ARTICLE
Auteur(s) : Evren
Sarifakioglu1, Canan Gunduz2, Canan
Gorpelioglu1
1Department of Dermatology, Fatih University, Faculty
of Medicine, Alparslan Turkes Caddesi No: 57, 06510, Ankara,
TurkeyFax: + 90 312 221 32 76
2Department of Gynecology and Obstetrics, Fatih
University, Faculty of Medicine, Ankara, Turkey
accepté le 14 Juillet 2006
Pregnancy is a special state where major physiological and hormonal
changes occur. Temporary adaptive changes occur in the body of the
mother as the result of an increased production of estrogens,
progesterone, and relaxin, etc. The oral cavity is also affected by
these endocrine conditions [1, 2]. Estrogen levels rise more than
100-fold from the beginning of pregnancy. Progesterone
concentration rises even more. The main source of these hormones,
from the 2nd triemester to term, is the placenta [2].The
international literature abounds with epidemiological studies of
oral lesions [3-5], although few studies offer information on the
oral lesions characterizing pregnancy [1, 6-9]. Therefore, the
present study was designed to assess the number and the type of
oral mucosa lesions in pregnant (study group) and non-pregnant
women. Knowledge of such lesions, derived from actual pregnancy or
attributable to the circumstances associated with this special
physiological state, may allow early identification and management
of such alterations.
Material and methods
Study population
The study population consisted of 200 women (100 pregnant and 100
non-pregnant controls) with an age range of 17-42 years. These
women were chosen at random from the obstetrics and dermatology
clinics. The study protocol was approved by the Ethical Committee
of Fatih University of Medical Faculty. An informed written consent
was obtained from all subjects who wanted to take part in the
study.
Pregnant women with dermatological diseases, systemic diseases
such as anemia, diabetes, immune disorders, those taking
antibiotics recently, smokers before their pregnancy or controls
with the mentioned above dieases, gastrooesapheal reflux, abnormal
menstrual cycles, those on oral contraceptives, multivitamins, iron
and smokers were not included in the study. Pregnant women only
took part in the study in the 2nd or the 3rd
trimester of their pregnancy. Additionally, control subjects who
had been pregnant within the previous year were excluded. Pregnant
women were asked during oral examination for the existance of
vomiting, hypersalivation and gastrooesaphageal reflux (GUR),
symptoms which can be associated with the pregnancy period.
Oral mucosa examination
All subjects were examined by a medical doctor who was a specialist
in family medicine. The examiner was standardized for oral
examination before the study by using the model proposed by Zain et
al. [9]. The type of oral mucosa lesions were recorded. Peridontal
diseases were not included in the study. If the oral mucosa lesion
was candidiasis the diagnosis was confirmed by culture.
Statistical analysis
Data analysis was performed using SPSS for Windows (version 11.5)
statistical package. Nominal variables were shown as number of
cases with percentage. Chi-square and Fisher’s Exact tests were
used for the categorical comparisons. The differences were
statistically significant for p < 0.05.
Results
A total of 200 women were examined. The study group and the control
group were age matched (17-42 years). The mean patient age (±
standard deviation, SD) was 27.3 (± 5.56) and 27.9 years (± 6.1) in
the group of pregnant women and in the control series,
respectively. The frequency of oral mucosa lesions was greater
among the pregnant women than in the control group (71.0% versus
29.0%).
Among the 100 pregnant patients, 53 were multigravida and 47
were primigravida. Primigravida who presented with oral mucosa
lesions were 28 (59.6%) and multigravida were 40 (75.5%) which was
not statistically significant p = 0.089.
Fifty (50%) of the pregnant women presented with only 1 oral
mucosa lesion compared to 25 (25%) in controls, which was
statistically significant p < 0.001.
Presentation of 2 or more oral mucosa lesions in pregnant women
was 21(21%) and 4(4%) in controls, which was statistically
significant p < 0.001.
