Matern Child Health J (2015) 19:504–510
DOI 10.1007/s10995-014-1531-y
Dental Pain and Associated Factors Among Pregnant Women:
An Observational Study
Marta S. M. Krüger • Celina A. Lang •
Luiza H. S. Almeida • Fernanda O. Bello-Corrêa •
Ana R. Romano • Fernanda G. Pappen
Published online: 4 June 2014
Ó Springer Science+Business Media New York 2014
Abstract The present study aimed to determine the
prevalence of dental pain during pregnancy and its asso-
ciation with sociodemographic factors and oral health
conditions among 315 pregnant women in South Brazil.
Participants were interviewed to obtain sociodemographic
data, such as age, educational level, employment status,
family income, and marital and parity status. Medical and
dental histories were also collected, including the occur-
rence of dental pain and the use of dental services during
pregnancy. Clinical examinations were performed to assess
the presence of visible plaque and gingival bleeding and to
calculate the decayed, missing, and filled teeth index.
Means and standard deviations of continuous variables and
frequencies and percentages of categorical variables were
calculated. Independent variables were included in a mul-
tivariate logistic regression analysis. A total of 173
(54.9 %) pregnant women reported dental pain during
pregnancy. After adjustment of the analysis, caries activity
remained the main determinant of dental pain (odds
ratio 3.33, 95 % CI 1.67–6.65). The prevalence of dental
M. S. M. Krüger
L. H. S. Almeida
A. R. Romano
Department of Pediatric Dentistry, Federal University of
Pelotas–UFPel, Pelotas, RS, Brazil
C. A. Lang
F. G. Pappen
Department of Endodontics, Federal University of Pelotas–
UFPel, Pelotas, RS, Brazil
F. O. Bello-Corrêa
Department of Periodontology, Federal University of Pelotas–
UFPel, Pelotas, RS, Brazil
F. G. Pappen (&)
Faculty of Dentistry, Federal University of Pelotas, Rua
Gonçalves Chaves, 457/507, Pelotas, RS 96015-560, Brazil
e-mail: ferpappen@yahoo.com.br
123
pain during pregnancy was high and the presence of caries
activity was a determinant of dental pain. Moreover, access
to oral health care was low, despite pregnant women’s
increased need for dental assistance.
Keywords Oral health
Prenatal care
Toothache

Prevalence
Logistic model
Background
During pregnancy, physical and hormonal changes have
significant impacts on women’s organ systems, including
the oral cavity [1]. In the third trimester, when fetal
development decreases the stomach’s volumetric capacity,
pregnant women usually increase the frequency and
quantity of carbohydrate consumption. These changes are
associated with increased dental plaque formation, acid
production, and dental decay [2, 3].
Rising levels of estrogen and progesterone increase the
permeability of oral vascular structures and reduce immu-
nocompetence during pregnancy, thereby increasing the
tendency for and severity of oral inflammation [3–6].
Pregnant women are more susceptible to gingivitis, tooth
mobility, dental caries, and erosion, and thus should
receive appropriate preventive oral health care [7, 8].
Pregnant women also frequently require emergency dental
services due to episodes of acute dental pain [9].
Dental treatment during pregnancy is influenced by
patients’ and providers’ limits and barriers. Pregnant
women usually do not seek dental treatment due to fear and
anxiety about such treatment, low levels of awareness
about dental problems, and misconceptions about the effect
of dental treatment on fetal development [10–12]. Fur-
thermore, many dental providers are uncertain about the
Matern Child Health J (2015) 19:504–510
safety of performing dental procedures in pregnant women
[2, 13, 14] and obstetricians do not commonly recommend
routine prenatal dental care [15].
Although dental pain and oral health assistance during
pregnancy are important outcomes in dentistry, their fre-
quency and association with risk factors have not been well
characterized in dental care populations. To fill this
important knowledge gap, this reporting observational
study assessed the prevalence of dental pain during preg-
nancy; its association with sociodemographic factors and
oral health conditions; and prenatal dental care history, in a
group of pregnant women in South Brazil.
