The effects of pregnancy on oral health, salivary ph and flow rate

The effects of pregnancy on oral health, salivary ph and flow rate | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effects of pregnancy on oral health, salivary ph and flow rate Fatma Yilmaz, Ozgul Carti Dorterler, Saniye Eren Halici, Burcu Kasap, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4730123/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Oct, 2024 Read the published version in BMC Oral Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background: The frequent occurrence of dental caries and periodontal diseases in women during pregnancy may be due to many factors, such as salivary variables. The aim of this study was to evaluate the effects of pregnancy on salivary pH, flow rate, the DMFT index, and CPI sores. Methods: A total of 198 volunteers (pregnant in different trimesters and non- pregnant) were included. Data about sociodemographic characteristics and dental and systemic health conditions were recorded. Unsitumulated saliva samples were collected for 5 minutes via the spitting method. The pH of the saliva was measured by a portable pH meter. The salivary flow rate was determined by the weight measurement method. The DMFT index and CPI were determined. Results: There were significant differences between the pH values of the control and study groups (p < 0.05). There was no difference among the salivary flow rates of the study and control groups. The mean CPI of pregnant women was significantly greater than that of non-pregnant women (p < 0.05), while the DMFTs were similar among all groups. Conclusion: Pregnancy causes a direct decrease in unsitumulated salivary pH and an increase in periodontal disease. It also negatively affects oral and dental health. Trial registration: Clinical Trials-ID: NCT06343337; Registration Date: 04.01.2024. Periodontal diseases Dental caries Saliva Pregnant woman Figures Figure 1 Figure 2 1. Introduction The basic physiological changes that occur during pregnancy affect the oral health of women as well as their general health [ 1 ]. Although physiological and hormonal changes increase susceptibility to periodontal diseases and dental caries, which are among the most common health problems in society, the results obtained from studies on this subject are controversial [ 1 ]. The frequent presence of these diseases during pregnancy may be due to many factors, such as the accumulation of dental plaque, differences in microbial composition, changes in the amount of saliva, and decreases in pH [ 2 – 4 ]. Increases in the levels of steroid hormones, especially during pregnancy, decrease the resistance of the gingiva to periodontal pathogens and increase gingival vascularity and blood flow, causing pregnancy gingivitis [ 5 – 7 ]. Dental caries is a multifactorial infectious disease characterized by mineral loss in dental hard tissues [ 8 ]. In pregnancy, calcium loss occurs in the hard tissues of the teeth, similar to the bones, through the pulpal route, and the concentration of calcium and phosphate in the saliva also decreases [ 9 ]. This change increases demineralization and decreases remineralization in dental tissues [ 3 ]. Many environmental factors, such as nutrition, oral hygiene habits, socioeconomic status, educational status, and the amount and quality of saliva, play roles in the development of caries [ 8 ]. One reason why dental caries are more common during pregnancy is changes in the amount and content of saliva. Although some studies have shown that the salivary glands are affected by pregnancy, as in other exocrine glands, others have reported that the amount of saliva and its flow rate do not change significantly during this period [ 7 , 10 , 11 ]. In the literature, there are many controversial results regarding whether the amount and quality of saliva change during pregnancy, how they change during different trimesters of pregnancy, and how these changes affect tooth and periodontal diseases. For this reason, this study aimed to evaluate the salivary pH, flow rate, caries incidence, and periodontal status of pregnant and non-pregnant women in different trimesters. 2. Methods 2.1. Study design The experimental design of this cross sectional study was in accordance with the consolidated standards of reporting trials (CONSORT) statement. The study was retrospectively registered at ClinicalTrials.gov (NCT06343337). 2.2. Human Ethics and Consent to Participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was received for this research from the Ethics Committee of Health Sciences of Mugla Sitki Kocman University (Report no: 2021/21-VII). Written informed consent was obtained from the participants involved in the study. 