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The magnitude of untreated dental caries and its predictors among pregnant women attending antenatal care at health facilities in Gondar town, Northwest Ethiopia

BMC Pregnancy and Childbirth volume 25, Article number: 300 (2025) Cite this article

Abstract

Introduction

Pregnancy-associated hormonal alterations and reduced immunological function contribute to diminished oral hygiene, thereby increasing the susceptibility of pregnant women to oral diseases, especially dental caries. Despite the high burden of dental caries among pregnant women, there is a lack of evidence on the magnitude of untreated dental caries and its predictors in Ethiopia. Hence, this study aimed to assess the magnitude of untreated dental caries and its associated factors among pregnant women attending antenatal care at Gondar town health facilities.

Methods

A facility-based cross-sectional study was conducted among pregnant women attending antenatal care at Gondar town health facilities from February 2024 to June 2024. Data were collected by health professionals using pretested structured interviewer-administered questionnaires and intraoral examinations. The collected data was exported to Stata version 17 for data analysis. A binary logistic regression analysis was done to identify risk indicators of dental caries among pregnant women. Hosmer’s and Lemeshow’s goodness of fit test was used to check the fitness of the model.

Results

Of the total 628 pregnant women who participated in this study, 312 (49.7, 95%CI: 45.7,53.7) were found to have untreated dental caries. Age (AOR = 1.06, 95%CI: 1.01,1.11), primary educational attainment (AOR = 0.47, 95%CI: 0.24, 0.94), college-level education or beyond (AOR = 0.51, 95%CI: 0.26, 0.99), no regular tooth brushing habit (AOR = 1.41, 95%CI: 1.01, 1.99) and parity (AOR = 1.20, 95%CI: 1.01,1.44) were predictors of untreated dental caries among pregnant women.

Conclusion

The study demonstrated a high level of untreated dental caries experience among pregnant women. Age, educational status, parity, and toothbrushing practice significantly affect dental caries development among pregnant women. Midwives and ANC providers should be trained in basic oral health training procedures. Pregnant women with multiple pregnancies and irregular tooth brushing practices should practice frequent teeth brushing to decrease the burden of untreated dental caries. Ministry of Health should integrate oral health education into their ANC program and promote dental referrals for high-risk pregnancies to decrease the burden of untreated dental caries.

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Introduction

Dental caries is a multifactorial, progressive, and localized infectious disease of the hard tissues of the teeth caused by the interaction of cariogenic microorganisms in dental plaque, fermentable dietary carbohydrates, and host factors such as saliva and tooth structure [1]. According to the World Health Organization (WHO) report around 2.4 billion individuals worldwide have dental caries [2]. Pregnancy-associated hormonal changes and lowered immunity induce poor oral hygiene that increases the risk of pregnant women developing oral diseases [3,4,5]. The prevalence of dental caries among pregnant women is substantial, with regional variations observed across different countries. The reported prevalence is 59% in Colombia [6], 60.5% in Tanzania [7], 62.7% in Brazil [8] and 14% in Iraq [9].

Hormonal changes cause the oral environment to change during pregnancy, which may lead to a decrease in salivary pH and buffering capacity at the end of the pregnancy [10]. Emerging increased craving for fermentable carbohydrates [11], changes in salivary component and acidity, tooth brushing practice [4, 12], gestational age [13], and limited access to dental care [5, 14] increased the burden of dental caries, especially in developing countries. Moreover, the physiologic changes such as morning sickness, vomiting, and nausea during pregnancy result in the oral cavity being consistently acidic, which creates an environment conducive to the growth of cariogenic bacteria [15].

Dental caries is the primary cause of oral pain among pregnant women [16]. The consequence of poor oral health extends beyond the mouth, demonstrating associations with systemic conditions such as cardiovascular disease and diabetes mellitus [17, 18]. Recent evidence has also indicated that dental caries is linked to unfavorable pregnancy outcomes, including preterm delivery and preeclampsia [19,20,21]. Moreover, untreated dental caries in expectant mothers may increase the likelihood of their infants developing early childhood caries [22].