Forty-eight of the pregnant women were taking iron and vitamin
supplements and 52 were not taking any of the above mentioned
drugs. Pregnant women who were taking iron and vitamin supplements
who were diagnosed with oral mucosa lesions were 28 (58.3%) and
without taking any drugs were 33(63.5%) which was not statistically
significant p = 0.599.
Pregnant women with vomiting were seen more frequently with oral
mucosa lesions than pregnant women without vomiting (35(77.8%)
versus 27(49.1%)) which was statistically significant (p = 0.
003).
In pregnant women with hypersalivation, the oral mucosa lesions
were observed in 14(66.7%) and without hypersalivation, the oral
mucosa lesions were observed in 53(67.1%) which was statistically
not significant p = 0.971.
In the study group with GUR, oral mucosa lesions were observed
in 31 (40.8%) versus 14 (58.3%) in the group without GUR, which was
not statistically significant p = 0.132.
Table 1( Table 1 ) summarises the
identified lesions in pregnant and control groups. When contrasting
the different types of oral mucosa lesions between the 2 groups,
significant differences were observed between cheek biting and oral
candidiasis. Pregnant women with cheek biting presented in 31
patients (31%) and in the control group only in 5 (5%) which was
statistically significant, p < 0.001. Oral candidiasis presented
in 15 (15%) pregnant versus 5 (5%) in control, which was also
statistically significant, p = 0.018.
Table 1 Prevelance of oral mucosa lesions in study and
control groups
|
Lesions
|
|
|
|
|
Fordyce spots
|
4
|
2
|
0.683
|
|
Aphtous stomatitis
|
3
|
2
|
1.00
|
|
Fissured tongue
|
6
|
12
|
0.138
|
|
Hairy tongue
|
10
|
5
|
0.179
|
|
Cheek biting
|
31
|
5
|
< 0.001
|
|
Oral candidiasis
|
15
|
5
|
0.018
|
|
Traumatic ulcer
|
4
|
0
|
0.121
|
|
Benign migratory glossitis
|
5
|
0
|
0.059
|
Discussion
Most of the studies reported in the literature reveal the
periodontal disease behavior in pregnant women [2, 6, 10, 11].
Therefore, it was difficult to compare our results with other
studies as our study involved only oral mucosa lesions.
The total number of lesions diagnosed in pregnant women in this
study was higher when compared with the controls. Ojanotko-Harri et
al. [11]suggested that high progesterone levels during pregnancy
induce a degree of immunosupression, which in turn contributes to
inhibit inflammatory cell function. In addition, stress and anxiety
during pregnancy may lead to neglect of oral hygiene. These factors
may contibute to the increased number of oral lesions during
pregnancy.
During pregnancy it is known that the levels of yeasts increase
in saliva. The pH and buffer effect values of saliva have been
found to decrease during pregnancy [10]. The above mentioned
factors may be the reason for the increased oral candidiasis during
pregnancy in our study.
Cheek biting is a chronic irritation or injury to the buccal
mucosa from repetitive chewing or biting. It typically presents as
shaggy white lesions of the anterior buccal mucosa that approximate
the area where the upper and lower teeth meet. It is a benign
condition requiring no treatment [12]. The number of pregnant
patients diagnosed with cheek biting was higher in this study when
compared with control. This may be as a result of weight gain and
the anxiety during pregnancy. Cheek biting may cause mechanical
trauma on the buccal mucosa. This may be further be infected by
candida species. This can be another reason for the increased oral
candidiasis in our pregnant patients.
Fordyce spots are sebaceous glands that are located in the oral
mucosa. They are regarded as a variation of normal anatomy. The
prevelance of these spots range from 70% to 84% of the normal
population [12]. Fordyce spots prevelance was not different in our
pregnant patients when compared with the controls.