2.3. Participants Volunteer pregnant women in different trimesters (for study groups) and non-pregnant women (for control group) (18–35 years) who were treated at the Obstetrics and Gynecology Outpatient Clinic of the Faculty of Medicine of Mugla Sitki Kocman University were included in this study. Patients with even-numbered registration numbers were preferred for randomization. After the patients were briefly informed about the study face to face and verbally, those who agreed to participate were included. Individuals with severe systemic disease, those who used drugs that directly affect the salivary flow rate (e.g., antihypertensive, diuretic, psychotherapeutic, and antiarthritic medications), and those who used cigarettes or alcohol were excluded from the study. 2.4. Data sources/measurement New oral health questionnaire and assessment forms were developed based on the WHO’s reports [ 12 ] for this study. Questions were asked about participants’ sociodemographic characteristics, systemic health conditions, eating habits, dental care routines, and oral and dental problems, and the data were recorded. Interviews with the participants and intraoral examinations were conducted by researchers OCD and FY, respectively. Additionally, the gestational weeks of pregnant women were queried, and they were assigned to study groups (1st trimester: 1–12 weeks, 2nd trimester: 13–26 weeks, 3rd trimester: 27th week to birth), while non-pregnant women were assigned to the control group. The recruitment of participants continued until the desired number was reached. To evaluate the salivary flow rate and pH, the unstimulated saliva of the participants was collected at least 1 hour after breakfast, between 10:00 and 11:00 in the morning, at 23°C at room temperature with 61.5% humidity for 5 minutes using the spitting method by researcher OCD. Before beginning the saliva collection process, those who felt hungry or thirsty were allowed to drink water and eat, but then they were asked to brush their teeth, and saliva collection started 1 hour later. During sample collection, individuals were allowed to sit in a comfortable position with their head forward and mouth slightly open, and they were asked not to speak. Samples were collected in sterile, dry, preweighed deionized glass test tubes. Analysis of pH was performed using a calibrated benchtop pH meter (Hanna Instruments®, HI 2211, Woonsocket, RI, USA) within half an hour of sample collection to prevent degradation of the saliva. The salivary flow rate was determined by the weight measurement method using sensitive scales (Shimadzu, AW220, Japan). To determine the net saliva amount, the tare weight of the container tube was subtracted from the saliva-filled gross weight and divided by 5, and the flow rate per minute was determined in g/min or l/min considering a salivary density equal to 1 g/cm 3 with an uncertainty of ± 0.001 rpm (Flow rate = gross weight-bare weight/5 min). The obtained data were recorded. The salivary pH and flow rate measurements were made by a blind researcher (SEH) who was unaware of the subjects' groups. The caries experience and periodontal status of the participants were determined by the researcher (FY) who had undergone standardization and calibration training in accordance with the recommendations and criteria of the World Health Organization [ 12 ]. Caries experience was measured by the DMFT index (total number of decayed, missing, and filled teeth). The Community Periodontal Index (CPI) values used to determine periodontal health status were scored between 0 and 4 (0: healthy periodontal conditions; 1: gingival bleeding on probing; 2: calculus and bleeding; 3: periodontal pocket 4–5 mm; and 4: periodontal pocket ≥ 5.5 mm). 2.5. Study size The G*Power package program was used to perform a power analysis to determine the sample size. At the 95% confidence level, 80% power was obtained with at least 128 samples for f = 0.3 effect size (n = 32). In this context, we aimed to reach a minimum of 45 participants for each group. 2.6. Statistical methods The collected data from all groups were imported to the Statistical Package for Social Sciences (SPSS) for Windows software, version 25.0 (IBM, Armonk, NY: IBM Corp.). Standard descriptive methods, such as the mean, standard deviation, median, frequency, minimum and maximum were applied to determine the characteristics of the sample. The data were first evaluated using the Kolmogorov‒Smirnov and Shapiro‒Wilk tests to evaluate distribution normality. The chi-square test was used to compare the categorical demographic variables among the groups. Because the distribution of the data did not meet the requirements for normality and homogeneity of variance, non-parametric Kruskal‒Wallis one-way analysis of variance by ranks and Mann‒Whitney U tests were used for multiple and pairwise comparisons, respectively. Spearman’s correlation coefficient was used to examine the correlation between continuous variables. The confidence interval was set to 95%, and p < 0.05 was considered to indicate statistical significance. 