Comparative analysis of oral health status and hygiene practices in pregnant and non-pregnant women

Problems of Dental Medicine 51 DOI: 10.3897/pdm.51.e167370 Research Article Copyright by Ralitsa Bogovska-Gigova. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 Comparative analysis of oral health status and hygiene practices in pregnant and non-pregnant women Ralitsa Bogovska-Gigova1 1 Department of Pediatric Dentistry, Faculty of Dental Medicine, Medical University - Sofia, Sofia, Bulgaria Corresponding author: Ralitsa Bogovska-Gigova, Sofia, Bulgaria; Email: [email protected] Received: 31 July 2025 ♦ Accepted: 14 September 2025 ♦ Published: 13 October 2025 Citation: Bogovska-Gigova R (2025) Comparative analysis of oral health status and hygiene practices in pregnant and non-pregnant women. Problems of Dental Medicine 51: 1–5. doi: 10.3897/pdm.51.e167370 Abstract Aim: This study compares the oral health status and hygiene practices of 30 pregnant and 30 non-pregnant women in Sofia, Bulgaria, using the DMFT, FMPS, and PBI. Oral hygiene habits, including brushing frequency, toothbrush type, duration, and technique, were also assessed. Materials and methods: A cross-sectional study (January–June 2025) included 30 pregnant women (second/third trimester, aged 18–40 years) and 30 non-pregnant women (aged 18–40 years) from a private dental clinic. Exclusion criteria included systemic diseases and high-risk pregnancies. DMFT, FMPS, and PBI were evaluated by a dentist using standardized tools. Oral hygiene habits were collected via a validated questionnaire. Results: Pregnant women had lower mean DMFT, but higher FMPS and PBI, compared to non-pregnant women. Brushing frequency was similar (90% twice daily). Pregnant women used manual toothbrushes more, brushed for shorter durations and used less circular brushing. Conclusion: Pregnant women exhibit better caries experience (lower DMFT) but poorer oral hygiene (higher FMPS) and higher gingival inflammation than non-pregnant women, despite similar brushing frequency. Targeted oral health education promoting electric toothbrushes and circular brushing techniques is needed to improve maternal oral health. Keywords oral health, pregnancy, DMFT index, FMPS, PBI index, oral hygiene, brushing habits Introduction Pregnancy brings significant physiological changes that can impact oral health, including increased risks of gingivitis and dental caries due to hormonal fluctuations and altered dietary habits [1]. In Bulgaria, where oral health awareness is growing but still limited in certain populations, pregnant women represent a key group for intervention. Poor maternal oral health is linked to adverse pregnancy outcomes, such as preterm birth, and can influence the oral health of the child through bacterial transmission [2]. Understanding the oral health of pregnant women is essential for designing effective public health strategies [3]. Pregnancy gingivitis, the most common oral manifestation during pregnancy, is characterized by inflammatory gingival changes, with prevalence rates reported between Ralitsa Bogovska-Gigova 2 Problems of Dental Medicine I 2025 I Vol. 51 30% and 100%, typically ranging from 60% to 75% [4, 5]. Elevated levels of female sex hormones, particularly estrogen and progesterone, are considered primary contributors to this condition [6, 7]. These hormones lower the threshold for tissue injury by causing endothelial damage, increasing vascular permeability, and reducing blood flow, with progesterone having a more pronounced effect than estrogen [8]. Additionally, hormonal influences may disrupt gingival mast cells, releasing histamine and proteolytic enzymes that exacerbate inflammation triggered by local irritants like plaque [9]. Notably, maternal periodontal disease has been associated with adverse pregnancy outcomes, such as preterm delivery, low birth weight, and spontaneous abortions [10]. The DMFT Index is a widely used measure to quantify the prevalence and severity of dental caries in a population. It calculates the total number of decayed (D), missing due to caries (M), and filled (F) teeth in an individual’s mouth, providing a snapshot of caries experience [11]. For pregnant women, hormonal changes, dietary shifts, and altered oral hygiene practices can increase susceptibility to dental caries, making the DMFT Index a critical tool for evaluation [12]. The Full-Mouth Plaque Score (FMPS) assesses oral cleanliness by measuring the presence of plaque on all tooth surfaces, providing a comprehensive evaluation of oral hygiene status. Expressed as a percentage, FMPS quantifies the proportion of tooth surfaces with plaque, with lower scores indicating better oral hygiene [13]. Poor oral hygiene during pregnancy can exacerbate gingival inflammation and increase the risk of periodontal disease, which is linked to adverse pregnancy outcomes such as preterm birth and low birth weight [14]. The Full-Mouth Plaque Score (FMPS) is a validated quantitative index for assessing oral cleanliness, providing an objective measure of dental plaque accumulation across the entire dentition. FMPS is widely used in both clinical and research settings to evaluate oral hygiene status and predict risk for oral inflammatory complications. Recent cohort data demonstrate that higher FMPS is independently associated with increased risk