Benign migratory glossitis is a benign clinical condition. Many
patients are unaware of the condition. Its frequency is increased
in psoriasis. Its prevelance in the general population is 1-3%
[13]. Its frequency was statistically not different in pregnant
patients (5%) in this study when compared with controls, p = 0.059.
But in the literature, benign migratory glossitis was reported as
the oral mucosa lesion that was striking in the pregnant women. In
the study of Díaz-Guzmán et al. [1], a significantly greater
prevelance in pregnant women (3.23%) versus non-pregnant women was
reported. Musyka et al. [8] in turn reported a 6% prevelance in
pregnant human immunodeficiency virus (HIV)-negative women, versus
4.3% in pregnant HIV-positive women.
Fissured tongue is a common benign condition. Numerous furrows
are seen on the dorsum of the tongue. Prevelance is reported as
2-5% of the general population [14]. It requires no treatment.
Although fissured tongue is one of the most common lesions in the
Turkish population (5.2%) [5], its frequency was not different in
our pregnant population of the study.
Hairy tongue is a common benign condition that represents the
accumulation of varying amounts of keratin on the dorsum of the
tongue. Factors that may be associated with increased production of
keratin include smoking, poor oral hygiene, use of oxidizing
mouthwashes and hot beverages. Its prevelance in general population
is reported as 0.5% [15]. Its frequency was not higher in our
pregnant patients when compared with controls.
The etiology of a traumatic ulcer is related to acute or chronic
injury to the oral mucosa. For example, biting the cheek
accidentally [15]. In the study of Díaz-Guzmán et al. [1],
predominance of traumatic ulceration in pregnant women (4.30%)
versus non-pregnant women (4.15%) was reported. Its prevelance was
not different in the pregnant group then control in this study, p =
0.121.
The pathomechanism of apthous stomatitis is unknown but
immunologic factors may be involved. Women may be afflicted more
commonly then men [15]. But its frequency was not higher in the
pregnant patients in this study (3%) or in the study of Díaz-Guzmán
et al. [1] (1.08%).
In pregnant women with continuous vomiting, oral mucosa lesions
were observed more frequently in our study. A possible reason could
be the inability to brush efficiently because it may stimulate a
gagging reflex and vomiting. Vomiting interrupts the oral mucosa
hygiene. But this remains speculative [6].
Salivary glands contain steroid receptors and as other exocrine
glands may be affected by pregnancy. The secretion of female sex
steroid hormones in saliva is significantly increased during late
pregnancy. Relatively few studies show that no significant changes
in the flow rate of whole saliva occur [16, 17]. Although the flow
rate of hypersalivation was not measured in pregnant women,
hypersalivation was a complaint in our pregnant patients. However,
the type and the number of oral mucosa manifestations were not
different in the study between pregnant women with or without
hypersalivation.
An association between peridontal diseases and preterm births
was suggested recently [18, 19]. Pre-existing peridontal disease
diagnosed in mid-pregnancy was found to increase the risk of
preterm birth 4.5-7.1 times compared to the risk in periodontally
healthy mothers [19]. The mechanisms linking peridontal diseases
and preterm births are not known. It is thought that locally
produced inflammatory mediators such as prostaglandins and
cytokines are carried to the uterus by the blood to cause uterine
contractions. There is no study concerning oral mucosa lesions
during pregnancy and their link to preterm births.
Conclusion
We are aware that the links between pregnancy and oral mucosa
lesions are not clear in this study. Considering the lack of
information regarding oral mucosa lesions in pregnant women,
further studies with a larger study sample are advisable to explore
the oral mucosa lesions during pregnancy. Also studies can be
designed to see if women who experienced a preterm birth had any
differences in oral mucosa lesions compared with women who
delivered at term. Additionally, individual programs for the
maintenance of good oral health during pregnancy and after
delivery, as well as in the prevention of transmission of
unfavorable microbial flora from mother to the child can be
planned.
Acknowledgments
The authors wish to thank Salih Ergocen BSc, for his contribution
to the statistical analysis of this study.
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