Dental caries is a public health problem in Ethiopia with a pooled prevalence of 40.98 (95%CI: 31.62, 50.34) [23], and 23.64% among patients who visited dental centers in northwest Ethiopia [24]. Though dental caries is highly prevalent among pregnant women [6, 25], and is the primary source of pain during pregnancy [16], there is a scarcity of studies on the magnitude of untreated dental caries and its associated factors among pregnant women in Ethiopia. As the hormonal changes during pregnancy cause the oral environment to have decreased salivary pH and its buffering capacity, preventive and curative strategies during pregnancy reduce the risk of oral disease for the women and child [26]. So, knowing the magnitude and related factors of dental caries among pregnant women could help to design intervention programs and preventive strategies for these high-risk groups. Therefore, this study aimed to assess the magnitude of untreated dental caries and its associated factors among pregnant women attending antenatal care (ANC) service at Gondar town health facilities, in Northwest Ethiopia.

Methods and materials

Study design and setting

The study utilized a facility-based cross-sectional design and was conducted from February 2024 to June 2024. The study was conducted in selected health facilities in Gondar town. Gondar, one of the oldest cities in northwest Ethiopia, has eight health centers, and one tertiary hospital. Maternal and child health services are provided at three health centers and the tertiary hospital. University of Gondar Comprehensive and Specialized Hospital is one of the oldest tertiary hospitals in Northwest Ethiopia, offering advanced maternal and child health services to the catchment population. Data were gathered from three healthcare facilities: the University of Gondar Comprehensive and Specialized Hospital, Maraki Health Center, and Poly Health Center.

Study population

The study population consists of pregnant women who had ANC visits during the data collection period. The inclusion criteria required participants to be pregnant and receive antenatal care at selected health facilities in Gondar town during the study period. Also, those who voluntarily agreed to participate in the study by providing informed consent were involved in the study. While those with medical or obstetrics emergencies were excluded from the study.

Sample size determination and sampling technique

The sample size was determined using a single population proportion formula [27], assuming a 50% prevalence of dental caries due to the lack of prior studies in Ethiopia, a 5% margin of error (d), and a 95% confidence level. Moreover, a 10% non-response rate, and a design effect of 1.5, accounting for the study’s multi-facility nature, were considered. The final estimated sample size would be 634.

$$ n = \frac{{{{({z_{\alpha /2}})}^2}\left( {p(1 - p} \right)}}{{{{(d)}^2}}} $$

Samples were selected from the selected three health facilities proportionally based on the estimated number of pregnant women who received antenatal care at each site during the last quarter of 2023 (October- December). According to the three-month ANC case report of 2023, a total of 3,621 pregnant women had attended ANC at the selected health facilities. Of these, 3,002 were seen at the University of Gondar Comprehensive and Specialized Hospital, 356 at Poly Health Center, and 263 at Maraki Health Center. Based on this distribution, 525 pregnant women were selected from the University of Gondar Comprehensive and Specialized Hospital, 62 from Poly Health Center, and 47 from Maraki Health Center. Finally, study participants were selected using a systematic random sampling approach, selecting every third pregnant woman on a daily basis.

Variables and measurements

The outcome variable of this study was untreated dental caries, defined as a bacterial infection of the hard tissues of a tooth. The diagnosis involved a thorough examination of the entire oral cavity, looking for one or more of these indicators: visible cavitation on the surface of the tooth, a detectable loss of enamel or dentine integrity, or the presence of chalky white or brown areas suggesting tooth hard tissue demineralization [28]. The outcome variable was categorized into two groups: individuals with dental caries were labeled as “Yes”, while those without were designated “No”.

The independent variables included age of pregnant women (years) categorized into three groups: (16–25, 26–35 and ≥ 36), religion (Muslim, Orthodox), educational status (no formal education, primary, secondary and college and above), marital status (currently married, currently unmarried), occupation(governmental employee, house wife, self-employee, and others), residency (urban, rural), family size (small family(up to 3), medium family [4,5,6], and large family(7 and above)), tooth brushing habit (yes, no), frequency of brushing (sometimes, once/day, twice/day, three/day), dental visit during the last 6 month(yes, no), frequency of sugared food intake (twice/day, once/day, sometimes, three/week), medication intake(yes, no), gestational diabetes (yes, no), medical comorbidity (yes, no), gestational age (first trimester, second trimester, third trimester), parity (nulliparity, primiparity, multiparous), and gravidity(primigravida, multigravida).