of postoperative inflammatory complications, pain, and swelling after oral surgery, underscoring its utility as a marker of oral cleanliness and risk stratification in dental practice [15]. In a study from Zahedan, Iran, pregnant women had a mean OHI-s score of 1.51 ± 0.542, indicating satisfactory but not optimal oral hygiene [16]. In Bulgaria, no specific data on the oral hygiene for pregnant women are available. Hormonal fluctuations during pregnancy can increase plaque accumulation and gingival sensitivity, potentially leading to higher FMPS compared to non-pregnant women [17]. The Papilla Bleeding Index evaluates gingival inflammation by measuring bleeding upon gentle probing of the gingival papillae [18]. It is a sensitive indicator of periodontal health, particularly relevant during pregnancy when hormonal changes increase the risk of gingivitis [14]. The DMFT Index measures caries experience, the FMPS evaluates oral hygiene, and the PBI assesses gingival inflammation, providing a comprehensive view of oral health status. This study compares these indices between 30 pregnant and 30 non-pregnant women in Bulgaria to identify pregnancy-related oral health differences and inform public health strategies. Aim: This study aims to compare the oral health status of pregnant and non-pregnant women using standardized indices: Decayed, Missing, Filled Teeth (DMFT), FMPS, and Papilla Bleeding Index (PBI). Additionally, we examine differences in oral hygiene practices, including brushing frequency, toothbrush type (manual or electric), brushing duration, and brushing technique (horizontal, vertical, circular, or chaotic). Materials and methods Methods The study was conducted in Sofia, Bulgaria, from January to June 2025. The study included 30 pregnant women (second and third trimesters, aged 18–40 years) and 30 non-pregnant women (aged 18–40 years) attending private dental clinic. Exclusion criteria included systemic diseases, high-risk pregnancies, and long-term medication use. Informed consent was secured from all participants. Oral examinations were performed by a dentists using a mirror, explorer, and periodontal probe under standardized lighting. The following indices were assessed: DMFT: A detailed clinical examination of the oral cavity was conducted to assess dental caries. Each tooth was examined for decay (D), absence due to caries (M), or fillings (F), and documented accordingly. The total score was calculated by summing the number of decayed, missing, and filled teeth. FMPS Assessment The Full-Mouth Plaque Score (FMPS) was measured by assessing the presence of plaque on all tooth surfaces (mesial, distal, buccal, and lingual/palatal) of all teeth present in the oral cavity. Plaque was detected using a disclosing agent, and each surface was scored as follows: - 0: No plaque present. - 1: Plaque present on the tooth surface. The FMPS was calculated as the percentage of surfaces with plaque (number of surfaces with plaque divided by the total number of surfaces examined, multiplied by 100). A lower FMPS indicates better oral hygiene, with scores typically interpreted as: <20% (good), 20–40% (fair), and >40% (poor) [13]. PBI: The periodontal probe was inserted into the sulcus at the base of the papilla and moved along the gingival margin with light pressure. Bleeding scores were based on the intensity and extent of bleeding (0 = no bleeding, 1 = single bleeding point, 2 = several isolated bleeding points, 3 = a Comparative analysis of oral health status and hygiene practices in pregnant and non-pregnant women Problems of Dental Medicine I 2025 I Vol. 51 3 confluent line of blood, 4 = profuse bleeding). The PBI was calculated as the sum of bleeding scores divided by the number of papillae examined. Oral Hygiene Practices Participants completed a validated questionnaire on oral hygiene habits, including: - Frequency of brushing (once or twice daily). - Type of toothbrush (manual or electric). - Brushing duration (1, 2, or ≥3 minutes). - Brushing technique (horizontal, vertical, circular, or chaotic). Statistical Analysis: Data were analyzed using SPSS version 25.0. Mean DMFT, FMPS, and PBI scores were compared using independent t-tests. Oral hygiene habits were compared using chi-square tests. A p-value < 0.05 was considered statistically significant. Results Table 1 presents the results from the dental examination and the indices. Table 1. Mean DMFT, FMPS, and PBI scores of the participants in the study Groups Index Pregnant Nonpregnant t-test Mean ± SD Mean ± SD DMFT index 4.93 ± 2.49 5.37 ± 2.93 p > 0.05 FMPS (%) 35.22 ± 8.61 27.84 ± 6.15 p < 0.05 PBI 1.70 ± 0.84 1.10 ± 0.80 p < 0.05 The DMFT scores were similar between groups (p > 0.05). Pregnant women had significantly higher FMPS (p < 0.05) and PBI (p < 0.05) scores, indicating poorer oral hygiene and greater gingival inflammation. The distribution of oral hygiene habits is presented below. Table 2. Oral hygiene habits of the participants in the study Habit Pregnant (n=30) NonPregnant (n=30) Chisquare (χ²) Brushing Frequency Once daily 10% (3) 10% (3) p = 1.00 Twice daily 90% (27) 90% (27) Toothbrush Type Manual 70% (21) 65% (19) p = 0.58 Electric 30% (9) 35% (11) Brushing Duration 1 minute 40% (12) 30% (9) p = 0.62 2 minutes 50% (15) 55% (16) ≥3 minutes 10% (3) 15% (5) Brushing Technique Horizontal 45% (13) 30% (9) p = 0.74 Vertical 20% (6) 25% (8) Circular 25% (8) 35% (10) Chaotic 10% (3) 10% (3) Brushing frequency was comparable between groups (p > 0.05). Pregnant women reported shorter brushing durations (p > 0.05) and a lower prevalence of circular brushing, which is optimal for plaque removal (p > 0.05). Discussion This study aimed to compare the oral health status and hygiene practices of pregnant and non-pregnant women in Sofia, Bulgaria, using standardized clinical indices (DMFT, FMPS, and PBI) and oral hygiene questionnaire. The findings provide insight into how pregnancy influences oral health and behaviors and highlight areas for targeted intervention. The results indicate that pregnant women had significantly higher FMPS and PBI scores compared to non-pregnant women (p < 0.05), suggesting poorer oral hygiene and greater gingival inflammation during pregnancy. These findings are consistent with previous studies that attribute increased gingival bleeding and plaque accumulation during pregnancy to elevated estrogen and progesterone levels, which alter the vascular and immune responses of gingival tissues [4, 6, 8]. The FMPS, which measures plaque on all tooth surfaces, provides a more comprehensive assessment of oral hygiene compared to older indices like the OHI-S, as it accounts for plaque distribution across the entire dentition [13]. However, FMPS assessment requires more clinical time and training, which may pose challenges in resource-constrained settings like private dental clinics. Oral hygiene behaviors showed no statistically significant differences between the two groups. Most participants in both groups reported brushing twice daily, and usage of manual toothbrushes. However, pregnant women more frequently reported brushing for just one minute and were less likely to use circular brushing motions—both suboptimal habits that can reduce plaque removal efficacy. These behavioral trends, while not statistically significant, may contribute to the observed increase in plaque (FMPS) and gingival bleeding (PBI) among pregnant women. The DMFT scores were similar between groups, suggesting that caries experience is not significantly influenced by pregnancy status in this population. This finding aligns with studies indicating that caries risk is more closely tied to long-term dietary and hygiene habits than short-term pregnancy-related changes [12]. The retention of the PBI in this study is justified by its sensitivity to gingival Ralitsa Bogovska-Gigova 4 Problems of Dental Medicine I 2025 I Vol. 51 inflammation, a critical factor in pregnancy due to hormonal influences [14]. These results underscore the importance of not only maintaining the frequency of oral hygiene practices during pregnancy but also ensuring their quality and effectiveness [19]. The use of FMPS highlights the extent of plaque accumulation in pregnant women, reinforcing the need for targeted interventions to improve oral hygiene. While brushing twice a day is a widely promoted habit, its benefits are diminished when paired with poor technique and short duration [20]. Moreover, the use of manual toothbrushes predominated in both groups, though electric toothbrushes are generally more effective in removing plaque, especially when motivation or dexterity is compromised — as may occur during pregnancy due to fatigue or nausea [21]. Education regarding proper brushing techniques and tool selection (promoting electric toothbrush use) should be emphasized in prenatal care settings [22]. These findings highlight the necessity for improved prenatal oral health education, focusing on the quality rather than just the frequency of hygiene practices. Recommendations should include: - Instruction in effective brushing techniques, particularly circular motions; - Encouragement to increase brushing duration, ideally to 2 minutes or more; - Promotion of electric toothbrushes as more - By incorporating oral health education into routine prenatal care, healthcare providers can play a vital role in improving maternal oral health outcomes and potentially reducing adverse pregnancy outcomes linked to periodontal disease. Conclusion Pregnant women exhibit poorer oral hygiene and gingival health compared to non-pregnant women, as evidenced by higher FMPS and PBI scores, though DMFT scores are similar. Despite comparable brushing frequency, differences in brushing duration and technique suggest a need for targeted oral health education during pregnancy. Dental professionals should promote electric toothbrushes and circular brushing techniques to improve maternal oral health. Additional information Funding statement This manuscript is supported by the National Program "Young Scientists and Postdoctoral Fellows-2", Medical University of Sofia, Faculty of Dental Medicine – protocol №1/17.10.2024. Ethical compliance Ethical review and approval were waived for this study. This is because the research involved only standardized dental examinations conducted by pediatric dentistry specialists and did not include any treatment or medical experiments; therefore, no ethics approval number or issuance date is applicable. The study was conducted in accordance with the principles of the Declaration of Helsinki (1975, revised in 2013), and informed consent was obtained from all participants. 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