A Research Proposal: Oral Health and Pregnancy - A Systematic Review

This research proposal investigates the significance of maintaining optimal oral health during pregnancy, addressing the existing gap in research and awareness regarding the underlying pathologies and consequences of neglecting oral hygiene. It aims to explore the association between oral health and physiological changes in pregnancy, evaluate the impact of poor oral health on both maternal well-being and fetal development, and assess effective strategies for maintaining oral health during gestation. The proposal outlines a qualitative exploratory research design, employing systematic reviews and narrative synthesis for data collection and analysis, drawing from electronic databases such as CINAHL, Medline, BioMed, and PubMed. The study seeks to answer key questions about the changes occurring in the oral cavity during pregnancy, the effects of poor oral health on fetal growth, and the preventive strategies expectant mothers can adopt to maintain optimal oral health, ultimately aiming to highlight the necessity of integrating oral health assessments into routine prenatal care.

Running head: RESEARCH PROPOSAL: ORAL HEALTH DURING PREGNANCY
RESEARCH PROPOSAL: ORAL HEALTH DURING PREGNANCY
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1RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
Abstract
Pregnancy is a critical stage which necessitates maintenance of positive health outcomes
and required health parameters to ensure survival of both the mother and the baby, as well as
growth and development of a healthy child. Despite availability of adequate knowledge on the
varied physiological and psychological changes and their consequences in pregnancy, limited
research and emphasis exists on the maintenance of adequate oral health. Hormonal alterations in
estrogen and progesterone in pregnancy results in increased inflammation in the oral cavity
resulting in increased susceptibilities for expecting mothers to acquire oral diseases. Lack of
adequate management of the same, will result in birth of a low birth weight or preterm infant,
with compromised immunity. Hence the following research proposal will aim to outline a
qualitative exploratory research on understanding the associations between oral health and
pregnancy and utilize systematic reviews and narrative synthesis as the chosen method for data
collection and analysis. It is expected that a research will pave the way for future studies and
improvements in maternal health assessments in the inclusion of oral health as a part of
compulsory screening and patient education dissemination.

2RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
Introduction
Research Background
The stage pregnancy forms one of the most crucial area underlying the overall health and
wellbeing of a community in general and nation in particular, considering that it comprises of the
foundational cornerstones for an individual’s growth and development. Pregnancy brings forth a
number of psychological , physiological and emotional upheavals in a woman’s life due to the
complex interplay of a multitude of hormones, characteristic of this stage (Hartnett et al., 2016).
Of the multifaceted changes and health variations which can occur during pregnancy,
examination, monitoring and oral health - an aspect often overlook during provision of care –
will be the focus of concern discussed in the following paragraphs of this research proposal.
Research Rationale
As a resultant of the dramatic hormonal alterations undergoing during pregnancy,
expectant mothers are often susceptible to encountering detrimental oral health and gum disease,
mainly pregnancy-associated gingivitis, hence necessitating timely and robust oral care.
Increased circulating levels of progesterone resulting in inflammatory and vascular changes are
often accompanied with painful and swollen gums, coupled with abnormally high buildup of
plague (Vamos et al., 2015). Increased proliferation of bacterial colonies in the oral cavity result
in swallowing and associated circulation of harmful plague towards the developing fetus, leading
to increased susceptibility of giving birth to preterm or low birth weight babies. Despite the
harmful consequences, there lies limited research on the importance of maintaining optimal oral
health during pregnancy and the underlying pathologies rationalizing the same (Wen et al.,

3RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
2017).Hence, taking insights from the same, the problem statement for the proposed statement
will be as the following:
Problem Statement: To review the importance of maintaining optimum oral health
during pregnancy considering the problem of limited research availability and unawareness on
the underlying pathologies and consequences due to lack of mitigation of the same.
Literature Review
As reviewed by Aggarwal et al., (2019), upon conception and to the stages leading up to
birth of a baby, the interplay and fluctuating rises and pitfalls in the sex hormones result in varied
physiological and psychological changes within the body of the expecting mother to ensure
adequate fetal growth and development. Wu, Chen and Jiang (2015), postulated that sex
hormones during the stage of pregnancy has also now been implicated to exert detrimental
changes in the oral cavity of expecting mothers namely alterations in the normal flora of the sub-
gingival region, hindered immunological processes in the oral cavity hence leading to emergence
of frequent episodes of gingivitis as well intense and painful granulomas.
As researched by Gil et al., (2109), the associations between oral cavity and diseases can
be established during the first trimester of second month of pregnancy which is characterized by
high circulatory levels of progesterone and estrogen, namely for the purpose of facilitating fetal
growth via placental tissues and vascular proliferation. The resultant high levels of progesterone
results in increased dilation and permeability of capillaries in the gingival and associated
production of exudates in the sub-gingival cavities. An additional change associated as a result of
elevated circulatory levels of progesterone is the increased circulatory rates of prostaglandins,
namely PGE-2 leading to increased inflammation in tissues such as the gingival as well as

4RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
reductions in the immunological defense mechanisms in the oral cavity (Wu et al., 2016). As
examined by Fujiwara et al., (2017), this results in increased susceptibilities of acquiring oral and
gum diseases and bacterial proliferation in the oral cavities of expecting women. Warning
symptoms necessitating oral care in pregnant women, include swelling, redness and tenderness in
gums, bleeding gums during flossing and brushing and foul smell and breathe in the oral cavity.
Silva de Araujo Figueiredo et al., (2017) examined that lack of adequate oral hygienic
care during pregnancy will not only hinder food intake and basic oral immunological processes
in pregnant women, but will result in long term developmental hindrances in the fetus. Increased
gingival inflammation and gum disease will result in bacterial infestation and proliferation of
plague in the oral cavity leading to swallowing of such harmful microbiological components by
the mother and associated placental circulation of the same to the developing fetus. As
researched by Gupta and Acharya (2016), this increases possibilities of delivering a baby with
low birth weight and premature with compromised immunological systems. Hence, pregnant
women must adhere to adequate oral hygiene such as regular brushing, engagement in regular
and timely oral examination and rinses with warm water, especially during the second month of
gestation.
To enhance oral health during pregnancy, as researched by Bahramian et al., (2017), the
Health Belief Model can be used as the chosen conceptual framework. Following the same, prior
to administration of oral hygiene strategies, health belief based assessment must be considered,
comprising of screening the susceptibility of oral health disorders in pregnant women,
monitoring of the rate of severity and an evaluation of the knowledge deficits and financial
constraints which may affect pregnant women’s access to oral health services.

5RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
Questions and Hypothesis
Research Aim and Objectives
Hence, taking insights from the existing literature as well as the identified literature gap,
the aim of the proposed research is: To review the importance of maintaining optimum oral
health during pregnancy considering the problem of limited research availability and
unawareness on the underlying pathologies and consequences due to lack of mitigation of the
same.
Hence, considering the same, the following will comprise of the aims of the proposed
research:
1. To identify and explore the association between oral health and physiological changes
occurring during pregnancy.
2. To evaluate the consequences of poor oral health on maternal health as well as growth
and development of the fetus.
3. To assess the strategies underlying maintenance of optimum oral health and prevention of
oral issues in pregnant women.
Research Questions
The proposed research will hence seek to focus on answering and uncovering the
solutions to the following identified questions:
1. What are the changes and the underlying pathologies, occurring in the oral cavity and in
terms of overall oral health in expecting mothers during pregnancy?
2. How does poor oral health and disease affecting the oral cavity during pregnancy affect
the growth and development in the fetus?

6RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
3. What are the strategies which can be undertaken by expectant mothers to prevent
pregnancy associated oral disorders and maintain optimum oral health?
Hence, for the proposed research, the following hypothesis can be postulated: Pregnant
women are susceptible to acquisition of detrimental oral issues, for the prevention of which,
undertaking optimum strategies of oral health and hygiene is of utmost importance.
Research Design and Methodology
Research Design
For conducting research on the proposed study objectives and obtaining solutions to the
identified questions, an exploratory research using qualitative methods such as a systematic
review will be used. An exploratory research implies a type of study at used for explaining and
understanding a research issue which has currently been studied inadequately for the purpose of
establishing and identifying priorities, needs and possible appropriate studies future conductance
of improved studies (Green et al., 2016). Hence, considering the same, an exploratory research
design has been chosen as the preferred method of research conductance since oral health issues
associated with pregnancy have undergone limited research and hence, the same will provide an
improved understanding of the issue, the possible improvements in research and assessments
which can be incorporated in the future for ensuring positive health outcomes in pregnant women
(Reio Jr & Shuck, 2015).

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Research Methodology
Data Collection
The dependent and independent variables for the study will include oral health status and
pregnant women. For conductance of the proposed research, an exploratory research design will
hence be undertaken using systematic reviews as the chosen methodology. A systematic review
is a qualitative research procedure which comprises of searching and obtaining secondary data
such as articles relevant to the research question, followed by conceptualizing the findings of the
same into relevant themes of contents (McGowan et al., 2016). Hence, for executing research on
the highlighted research question, studies discussing oral health issues in pregnancy will be
collected – of which, it will be ensured that the sample participants explored by the selected the
authors will comprise of pregnant women. The relevant articles will be selected by conducting an
extensive literature via electronic databases such as CINAHL, Medline, BioMed and PubMed. In
order to obtain articles which will be suitable for obtaining findings pertaining to the identified
research issue, key words like ‘oral health’ and ‘pregnancy’ will be used accompanied by
Boolean operators for comprehensive and accurate study screening (McKeever et al., 2015).
Data Collection Tool
In order to ensure collection of valid and relevant data, it will be ensured that the
secondary data or articles so selected will be obtained from databases and journals which are
scholarly and peer reviewed. Peer reviewed and scholarly databases and journals imply that the
researches and studies available from the same are screened and evaluated by more than one
author of considerable academic credibility to prevent bias. For ensuring accuracy of the
collected data in the form of obtaining articles of relevant researches, limiters and specific
keywords will be selected in the above identified databases such as selecting the preferred