Methods
For this observational study, data were obtained from all
the attendants of the Federal University of Pelotas Prenatal
Oral Health Program, a spinoff of a program promoting
oral health in infants, in which the dental treatment is
focused also in the expectant mothers. The need of
restorative dental assistance for these women is evaluated
during the first appointment, and then, if necessary, com-
plete dental treatment is performed not only during preg-
nancy, but also after delivery, until the babies are 3 years-
old. The study population consisted of 315 women, in all
stages of pregnancy, who were referred to the Program
from March, 2001 to March, 2011. Review and approval by
the Institutional Review Board was performed before
starting the research, since it involves human subjects
(Document no. 214/2011, FO-UFPel, Brazil). All pregnant
women provided written informed consent prior to study
participation.
The patients were interviewed to obtain sociodemo-
graphic data, such as age, educational level, employment
status, family income, and marital and parity status. Med-
ical and dental histories were also collected, including the
occurrence of dental pain and the use of dental services
during pregnancy.
Trained examiners performed clinical examinations at
the dental care clinic of the Federal University of Pelotas
Prenatal Oral Health Program. Examinations were per-
formed under artificial lighting with patients seated in a
dental chair. The presence of visible plaque was recorded
if a film of supragengival plaque was visible after iso-
lating the area with cotton rolls and drying the tooth with
a blast of the air. Gingival bleeding was considered
present when the examiner noted at least one bleeding site
after the use of dental floss. Examiners used the World
Health Organization’s criteria to register decayed, miss-
ing, and filled teeth (DMFT index) [16]. The character-
istics of carious lesions were classified following Nyvad
et al. [17].
505
Data were entered twice into an Epi Info 6 (Centers for
Disease Control and Prevention, Atlanta, GA, USA) data-
base and their consistency and range were checked auto-
matically. Statistical analyses were performed using Stata
software (version 10.0 for Windows; Stata Corp. LP,
College Station, TX, USA). Descriptive statistics were
generated by calculating means and standard deviations of
continuous variables and frequencies and percentages of
categorical variables. The independent variables (age,
income, educational level, pregnancy trimester, general
health complications during pregnancy, dental assistance,
presence of visible plaque, presence of gingival bleeding,
and caries activity) were included in a multivariate logistic
regression analysis. To adjust the analysis, variables that
did not contribute to the model were removed and a new
model was constructed.
Results
All recruited pregnant women agreed to participate in the
study (n = 315; 100 % response rate). The sociodemo-
graphic and obstetric profiles of the study population are
shown in Table 1. Most (70.5 %) participants were aged
20–34 years. The majority (55.2 %) of respondents was
housewives and 41.5 % of family incomes were from 1.1 to
3 minimum wages (corresponding to US$351–1050). Most
(49.5 %) women were in the second trimester of pregnancy
and 44.1 % were expecting their first child.
Among the 105 (33.4 %) women who sought dental
care, 49 (47.6 %) were motivated by dental pain. Thirty
(28.0 %) women had difficulty obtaining assistance
(Table 2): 17 (51.5 %) women reported that dentists
refused to perform dental care and 10 (30.3 %) reported
that dentists provided incomplete care during appoint-
ments, leaving their dental problems unresolved.
Periodontal examinations revealed gingival bleeding in
246 (84.2 %) pregnant women, visible plaque in 220 (81.8 %)
women, and caries activity in 218 (69.6 %) women. The mean
DMFT index was 11.82 ± 6.541 and the mean numbers of
decayed, missed, and filled teeth were 4.25 ± 4.128,
2.35 ± 3.360, and 5.22 ± 5.319, respectively.
A total of 173 (54.9 %) pregnant women reported dental
pain during pregnancy, and the pain began during preg-
nancy in 143 (82.66 %) women (Table 2). Associations of
dental pain during pregnancy with other independent
variables are shown in Table 3. Logistic regression ana-
lysis indicated that the occurrence of dental pain was
associated with the presence of visible plaque [odds ratio
(OR) 4.98, 95 % confidence interval (CI) 2.41–10.2], gin-
gival bleeding (OR 2.73, 95 % CI 1.39–5.33), family
income of US$351–1050 (OR 2.24, 95 % CI 1.27–3.94),
family income B US$350 (OR 2.77, 95 % CI 1.51–5.08),
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Table 1 Sociodemographic and obstetric profiles of the studied Table 2 Responses to the use of dental services and dental pain
population of mothers (n = 315) experience during pregnancy
n (%) n (%)

Age group Dental attendance during pregnancya

15–19 years 50 (15.9) Yes 105 (33.4)
20–34 years 222 (70.5) No 209 (66.6)
35–44 years 43 (13.7) Difficult in visiting the dentist during pregnancy?
