants was performed, we observed that over 77% actually had the normal pink gingivae and 28.5% had red gingivae as opposed to 3.6% who thought they did. The disparity of judgment is statistically significant. Although in this case, it appears that many participants might have misjudged their own gingiva colour as abnormal, the bottom line is that a considerable proportion could not properly recognize the gingiva colour or colour changes. On another occasion, the reverse could have happened in which subjects may have judged abnormal colours as normal. This goes to justify the need for incorporating dental health education into antenatal care. This would enable pregnant women to detect any abnormal colour change early enough to institute appropriate therapy and avoid undesirable sequelae of uncontrolled periodontal disease. Moreover, it must be emphasized that periodontal treatment during pregnancy is safe as several studies [18],[34],[35],[36],[37] have demonstrated the safety and beneficial effects of periodontal therapy in pregnancy.

  Conclusion Top

This study has corroborated the observation of higher prevalence of gingivitis during pregnancy. Since a change in gingival colour may be an early indication of gingival inflammation, early detection and prompt treatment could prevent further periodontal deterioration. Hence, the need to incorporate and intensify oral health education during antenatal care cannot be overemphasized. This will enable pregnant women to identify gingival changes that may be associated with inflammatory and noninflammatory periodontal diseases.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]

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