Data collection methods and tools

Data was collected through interviewer-administered structured questionnaires and intra-oral examination. A team of healthcare professionals, consisting of a gynecology resident, a dental surgeon, and two midwives, carried out the data collection process. The questionnaire was developed based on existing literature [7, 29, 30] and the WHO health survey tool [28]. A pretest was done, and based on the results, the questions were refined for clarity, the sampling method was adjusted to ensure adequate sample size and a separate data collection room was allocated to reduce social desirability bias on behavioral factors. Besides, the questionnaire underwent translation from English to Amharic (the local language) and back to English by another translator, to ensure consistency. A questionnaire that is linguistically and culturally appropriate for the study participants through maintaining the original content of the study is the outcome process of this translation. Moreover, content and face validity were employed to maintain the validity of the data collection.

The intra-oral cavity of the study participants was evaluated by a single dental surgeon using disposable gloves, mouth mirrors, dental explorers, and LED Headlamps. Dental caries assessment was conducted using the decayed, missed, and filled (DMFT) index, which involves examining and scoring each tooth as decayed, missed, or filled. Pregnant women identified with urgent dental concerns were linked to the University of Gondar Comprehensive and Specialized Hospital’s dental clinic for additional evaluation and necessary treatment.

Data quality assurance

To ensure the quality of the data, both data collectors and supervisors were trained for one day on data collection techniques and ethics of human research. Moreover, before data collection, pretested was done on 5% of the sample size that was not included in the main study, and modifications were made to improve the validity and reliability of the tool. To evaluate the intra-examiner reliability, dental caries was assessed twice in 5% of the sample, with a two-week gap. The Cohen’s Kappa Coefficient was 0.90 indicating excellent reliability. The data collection tool was also translated into the local language, Amharic to ensure the consistency of the questionnaire. Supervisors conducted daily checks on the collected questionnaires to verify data completeness and clarity.

Data management and analysis

Data were collected using online data collection tool, Koob toolbox. The collected data were transferred into Excel for visualization and then transferred into Stata version 17 for coding, labeling, and further analysis. Descriptive statistics findings were summarized in terms of frequency, and percentage for categorical variables, and mean or median and standard deviation for continuous variables based on their distribution.

Univariable binary logistic regression analysis was done to assess the relationship between predictors and dental caries among pregnant women. Variables with a P-value of ≤ 0.20 at univariable binary logistic regression analysis were exported into the multivariable binary logistic regression analysis to control the possible effects of the confounders and determine the potential predictors of dental caries among pregnant women [31]. Then adjusted odds ratio (AOR) with its corresponding 95% CI was used to assess the strength of association between independent variables and dental caries. A P-value of < 0.05 was used to declare a statistically significant association between the dependent and independent variables. The fitness of the model was evaluated using Hosmer and Lemeshow’s test of goodness of fit test.

Ethical considerations

Ethical approval was obtained from the institutional research Ethics Committee (IRERC) of the College of Medicine and Health Sciences Specialized Referral Hospital of University of Gondar (Ref.No: IRERC/61/11/2024). Moreover, permission was obtained from the management of the selected health facilities, and the Department of Obstetrics and Gynecology, University of Gondar. A written informed consent was obtained from each participant before they engaged in the data collection process. To ensure the confidentiality of the data, study subjects were identified using codes, and unauthorized individuals were not allowed to access the collected data.

Results

Sociodemographic characteristics of pregnant women

Out of 634 study participants, 628 pregnant women completed both the interview and intraoral examination making a response rate of 99.05%. The mean age of the study participants was 27.82 ± 5.11(SD) years, and majority of them (56.7%) were 26–35 years old. Most of the study participants were Orthodox Christians (93.8%), currently married (97.6%), and urban residents (86.6%). Moreover, more than one-third (38.1%) of the study participants had an educational status of college and above level. Majority of the study participants (69.8%) had a family size of up to three individuals in the household. Regarding the occupation of the study participants, more than half were housewives (58.4%) (Table 1).

Table 1 Sociodemographic characteristics of pregnant women attending ANC at health facilities in Gondar town, Northwest Ethiopia (n = 628), 2024
Full size table

Behavioral and health-related factors of dental caries

The study found that 289 pregnant women (46%) have a habit of tooth brushing, with only 15.6% of them brushing twice daily. In terms of recent dental care, a mere 48(7.6%) individuals had visited a dentist in the preceding months. Medical comorbidities were present in 42 participants (6.7%). Majority of the study participants (59.4%) were in their third trimester of pregnancy, (68.5%) multigravida, and 260 (41.4%) were nulliparous (Table 2).