3. Results 3.1. Descriptive data The sociodemographic characteristics, systemic health conditions, eating habits, dental care routines, and oral and dental problems of the participants are shown in Table 1 . A total of 198 participants (51 women in the control group, 47 women in the 1st trimester group, 51 women in the 2nd trimester group, and 49 women in the 3rd trimester group) were included in this study (Fig. 1 ). Table 1 Demographic data of the participants Control 1st trimester 2nd trimester 3rd trimester Total p Age Mean ± S.D. 29.04 ± 6.89 28.87 ± 5.46 28.92 ± 4.12 27.84 ± 5.93 28.67 ± 5.67 0.72 (kw = 1.338) Med (IQR) 29 (22–35) 28 (25–33) 29 (26–31) 29 (23–31.5) 29 (24–33) Min - max 20–42 18–42 20–39 18–44 18–44 Education level Primary school 8 (15.7%) 15 (31.9%) 13 (25.5%) 14 (28.6%) 50 (25.3%) 0.009* (cs = 21.832) High school 7 (13.7%) 11 (23.4%) 14 (27.5%) 19 (38.8%) 51 (25.8%) University 32 (62.7%) 21 (44.7%) 23 (45.1%) 14 (28.6%) 90 (45.5%) MSc-Phd 4 (7.8%) 0 (0%) 1 (2%) 2 (4.1%) 7 (3.5%) Health assurance No 3 (5.9%) 3 (6.4%) 3 (5.9%) 5 (10.2%) 14 (7.1%) 0.821 γ Yes 48 (94.1%) 44 (93.6%) 48 (94.1%) 44 (89.8%) 184 (92.9%) Systemic disease (non-severe) No 38 (74.5%) 33 (70.2%) 40 (78.4%) 42 (85.7%) 153 (77.3%) 0.31 (cs = 3.583) Yes 13 (25.5%) 14 (29.8%) 11 (21.6%) 7 (14.3%) 45 (22.7%) The use of drugs (that do not affect the flow of saliva) No 39 (76.5%) 34 (72.3%) 45 (88.2%) 41 (83.7%) 159 (80.3%) 0.192 (cs = 4.738) Yes 12 (23.5%) 13 (27.7%) 6 (11.8%) 8 (16.3%) 39 (19.7%) Teeth brushing frequency 2 times a day 27 (52.9%) 23 (48.9%) 24 (47.1%) 22 (44.9%) 96 (48.5%) 0.452 (cs = 8.838) 1 times a day 18 (35.3%) 19 (40.4%) 23 (45.1%) 15 (30.6%) 75 (37.9%) Less than 1 per day 5 (9.8%) 4 (8.5%) 4 (7.8%) 11 (22.4%) 24 (12.1%) More than 2 times a day 1 (2%) 1 (2.1%) 0 (0%) 1 (2%) 3 (1.5%) Usage of dental floss/interface brush No 34 (66.7%) 41 (87.2%) 44 (86.3%) 45 (91.8%) 164 (82.8%) 0.004* (cs = 13.229) Yes 17 (33.3%) 6 (12.8%) 7 (13.7%) 4 (8.2%) 34 (17.2%) Usage of mouthwash No 47 (92.2%) 39 (83%) 43 (84.3%) 43 (87.8%) 172 (86.9%) 0.532 (cs = 2.199) Yes 4 (7.8%) 8 (17%) 8 (15.7%) 6 (12.2%) 26 (13.1%) Acidic food with sugar consumed daily 1 times a day or less than 36 (70.6%) 38 (80.9%) 36 (70.6%) 34 (69.4%) 144 72.7(%) 0.237 (cs = 8.009) 3 times a day 11 (21.6%) 6 (12.8%) 9 (17.6%) 5 (10.2%) 31 (15.7%) More than 3 times a day 4 (7.8%) 3 (6.4%) 6 (11.8%) 10 (20.4%) 23 (11.6%) Indispensable food or beverage No 35 (68.6%) 32 (68.1%) 34 (66.7%) 34 (69.4%) 135 (68.2%) 0.993 (cs = 0.092) Yes 16 (31.4%) 15 (31.9%) 17 (33.3%) 15 (30.6%) 63 (31.8%) Feeling of dry mouth No 31 (60.8%) 25 (53.2%) 37 (72.5%) 27 (55.1%) 120 (60.6%) 0.191 (cs = 4.751) Yes 20 (39.2%) 22 (46.8%) 14 (27.5%) 22 (44.9%) 78 (39.4%) *p < 0.05 indicates statistical significance; S.D: standard deviation; Med (IQR): median (25th–75th percentiles); min–max: minimum–maximum values; kw: Kruskal‒Wallis variance analysis; cs: chi-square test; γ: Fisher’s exact test. 3.2. Main outcomes The statistical comparisons of the DMFT index, CPI, unsitumulated salivary pH and flow rate between the study and control groups are shown in Table 2 . Furthermore, the CPIs of the pregnant women (mean ± SD = 1.73 ± 0.89, median (IQR) = 2 (1–2.5), minimum–maximum = 0 − 4) were significantly greater than those of the non-pregnant women (mean ± SD = 1.41 ± 0.92, median (IQR) = 1.5 (0.75–2), minimum–maximum = 0–3) (p = 0.027, z = − 2.215, statistically significant, Mann-Whitney U test). Table 2 Statistical comparison of the DMFT index, CPI, and salivary data among groups Control 1st trimester 2nd trimester 3rd trimester p DMFT Index Mean ± S.D. 4.25 ± 3.46 4.17 ± 3.6 5.1 ± 4.8 4.14 ± 2.87 0.871 (kw = 0.711) Med (IQR) 3 (2–7) 3 (2–6) 4 (2–6) 4 (2–5.5) min - max 0–14 0–19 0–23 0–13 CPI Scores Mean ± S.D. 1.41 ± 0.92 1.69 ± 0.9 1.7 ± 0.92 1.81 ± 0.85 0.169 (kw = 5.042) Med (IQR) 1.5 (0.75–2) 2 (1.25–2.5) 1.75 (1–2.5) 2 (1–2.5) min - max 0–3 0–3 0–3 0–4 Salivary pH Mean ± S.D. 7.06 ± 0.35 a 6.77 ± 0.44 b 6.43 ± 0.76 b 6.52 ± 0.51 b 0.0001* (kw = 43.170) Med (IQR) 7.08 (6.88–7.31) 6.81 (6.61–7.12) 6.66 (6.08–6.95) 6.62 (6.23–6.79) min - max 6.11–7.62 5.71–7.52 4.02–7.5 5.2–7.68 Salivary Flow Rate Mean ± S.D. 0.64 ± 0.4 0.73 ± 0.41 0.73 ± 0.45 0.56 ± 0.29 0.094 (kw = 6.403) Med (IQR) 0.49 (0.32–0.93) 0.62 (0.45–0.94) 0.61 (0.42–0.96) 0.47 (0.35–0.74) min - max 0.08–1.64 0.08–1.59 0.15–2.96 0.11–1.62 *The difference between the data shown with different superscripts is statistically significant (p < 0.05); Kruskal‒Wallis test; S.D: standard deviation; Med (IQR): median (25th–75th percentiles); min–max: minimum–maximum values. 3.3. Relationships between the salivary flow rate, pH, DMFT index and CPI among the groups The correlations between the saliva flow rate and pH are shown in Fig. 2 . Statistically significant positive relationships were found between the control and 2nd trimester groups (r = 0.473, p = 0.001; r = 0.324, p = 0.02, respectively, Spearman correlation test). On the other hand, there was no relationship between the saliva flow rate and pH in the 1st trimester or 3rd trimester (r = 0.211, p > 0.160; r = 0.180, p > 0.215, respectively). Significant negative correlations were found between salivary pH and the DMFT index in the 1st trimester and 2nd trimester groups (r = -0.384, p = 0.008; r = -0.284, p = 0.043, respectively; Spearman correlation test). There was no correlation between salivary pH and the DMFT index in the 3rd trimester. In addition, no difference in the salivary flow rate, pH, DMFT index or CPI was detected among the other groups (p > 0.05). 