Education level No 75 (71.4)
[8 years 166 (52.7) Yes 30 (28.6)
B8 years 149 (47.3) Reason for visiting the dentist?
Employment status Regular dental check up 15 (14.3)
Housewife 174 (55.2) Dental pain 49 (46.6)
Employed 65 (20.7) Restorative procedures 19 (18.1)
Student 36 (11.4) Periodontal procedures 8 (7.6)
Others 40 (12.7) Prevention for the mother and for the baby 4 (3.8)
Family income (minimum wages)a Others 10 (9.5)
C3 82 (26.4) Did you have dental pain during pregnancy?
From 1.1 to 3 129 (41.5) No 142 (45.1)
\1 100 (32.2) Yes 173 (54.9)
Marital status If yes, when did it begin?b
Married 248 (79.5) Before the gestational period 27 (15.9)
Single 54 (17.3) Within the gestational period 143 (84.1)
Separated or divorced 11 (3.5) a
One missing value
Parity status b
Three missing values
Primigravida 137 (44.1)
Multigravida 174 (55.2)
Stage of pregnancyb The results highlights showed that over half of pregnant
First trimester 33 (10.5) women had dental pain, and this pain was not present prior
Second trimester 156 (49.5) to pregnancy in the majority of cases (84 %). In the present
Third trimester 126 (40.0) study, 33.4 % of women sought dental care during preg-
a
nancy, and while over half of women in the study had
The family income was measured in terms of the Brazilian mini-
dental pain, only 28 % of these women with pain sought
mum wages, which corresponds to approximately US$350 [28]
b dental care. Reported rates of dental visits during preg-
Stage of pregnancy at the moment that mothers arrived at the
Prenatal Oral Health Program nancy have varied among countries, including 49 % in
Germany [23], 50 % in Kuwait [19], 61 % in the United
caries activity (OR 4.04, 95 % CI 2.41–6.77), and low Kingdom [12], 35–43 % in the United States [11, 18], and
educational level (OR 2.09, 95 % CI 1.32–3.29). After 90 % in Denmark [24]. In the United Kingdom, 39 % of
adjustment of the analysis, caries activity remained the women did not visit a dentist during pregnancy, although
main determinant of dental pain (OR 3.33, 95 % CI dental care is provided at no cost to pregnant women [12].
1.67–6.65). Their reasons for not seeking dental treatment were the
feeling that they do not need to; fear; and dislike of den-
tists. In Brazil, the state provides dental care assistance at
Discussion no cost, but the services are limited. Thus, women with
lower incomes were less likely to seek dental care than
Several studies have shown the need for dental assistance women with higher incomes in our study population. Fur-
during pregnancy [18–21]. However, the World Health thermore, no recall system is used in Brazil; thus, special
Organization did not include attention to oral health as a efforts should be made to encourage women to visit den-
basic component in a recently published manual for the tists during pregnancy.