Table 2 Behavioral and health-related factors of dental caries among pregnant women attending ANC at health facilities in Gondar town, Northwest Ethiopia (n = 628), 2024
Full size table

Magnitude of untreated dental caries

The magnitude of untreated dental caries among pregnant women in the study area was 49.7% (95%CI: 45.7,53.7).

Predictors of dental caries

In the univariable logistic regression, variables such as age, educational status, gestational age, parity, comorbidity, and tooth brushing practice had a statistically significant association with dental caries among pregnant women at a P-value of 0.20. Variables with a p-value of ≤ 0.20 were entered into the multivariable binary logistic regression analysis to determine the potential predictors of dental caries among pregnant women. In the multivariable binary logistic regression model variables such as age, educational status, tooth brushing practice, and parity were significantly associated with dental caries.

The odds of dental caries among pregnant women increase by 1.06 for each year increase in participant’s age (AOR = 1.06, 95%CI: 1.01, 1.11), indicating that untreated dental caries become more prevalent as individuals grow older.

Furthermore, higher educational attainment is associated with a reduced risk of dental caries. Pregnant women who completed primary education were 53% less likely to have dental caries compared to those without formal schooling (AOR = 0.47, 95%CI: 0.24, 0.94). Similarly, the odds of dental caries for those with college-level education or beyond were 0.51 (95%CI: 0.26, 0.99), suggesting that pregnant women in this educational category were 49% less prone to dental caries than their counterparts lacking formal education.

The model also revealed that pregnant women who did not brush their teeth regularly were observed to have 1.41 times higher odds of developing dental caries (95%CI: 1.01, 1.99) than their counterparts. This indicates a 41% increase in the likelihood of dental caries in those without consistent toothbrushing habits compared to their counterparts. Furthermore, the study found a significant association between parity and dental caries among pregnant women (AOR = 1.20, 95%CI: 1.01,1.44). Specifically, each additional pregnancy increased the odds of dental caries by a factor of 1.20 for the expectant mother (Table 3).

Table 3 Multivariable binary logistic regression analysis showing the predictors of dental caries among pregnant women attending ANC at health facilities in Gondar town, Northwest Ethiopia (n = 628),2024
Full size table

The Hosmer-Lemeshow goodness of fit test assesses the goodness of a logistic regression model by comparing the observed and predicted probability of the outcome variables. Our model showed a higher P value (P = 0.8285) which suggests that the model adequately fits the data.

Discussion

This study assessed the magnitude of untreated dental caries among pregnant women attending ANC at health facilities in Gondar town, northwest Ethiopia. The study found that almost half of the study participants had untreated dental caries. Variables such as age, educational status, toothbrushing practice, and parity were significant risk indicators for dental caries among pregnant women.

The magnitude of untreated dental caries in the present study was 49.7% (95%CI: 45.7,53.7). This finding presents a contrast when compared to other studies. Notably, the result is lower than studies done in Colombia (59%) [6], and Tanzania (60.5%) [7], as well as in India (63.3%) [32], Brazil (62.7%) [8] and Cameroon ( 73.2%) [25]. These variations might be due to the differences in the oral health care system, access to dental care services, and socioeconomic factors across the regions.

Conversely, our finding is significantly higher than a result reported in Iraq, where only 14% of pregnant women attending antenatal care had dental caries [9]. This difference might be due to a difference in health oral care access, tooth brushing habits, and dental care utilization. In Iraq, 56% of pregnant women had regular dental visits, and 37% practiced twice-daily tooth brushing [9].

The present study found a statistically significant relationship between age and dental caries among pregnant women, when age increases the burden of untreated dental caries also increases. In line with the current study, a study done in Colombia found that the burden of dental caries also increases as the age of the study participants, pregnant women, increases [6]. Similarly, a study done in the USA found that a one-year increase in pregnant women increases the dental caries experience by 0.3 [33]. This might be due to the influence of age-related salivary changes, and cumulative effects of oral hygiene and dietary practice which gradually increase individuals’ risk of dental caries [34, 35].

Our study demonstrated that the burden of untreated dental caries was low among pregnant women with educational attainment of college or above compared to those without formal education. A comparable finding was reported in Colombia, where the burden of untreated dental caries was low among those with a university degree or higher educational attainment relative to those without formal education [6]. Moreover, a study conducted in Norway found that pregnant women with less than secondary education had 2.06-fold increased odds of experiencing higher dental caries compared to those with tertiary educational attainment [36]. This association may be attributed to the possibility that individuals with higher educational attainment possess superior oral health literacy and practice compared to their counterparts.