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research language as English, the sample recruited for the study as humans, and by specifying
appropriate key words such as ‘oral health’ and ‘pregnancy’ (Peters et al., 2015).
Variables to Control
In addition to ensuring that the articles contain the above identified dependent and
independent variables, care will be taken to avoid interferences by confounding variables to
ensure accuracy, validity and significance of the data so obtained. For the process of obtaining
articles dealing with studies on evaluating oral health in pregnancy, external variables such as
demographic characteristics of participants especially healthcare settings and socioeconomic
conditions will be controlled (Martin & Nissenbaum, 2016). This can be done expanding on key
words terms used resulting in inclusion of words like ‘hospital settings’ and ‘developed
countries’ or by extensively reading te abstracts of the chosen articles to ensure that the select
studies deal with a sample of pregnant women being treated in controlled healthcare settings like
hospitals and belonging to privileged socioeconomic groups or in developed countries. The
reason for considering these demographic characteristics as interfering variables requiring
control, since expecting mothers belonging to underprivileged socioeconomic groups and not
receiving medical care in controlled settings may pose greater susceptibilities towards the
acquisition of oral as well as a conundrum of associated diseases due to lack of adequate
healthcare services and educational resources resulting in obtaining incorrect results and findings
pertaining to the research question (Lee et al., 2016).
Validity
Articles dealing with studies containing small sample sizes or unequal sample
distribution are often susceptible to loss of internal validity as well as statistical errors. Further,
selection of qualitative or review based studies are also susceptible to publisher bias and loss of

9RESEARCH PROPOSAL: ORAL HEALH DURING PREGNANCY
external validity (Leung, 2015). To prevent the same, studies containing randomized controlled
trials or additional qualitative articles will be collected from peer reviewed journals and
databases since the same has been associated with adequate validity and prevention of bias.
Likewise, relevant tools of critical appraisal may be used to ensure selection of valid articles
considering the comprehensive set of evaluation criteria provided by the same (Noble & Smith,
2015).
Statistical Evaluation
Considering that a systematic review will be performed, narrative synthesis will be used
as the chosen method for evaluation of collected data, comprising of grouping the relevant
findings into major contents or themes such as ‘oral health during pregnancy’, ‘oral health and
fetus development’ and ‘oral health and hygiene strategies’ consisting of further sub themes.
Such an evaluation process is of relevance since it aids in concise organization of a large amount
of data into appropriate sections or topics (Cruzes et al., 2015).
Summary and Evaluation
Hence, the proposed research will pave the way for increased understanding on the
importance and strategies of maintaining oral health hygiene during pregnancy. This research
will further pave the way for future research on exploration of additional concerns such as
improvement of oral health in pregnant women belonging to underprivileged socioeconomic
countries, conductance of primary, quantitative studies assessing changes in oral health status
among pregnant women as well the development of public maternal health policies or
assessment tools including compulsory screening of oral health as a part of multidisciplinary
maternity care (Pervin, 2017).

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Dissemination
In order to ensure further future researches in this field of study by academicians,
findings of the proposed research will be published across peer reviewed journals. Further, for
the purpose of disseminating education on the importance of oral health during pregnancy, the
findings will be discussed across health organizations or maternity clinics using audio-visual or
oral presentations. Likewise, to garner academic support as well as initiate future research
conductance, the findings will also be discussed in notable medical or healthcare based
conferences (Iida, 2017).

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References
Aggarwal, N., Nayyar, S., Singla, I., Sheikh, S., & Pallagatti, S. (2019). Pregnancy and Oral
Health: A Review. Research & Reviews: A Journal of Dentistry, 4(2), 23-31.
Bahramian, H., Mohebbi, S.Z., Khami, M.R. and Sighaldeh, S.S., 2017. A Health Belief Model-
Based Instrument for Assessing Factors Affecting Oral Health Behavior During
Pregnancy. Iranian Red Crescent Medical Journal, 19(8).
Cruzes, D. S., Dybå, T., Runeson, P., & Höst, M. (2015). Case studies synthesis: a thematic,
cross-case, and narrative synthesis worked example. Empirical Software
Engineering, 20(6), 1634-1665.
Fujiwara, N., Tsuruda, K., Iwamoto, Y., Kato, F., Odaki, T., Yamane, N., ... & Komatsuzawa, H.
(2017). Significant increase of oral bacteria in the early pregnancy period in Japanese
women. Journal of investigative and clinical dentistry, 8(1), e12189.
Gil, L., Mínguez, I., Caffesse, R., & Llambés, F. (2019). Periodontal Disease in Pregnancy: The
Influence of General Factors and Inflammatory Mediators. Oral health & preventive
dentistry, 17(1).
Green, R. C., Goddard, K. A., Jarvik, G. P., Amendola, L. M., Appelbaum, P. S., Berg, J. S., ...
& Bowling, K. M. (2016). Clinical sequencing exploratory research consortium:
accelerating evidence-based practice of genomic medicine. The American Journal of
Human Genetics, 98(6), 1051-1066.