4. Discussion Unstimulated saliva is one of the most important indicators of oral health since it reflects the function of the salivary glands at rest. When it is not stimulated, it is secreted intermittently throughout the day and reflects the physiological state of the oral cavity and the whole body [ 13 , 15 – 17 ]. Therefore, in this study, unstimulated saliva was used to examine salivary changes. However, various studies have examined both stimulated and unstimulated saliva in the literature [ 13 , 14 ]. Kullander and Soneson [ 18 ] and Migliario et al. [ 19 ] reported that salivary pH decreased during pregnancy. Rockenbach et al. [ 20 ] reported that the pH of unstimulated saliva during pregnancy was 6.7, while it was 7.5 in non-pregnant women. Similarly, in this study, the pH of unstimulated saliva was 7.08 for the control group and 6.81, 6.66, and 6.62 for the 1st, 2nd, and 3rd trimester groups, respectively. This situation can be explained as follows. During gastroesophageal reflux, which is commonly observed in pregnancy, there is a decrease in salivary pH due to the relationship between pH and the volume of saliva and the esophagus [ 21 , 22 ]. Some investigators have reported lower salivary pH as a result of the effect of progesterone on plasma bicarbonate levels during pregnancy [ 14 ]. Increased frequency of eating, differences in oral hygiene habits, and taste changes may also be reasons for lower salivary pH during pregnancy [ 23 – 25 ]. It was also reported that the decrease in pH was directly related to the saliva collection method [ 13 ]. Differences in pH were not significant in stimulated saliva in the third trimester compared to the first, whereas a significant association and decreased heterogeneity were reported in unstimulated saliva in all trimesters compared to the control [ 13 ]. Similarly, in this study, the unstimulated salivary pH values of all study groups were lower than those of the control group, but statistical similarity was found between the study groups. When changes in the salivary flow rate during pregnancy are evaluated in studies, different results emerge. While some researchers have reported a decrease in the salivary flow rate during pregnancy [ 17 , 26 ], others have reported an increase [ 14 ]. In this study, it was determined that there was no significant difference between the salivary flow rates of pregnant and non-pregnant women. Similarly, another study reported no statistically significant difference in salivary phosphate, pH, buffering capacity, flow rate, or DMFT index among all trimesters compared with the control and concluded that the stimulated salivary flow rate increased in the third trimester of pregnancy [ 13 ]. This result is inconsistent with the results of other studies [ 9 , 27 – 29 ]. These differences can be explained by the small sample sizes, the assessment of parotid gland salivary secretion, and the variation in salivary content among normal individuals. In addition, it has been reported that there may be an increase in the stimulated salivary flow rate due to the presence of estrogen receptor-beta in the oral epithelium and salivary glands of individuals receiving hormone therapy [ 30 , 31 ] or the effect of estrogen [ 13 ]. In this study, however, since the unstimulated salivary flow rate was evaluated, there may not have been a similar estrogen effect; therefore, the salivary flow rate between the groups may have been similar. The salivary flow rate has a regulating effect on the pH of saliva [ 17 , 22 ]. Veenendaal et al. [ 32 ] reported that sialorrhea or pregnancy ptyalism is a recurrent symptom in pregnant women. This can be attributed to the increase in the salivary flow rate to suppress this acidic environment due to the body’s defense system and decreasing intraoral pH due to severe nausea and vomiting. This condition is called “hyperemesis gravidarum” and is observed predominantly in female fetuses, fetuses with lower birth weights, and fetuses with shorter gestational ages at birth. Although an increase in the probability of being affected by caries during pregnancy seems to be generally accepted, some conflicting results have been reported in the literature [ 13 ]. According to Quock [ 33 ], changes in the structure and quality of saliva, pH, flow rate, and time play important roles in caries formation [ 17 ], and the greatest changes occur in the 3rd trimester of pregnancy [ 33 ]. In fact, since the experience of caries is a long-term and multifactorial etiological condition, it cannot