The dental caries burden increases by 1.20 for each additional child a woman has, as evidenced by research conducted in the United States, which identifies higher parity as a risk indicator for untreated dental caries and tooth loss [33]. Additionally, the US National Health and Nutrition Examination Survey found a significant link between parity levels and dental caries experience, suggesting that women of reproductive age with more children are more likely to experience dental caries [33]. This might be due to the hormonal changes that can increase oral vasculature permeability and decrease the body’s immunocompetency, which creates a favorable environment for bacterial proliferation, and dental caries initiation [37, 38].

Our study also found that toothbrushing practice had a statistically significant relationship with dental caries, which means those who had no regular toothbrushing practice were 41% more likely to have dental caries than their counterparts. Our finding was supported by a study done in Nigeria where those who had fair oral hygiene had 84% decreased odds of dental caries than those with poor oral hygiene [39]. Furthermore, Utami et al. [40] in Indonesia revealed a significant relationship between toothbrushing practice and dental caries level among subjects. This might be due to the accumulation of plaque in the oral cavity, which produces acid through the fermentation of carbohydrate foods that facilitate demineralization of the hard tissues of a tooth such as enamel, dentine, and cementum.

Strengths and limitations of the study

As a strength, data were collected by skilled dental surgeon, and gynecology and obstetrics residents that increases the validity of the diagnosis of dental caries. Also, this is the first comprehensive study among pregnant women in the country.

As a limitation, the study only includes pregnant women who had ANC at the health facilities, who might have better oral health literacy, hence community-based study should be needed to generalize the findings among pregnant women.

Conclusion and recommendation

The study demonstrated a high level of untreated dental caries experience among pregnant women. Age, educational status, parity, and toothbrushing practice significantly affect dental caries development among pregnant women. Midwives and ANC providers should be trained in basic oral health training procedures. Pregnant women with multiple pregnancies and irregular tooth brushing practices should practice frequent teeth brushing to decrease the burden of untreated dental caries. Ministry of Health should integrate oral health education into their ANC program and promote dental referrals for high-risk pregnancies to decrease the burden of untreated dental caries.

Data availability

The data analyzed for the current study is provided within the manuscript.

Abbreviations

ANC:

Antenatal care

AOR:

Adjusted odds ratio

CI:

Confidence interval

WHO:

World Health Organization

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Acknowledgements

We would like to acknowledge the University of Gondar for funding this research. Moreover, our gratitude extends to the study participants, data collectors, and clinical directors of the University of Gondar Comprehensive and Specialized Hospital.

Funding

The project was funded by the University of Gondar.

Author information

Authors and Affiliations

  1. Department of Dentistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Amare Teshome Tefera & Samuel Seifu

  2. Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Solomon Berhe & Zelalem Ayichew

  3. Department of Pediatrics and Child Health, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Martha Solomon

  4. Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Aynishet Adane

  5. Department of Medical Microbiology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Wubet Birhan

  6. Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

    Tadesse Awoke Ayele

  7. Gondar Town Health Department, Maternal and Child Health Coordinator, Amhara, Ethiopia

    Shashe Zewdu

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  1. Amare Teshome Tefera
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Contributions

A.T.T and S.B conceived the design of the study. A.T.T, S.B, M.S, A.A, T.A.A, S.S, and Z.A were responsible for data collection, data analysis and interpretation of the data. A.T.T, T.A.A, W.B and S.Z drafted and revised the manuscript. T.A.A, A.A, W.B and Z.A were involved in the revision of the manuscript. All authors approved the final version of the manuscript. All the authors take full responsibility for the content of the article.

Corresponding author

Correspondence to Amare Teshome Tefera.

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Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Research Ethics Committee (IRERC) of the College of Medicine and Health Sciences Specialized Referral Hospital of University of Gondar (Ref. No: IRERC/61/11/2024). All study participants were informed about the nature of the study and provided written informed consent before data collection. The study was done in accordance with the declaration of Helsinki (Code of Ethics of the World Medical Association).

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests.

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Tefera, A.T., Berhe, S., Seifu, S. et al. The magnitude of untreated dental caries and its predictors among pregnant women attending antenatal care at health facilities in Gondar town, Northwest Ethiopia. BMC Pregnancy Childbirth 25, 300 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07426-1

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07426-1

Keywords

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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