implementation of antenatal care [22]. The present study Among pregnant women in our study population who
revealed a high prevalence of dental pain among pregnant sought dental care, 28.0 % had difficulty obtaining dental
women, highlighting the importance of integrating oral assistance. Although the safety of providing pregnant
health care into prenatal care. patients with dental care has been addressed, including the

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Table 3 Crude and adjusted Variables Dental pain Crude OR P value Adjusted OR P value
analysis [Odds ratio (OR)] for (n = 173) (95 % CI) (95 % CI)
the association between
independent variables and General health complications during pregnancy
dental pain in pregnant women
No 89 (50.9) 1.00
Yes 84 (60.4) 1.47 (0.93–2.31) 0.091
a
Seek dental treatment during pregnancy
Yes 64 (61.0) 1.00
No 108 (51.7) 0.68 (0.42–1.10) 0.121
Visible plaqueb
Yes 11 (22.4) 1.00 1.00
No 130 (59.1) 4.98 (2.41–10.2) \0.001 2.16 (0.91–5.11) 0.077
Gingival bleedingc
No 15 (33.3) 1.00 1.00
Yes 142 (57.7) 2.73 (1.39–5.33) 0.003 0.94 (0.33–2.69) 0.920
Age group
15–19 years 30 (60.0) 1.00
20–34 years 121 (54.5) 0.79 (0.42–1.49) 0.481
35–44 years 22 (51.2) 0.69 (0.30–1.59) 0.394
Stage of pregnancy
First trimester 18 (54.5) 1.00
Second trimester 84 (53.8) 0.97 (0.45–2.06) 0.942
Third trimester 71 (56.3) 1.07 (0.49–2.32) 0.853
Family incomea
US$1051 and up 32 (39.0) 1.00 1.00
From US$351 to US$1050 76 (58.9) 2.24 (1.27–3.94) 0.005 1.28 (0.63–2.58) 0.481
Up to US$350 64 (64.0) 2.77 (1.51–5.08) 0.001 1.25 (0.56–2.82) 0.576
Caries activitya
No 30 (31.6) 1.00 1.00
Yes 142 (65.1) 4.04 (2.41–6.77) \0.001 3.33 (1.67–6.65) 0.001
a Education
One missing value
b [8 years 77 (46.4) 1.00 1.00
32 Missing values
c B8 years 96 (64.4) 2.09 (1.32–3.29) 0.001 1.43 (0.77–2.62) 0.248
16 Missing values

judicious use of analgesic medications [8] and X-rays [25],
barriers discouraging prenatal dental visits remain. Many
patients who do not seek routine prenatal dental care have
not been advised to do so [11, 15, 26], demonstrating
inadequate confidence in the safety of dental care during
pregnancy among obstetricians, dentists, and patients [15].
The difficulties that pregnant women encountered in
attempting to meet their dental care needs may have con-
tributed to the seeking of such care mainly due to dental
pain in the present study.
The population examined in the present study consisted
of pregnant women attending a Prenatal Oral Health Pro-
gram, thus it can be expected a higher prevalence of oral
health care needs in comparison with the general popula-
tion. Most (54.9 %) women in this study reported dental
pain during pregnancy, and 84.4 % of women reporting
pain described its initiation during pregnancy. Similar
studies have found that 25.8–44 % of pregnant women
reported dental pain experience [9, 21, 27]. In the general
population, the reported prevalence of ‘‘toothache’’ has
ranged from 7 to 32 % [28–32]. A cross-sectional popu-
lation-based study [28], conducted in the same city as the
present study, can represent a very suitable for comparison
with our results. The authors reported a toothache preva-
lence of 17.7 % among non-institutionalized urban resi-
dents of both sexes aged C20 years.
Low income and educational levels are determinants of
the fear of dental treatment [29] and caries severity [30].
Income and education have clearly influenced the use of
health services in the general population, as higher edu-
cation levels can lead to a greater appreciation of general
health status, resulting in clearer perceptions of health
problems [31]. Individuals with higher educational levels
seek preventive health services more frequently and have
fewer dental diseases than do individuals with less educa-
tion [32]. Consequently, the low socioeconomic status

123
508
among the studied population may also have an important
role in higher prevalence of dental pain during pregnancy,
as studies in the general population have revealed that
subjects with low educational attainment and family
incomes are more likely to report dental pain [28, 33].
Similarly, our results indicate that low family income and
educational level were determinants of the risk of dental
pain in the study population. In this study, the income
categories were converted in Brazilian minimum wages
[28]. A Brazilian minimum wage corresponds to approxi-
mately U$350.00, and the National standard for measuring
poverty, refers to the proportion of the population receiving
a per capita household income lower than half the Brazilian
minimum wage [34].
Although no evidence of inflammatory exacerbation or a
greater tendency for pulp tissue inflammation as a result of
hormonal changes has been found, this possibility cannot
be discarded. It might explain the high prevalence of dental
pain among pregnant women, especially considering that
most women reported pain initiation during pregnancy.