be said that the amount of caries affecting individuals increases only according to their pregnancy period. To arrive at a more precise conclusion, further studies with more comprehensive and larger sample sizes are needed. In this study, there was no statistically significant difference between the DMFT values of the study and control groups. Past studies have also reported that no significant change in the DMFT index is expected during pregnancy [ 33 ]. In this study, there was no statistically significant difference in the DMFT index between the control group and pregnant women at different gestational ages. For this reason, this study evaluated the relationships between salivary pH, salivary flow rate, and DMFT. There was a significant negative association between pH and the DMFT index for the 1st and 2nd trimester groups. The decrease in salivary pH from the 1st trimester to the 2nd trimester can be explained by the increase in caries exposure and DMFT. Although individuals in the 3rd trimester in this study had the lowest pH values, the lack of a relationship between pH and DMFT in the 3rd trimester group may have been due to the predominance of other caries-causing factors in this group. Therefore, the decrease in pH during caries formation should not be ignored. Similarly, Kamate et al. [ 3 ] reported that the decrease in saliva pH continued in the postpartum period, and these changes were reflected in the increase in the DMFT index. When the effect of the salivary flow rate on DMFT was evaluated in past studies, no relationship was found between the two parameters [ 13 ]. Birkhed and Heintze [ 34 ] and Russell et al. [ 35 ] suggested that there was no linear relationship between the salivary flow rate, DMFT/DMFS index, and dental caries activity. Mandel [ 36 ] and Russell et al. [ 35 ] reported that there was only a weak or no correlation between the saliva secretion rate and caries incidence. Similarly, no relationship was found between the flow rate and DMFT in this study. Female sex hormones (estrogen, progesterone, and human gonadotropin) secreted mainly by the placenta are responsible for physiological changes during pregnancy, such as changes in saliva flow, composition, pH, and hormone levels. During pregnancy, conditions such as gingival bleeding, increased gingival infection, and periodontal pocket formation, known as pregnancy gingivitis, may occur without specific plaque accumulation [ 37 ]. Although it is thought that this condition is due to hormonal changes, its etiology is still unclear [ 37 ]. Gestational gingivitis usually begins to appear in the 1st trimester of pregnancy [ 38 ]. In the literature, an increase in the CPI score has been reported, reflecting the worsening of the periodontal condition with the progression of pregnancy [ 38 – 40 ]. In this study, a numerical increase was observed in CPI scores from the 1st to the 3rd trimester, similar to prior studies. At the same time, the CPI scores of pregnant women were found to be significantly greater than those of non-pregnant women. In this study, changes in the salivary flow rate and pH were evaluated as the causes of dental caries and periodontal diseases encountered during pregnancy. However, these two diseases are the most common oral diseases worldwide and are multifactorial. Changes in environmental factors such as sociodemographic characteristics, physiological individual factors, and general systemic health make individuals prone to oral diseases. Although pregnancy alone is not effective, it is among the etiological factors that causes oral and dental diseases. Observational studies with a larger number of participants need to be conducted, taking into account factors other than salivary variables that may be effective in treating oral and dental diseases during pregnancy. 5. Conclusion In this study, a significant decrease in the salivary pH of pregnant women was detected, while no significant difference in the salivary flow rate was detected between the control and study groups. The periodontal health of pregnant women was worse than that of non-pregnant women. During pregnancy, factors such as changing oral hygiene habits, eating habits, hormonal status, and salivary characteristics directly or indirectly affect oral and dental health. It is important to determine the cause of oral and dental health problems, which are more common in this period, in terms of establishing prevention and treatment protocols suitable for etiological factors. The data obtained from this study are important in terms of the formation of healthy individuals with healthy mothers and their babies. Abbreviations DMFT Total number of decayed, missing, and filled teeth CPI Community Periodontal Index Declarations Human Ethics and Consent to Participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was received for this research from the Ethics Committee of Health Sciences of Mugla Sitki Kocman University (Report no: 2021/21-VII). Written informed consent was obtained from the participants before they participated. Consent for publication Not applicable. Availability of data and materials Not applicable. Competing interests The authors declare no competing interests. Funding Not applicable. Authors' contributions FY: Conceptualization (equal); data curation (equal); formal analysis (lead); investigation (equal); visualization (equal); writing – original draft preparation (lead). OCD: Conceptualization (equal); data curation (equal); investigation (equal); visualization (equal); writing – original draft preparation (supporting). SEH: Conceptualization (equal); data curation (equal); investigation (equal); visualization (equal); writing – review and editing. BK: Conceptualization (equal); methodology (supporting); resources (equal); validation (equal); AD: Conceptualization (equal); methodology (lead); resources (equal); supervision (lead); validation (equal). All authors have read and approved the final manuscript. Acknowledgements The authors thank all participants for their cooperation. References Silness J, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand. 1964;22:121-35. Kateeb E, Momany E. Dental caries experience and associated risk indicators among Palestinian pregnant women in the Jerusalem area: a cross-sectional study. BMC Oral Health. 2018;18:1-8. Kamate WI, Vibhute NA, Baad RK. Estimation of DMFT, salivary streptococcus mutans count, flow rate, pH, and salivary total calcium content in pregnant and non-pregnant women: a prospective study. J Clin Diagnostic Res. 2017;11:ZC147. Bahri Binabaj N, Bahri Binabaj N, Iliati HR, Salarvand S, Mansoorian MR. Assessment of DMFT index in pregnant women and its relationship with knowledge, attitude and health behaviors in terms of oral and dental cares (Mashhad-2009). Iran J Obstet Gynecol Infertil . 2012;15:15-21. [In Arabic, English abstract] Srinivas SK, Parry S. Periodontal disease and pregnancy outcomes: time to move on? J Womens Health 2012;21:121-5. Wu M, Chen SW, Jiang SY. Relationship between gingival inflammation and pregnancy. Mediators Inflamm. 2015;2015. Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60:257-64. Selwitz RH, Ismail AI, Pitts NB. Dental caries. The Lancet . 2007;369:51-9. Rio R, Azevedo Á, Simões Silva L, Marinho J, Silva MJ, Sampaio Maia B. The biochemistry of saliva throughout pregnancy. Med Express 2015;2:M150506. Laine M, Tenovuo J, Lehtonen O-P, Ojanotko Harri A, Vilja P, Tuohimaa P. Pregnancy- related changes in human whole saliva. Arch Oral Biol. 1988;33: 913-7. Laine M, PienihaÈkkinen K. Salivary buffer effect in relation to late pregnancy and postpartum. Acta Odontol Scand . 2000;58:8-10. Organization WH. Oral Health Surveys. In: Basic methods. Geneva: WHO, 1997: 10-51. Yousefi M, Parvaie P, Riahi SM. Salivary factors related to caries in pregnancy: a systematic review and meta-analysis. J Am Dent Assoc 2020;151:576-88. Naveen S, Asha M, Shubha G, Bajoria A, Jose A. Salivary Flow rate, pH and buffering capacity in pregnant and non pregnant women-A comparative study. JMED Res 2014;2014:1- 7. Edgar W, Dawes C, O'Mullane D. Saliva and oral health. 4th ed. Suffolk: Stephen Hancocks Limited; 2012. Salvolini E, Di Giorgio R, Curatola A, Mazzanti L, Fratto G. Biochemical modifications of human whole saliva induced by pregnancy. BJOG: Int J Obstet Gynecol. 1998;105:656-60. Karnik AA, Pagare SS, Krishnamurthy V, Vahanwala SP, Waghmare M. Determination of salivary flow rate, pH, and dental caries during pregnancy: A study. J Indian Acad Oral Med Radiol 2015;27:372. Kullander S, Sonesson B. Studies on saliva in menstruating, pregnant and post- menopausal women. Eur J Endocrinol. 1965;48:329-36. Migliario M, Bindi M, Surico D, et al. Changes in salivary flow rate and pH in pregnancy. Eur Rev Med Pharmacol Sci 2021;25:1804-10. Rockenbach MI, Marinho SA, Veeck EB, Lindemann L, Shinkai RS. Salivary flow rate, pH, and concentrations of calcium, phosphate, and sIgA in Brazilian pregnant and non-pregnant women. Head Face Med . 2006;2:1-5. Body C, Christie JA. Gastrointestinal diseases in pregnancy: nausea, vomiting, hyperemesis gravidarum, gastroesophageal reflux disease, constipation, and diarrhea. Gastroenterol Clin. 2016;45:267-83. Caruso AA, Del Prete S, Ferrara L, et al. Relationship between gastroesophageal reflux disease and pH nose and salivary: proposal of a simple method outpatient in patients adults. Open Med . 2016;11:381-6. Sonbul H, Ashi H, Aljahdali E, Campus G, Lingström P. The influence of pregnancy on sweet taste perception and plaque acidogenicity. Matern Child Health J . 2017;21:1037-1046. Dolić O, Obradović M, Kojić Ž, Sukara S. Caries risk assessment in pregnant women using cariogram. Srp Arh Celok Lek . 2017;145:178-83. Ozturk L, Akyüz S, Garan A, Yarat A. Salivary and dental-oral hygiene parameters in 3rd trimester of pregnancy and early lactation: The effect of education. Marmara Dent J . 