This finding suggests that any harmful stimulation of the
pulp tissue might cause an exacerbated response in a
pregnant woman, and indicates the need for further studies
of the influence of hormonal changes on pulp tissue.
In the present study, pregnant women who presented
visible plaque and gingival bleeding in clinical examina-
tions frequently reported dental pain. Oral hygiene is a
major factor in the prevention of caries and gingivitis
because dental plaque is the main etiological factor in these
diseases [35]. In adjusted analysis, caries activity remained
determinant of the risk of dental pain (OR 3.33, 95 % CI
1.67–6.65). Clinical studies have shown that poor oral
hygiene is the only consistent risk indicator of caries pre-
sence and severity [6, 10, 36]. If plaque removal is not
performed frequently, a carious lesion develops and pro-
tects the biofilm; unless the patient is able to clean this area,
caries will progress [37] and potentially cause dental pain.
The mean DMFT index in our study population was
11.82 ± 6.541. Almost 70 % of pregnant women presented
caries activity and more than 80 % had visible plaque and/or
gingival bleeding. It had been stated that pregnant women are
especially susceptible to gingivitis and periodontal disease
[38], and they are also at higher risk of tooth decay for several
reasons, including increased acidity in the oral cavity, sugary
dietary cravings, and limited attention to oral health [39, 40].
However, while dental treatment is an important part of the
prevention and treatment of oral diseases, access to and uti-
lization of dental services is still inadequate among pregnant
women [40–42]. Some factors may contribute to the lack of
routine dental care during pregnancy: lack of perceived need
[42]; lack of routine dental care when they were not pregnant
and lack of financial resources [41]. The issues surrounding
insufficient dental care during pregnancy are likely to be
123
Matern Child Health J (2015) 19:504–510
complex, but the lack of awareness of the importance of dental
care during pregnancy and the inadequate confidence in the
safety of dental care during pregnancy are still barriers dis-
couraging prenatal dental visits [42, 43].
During pregnancy hormonal and vascular changes,
associated to lack of routine dental care predispose women
to some oral disorders [38], thus, the capacity of pregnant
women to be oriented about oral hygiene habits may also be
affected [44]. However, during pregnancy, women are
especially motivated to receive messages regarding their
health [41, 43]. Providers of prenatal care may use the
frequent visits made during the prenatal period to empha-
size good oral hygiene practices and the importance of oral
health. These visits are important opportunities for dentists
to affect women’s oral health behaviors and use of dental
care during and after pregnancy [41]. Educational cam-
paigns which target not only pregnant women but also
prenatal and oral health providers, may promote the need
for and safety of dental assistance during pregnancy in order
to improve receipt of care [41]. Such actions may include
screening and referral of pregnant women populations to
oral health assistance during pregnancy [41, 42], consider-
ing the association between oral and general health, and the
effect of oral health in the outcome of pregnancy [40].
Self-reported evaluations of pain may be biased, as
patients must feel that pain is sufficiently significant to be
recorded. When patients feel that pain is ‘‘to be expected,’’
symptoms may be unreported or underemphasized during
interviews. Also, the fact that this observational study was
conducted within a Prenatal Oral Health Program, can be
considered a study limitation. The results of this study,
however, are still valuable, once dental pain in pregnant
women is an understudied area.
Data related to the oral health status of pregnant women
have not been well documented in the literature, and the
present study may be useful in developing new programs,
and to design interventions that could improve general and
oral health outcomes, especially considering that children
who receive preventive dental care early in life have higher
overall oral health. The University Prenatal Oral Health
Program is focused in the dental treatment and preventive
dental care of pregnant women and their children. The
number of 315 assisted pregnant women included in this
study is very significant, especially considering that these
women, with no exception, received complete dental
assistance according to their needs, and this kind of assis-
tance is still rare in many instances.
Conclusion
The prevalence of dental pain during pregnancy was high
in the study population. The presence of caries activity was
Matern Child Health J (2015) 19:504–510
a determinant of dental pain. Despite pregnant women’s
increased need for dental assistance, almost one-third of
pregnant women in the study population who sought dental
care had difficulty obtaining it.
Conflict of interest The authors declare that they have no com-
peting interests. The authors also declare that they have no conflict of
interest or financial affiliation relevant to this work.
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