2013;1:1-8. González M, Montes de Oca L, Jiménez G. Changes in saliva composition of pregnant and non-pregnant patients. Perinatol Reprod Hum 2001;15:195-201. D'Alessandro S, Curbelo H, Tumilasci O, Tessler J, Houssay A. Changes in human parotid salivary protein and sialic acid levels during pregnancy. Arch Oral Biol. 1989;34:829-31. Kivelä J, Laine M, Parkkila S, Rajaniemi H. Salivary carbonic anhydrase VI and its relation to salivary flow rate and buffer capacity in pregnant and non-pregnant women. Arch Oral Biol. 2003;48:547-51. Saluja P, Shetty V, Dave A, Arora M, Hans V, Madan A. Comparative evaluation of the effect of menstruation, pregnancy and menopause on salivary flow rate, pH and gustatory function. J Clin Diagnos Res . 2014;8:ZC81. Eliasson L, Carlén A, Laine M, Birkhed D. Minor gland and whole saliva in postmenopausal women using a low potency oestrogen (oestriol). Arch Oral Biol . 2003;48:511-7. Valimaa H, Savolainen S, Soukka T, et al. Estrogen receptor-beta is the predominant estrogen receptor subtype in human oral epithelium and salivary glands. J Endocrinol 2004;180:55-62. Veenendaal MV, van Abeelen AF, Painter RC, van der Post JA, Roseboom TJ. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta‐analysis. BJOG: Int J Obst Gynecol . 2011;118:1302-13. Quock RL. Dental caries: a current understanding and implications. J Nat Sci. 2015;1:27. Birkhed D, Heintze U. Salivary secretion rate, buffer capacity, and pH. In: Tenovuo JO, editor. Human saliva: clinical chemistry and microbiology. Florida: CRC press; 2021. p:25-74. Russell JI, MacFarlane TW, Aitchison TC, Stephen KW, Burchell CK. Caries prevalence and microbiological and salivary caries activity tests in Scottish adolescents. Community Dent Oral Epidemiol . 1990;18:120-5. Mandel ID. The role of saliva in maintaining oral homeostasis. J Am Dent Assoc. 1989;119:298-304. Löe H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. Acta Odontol Scand .1963;21:533-51. Vogt M, Sallum AW, Cecatti JG, Morais SS. Factors associated with the prevalence of periodontal disease in low-risk pregnant women. Reprod Health. 2012;9:1-8. Carrillo‐de‐Albornoz A, Figuero E, Herrera D, Bascones‐Martínez A. Gingival changes during pregnancy: II. Influence of hormonal variations on the subgingival biofilm. J Clin Periodontol. 2010;37:230-40. Tilakaratne A, Soory M, Ranasinghe A, Corea S, Ekanayake S, De Silva M. Periodontal disease status during pregnancy and 3 months post‐partum, in a rural population of Sri‐Lankan women. J Clin Periodontol. 2000;27:787-92. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Oct, 2024 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 31 Jul, 2024 Editor assigned by journal 30 Jul, 2024 Submission checks completed at journal 30 Jul, 2024 First submitted to journal 12 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4730123","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":334206478,"identity":"0c7b95ef-0ee8-4095-83da-2ecc5992d1c9","order_by":0,"name":"Fatma Yilmaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBAC9gYwJSEDJBgfgNkHCGjhOcAM1sIDJJgNoFoYG4jQwgDSwiZBnBb280c3/Gyz4NFtP/6s6mYbgxzfjQT2xxX4tPAks93sbZPgMTuTkHY7t43BWPJGAmPjGTxa7BmS2W7wgrQcSDgG0pK4AaQFn8t4+B+z3fwL0nL+YVsxUEs9YS0SyWy3wbbcSGZjBmpJMCCs5bHZbZlzIC3PmKVzzkkYzjzzsHEmfoclPrv5pqxOzux8+sPPOWU28nzHkw98xKcFDBjZ4ExQ1OCPFij4Q4SaUTAKRsEoGLkAALUzTujxGiqsAAAAAElFTkSuQmCC","orcid":"","institution":"Mugla Sitki Kocman University","correspondingAuthor":true,"prefix":"","firstName":"Fatma","middleName":"","lastName":"Yilmaz","suffix":""},{"id":334206481,"identity":"ee52c1e1-4286-4a25-a4f0-aed77c5f8900","order_by":1,"name":"Ozgul Carti Dorterler","email":"","orcid":"","institution":"Mugla Sitki Kocman University","correspondingAuthor":false,"prefix":"","firstName":"Ozgul","middleName":"Carti","lastName":"Dorterler","suffix":""},{"id":334206485,"identity":"df445b7d-576b-4932-9b6e-779d2cd5f31f","order_by":2,"name":"Saniye Eren Halici","email":"","orcid":"","institution":"Mugla Sitki Kocman University","correspondingAuthor":false,"prefix":"","firstName":"Saniye","middleName":"Eren","lastName":"Halici","suffix":""},{"id":334206490,"identity":"2bcf41a3-a5fe-4cef-a74e-cb40ba3f3927","order_by":3,"name":"Burcu Kasap","email":"","orcid":"","institution":"Mugla Sitki Kocman University","correspondingAuthor":false,"prefix":"","firstName":"Burcu","middleName":"","lastName":"Kasap","suffix":""},{"id":334206491,"identity":"071c0005-cd69-415f-9db6-ba8dc709748b","order_by":4,"name":"Aysegul Demirbas","email":"","orcid":"","institution":"Ege University","correspondingAuthor":false,"prefix":"","firstName":"Aysegul","middleName":"","lastName":"Demirbas","suffix":""}],"badges":[],"createdAt":"2024-07-12 12:03:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4730123/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4730123/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-024-05057-0","type":"published","date":"2024-10-25T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63067130,"identity":"98f38b05-8532-47be-b152-dedc491fdf4d","added_by":"auto","created_at":"2024-08-22 18:09:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69457,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4730123/v1/9a6240cb22150820801e8c7c.jpg"},{"id":63067129,"identity":"9fdc8ce0-f384-4324-852b-43831914f655","added_by":"auto","created_at":"2024-08-22 18:09:29","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":778255,"visible":true,"origin":"","legend":"\u003cp\u003eUnsitumulated salivary pH and flow rate correlation curves of all groups (Spearman correlation test).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4730123/v1/d0c60e3c5e5a659f3e610ae3.jpg"},{"id":67681966,"identity":"814cf0bb-48c1-4b05-9bb8-0200a37f071e","added_by":"auto","created_at":"2024-10-28 16:11:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1502187,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4730123/v1/cd86a666-7cd5-4983-9fcf-03f1ada80179.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effects of pregnancy on oral health, salivary ph and flow rate","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe basic physiological changes that occur during pregnancy affect the oral health of women as well as their general health [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although physiological and hormonal changes increase susceptibility to periodontal diseases and dental caries, which are among the most common health problems in society, the results obtained from studies on this subject are controversial [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The frequent presence of these diseases during pregnancy may be due to many factors, such as the accumulation of dental plaque, differences in microbial composition, changes in the amount of saliva, and decreases in pH [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Increases in the levels of steroid hormones, especially during pregnancy, decrease the resistance of the gingiva to periodontal pathogens and increase gingival vascularity and blood flow, causing pregnancy gingivitis [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDental caries is a multifactorial infectious disease characterized by mineral loss in dental hard tissues [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In pregnancy, calcium loss occurs in the hard tissues of the teeth, similar to the bones, through the pulpal route, and the concentration of calcium and phosphate in the saliva also decreases [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This change increases demineralization and decreases remineralization in dental tissues [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany environmental factors, such as nutrition, oral hygiene habits, socioeconomic status, educational status, and the amount and quality of saliva, play roles in the development of caries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One reason why dental caries are more common during pregnancy is changes in the amount and content of saliva. Although some studies have shown that the salivary glands are affected by pregnancy, as in other exocrine glands, others have reported that the amount of saliva and its flow rate do not change significantly during this period [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the literature, there are many controversial results regarding whether the amount and quality of saliva change during pregnancy, how they change during different trimesters of pregnancy, and how these changes affect tooth and periodontal diseases. For this reason, this study aimed to evaluate the salivary pH, flow rate, caries incidence, and periodontal status of pregnant and non-pregnant women in different trimesters.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design\u003c/h2\u003e \u003cp\u003eThe experimental design of this cross sectional study was in accordance with the consolidated standards of reporting trials (CONSORT) statement. The study was retrospectively registered at ClinicalTrials.gov (NCT06343337).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Human Ethics and Consent to Participate\u003c/h2\u003e \u003cp\u003e This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was received for this research from the Ethics Committee of Health Sciences of Mugla Sitki Kocman University (Report no: 2021/21-VII). Written informed consent was obtained from the participants involved in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Participants\u003c/h2\u003e \u003cp\u003eVolunteer pregnant women in different trimesters (for study groups) and non-pregnant women (for control group) (18\u0026ndash;35 years) who were treated at the Obstetrics and Gynecology Outpatient Clinic of the Faculty of Medicine of Mugla Sitki Kocman University were included in this study. Patients with even-numbered registration numbers were preferred for randomization. After the patients were briefly informed about the study face to face and verbally, those who agreed to participate were included. Individuals with severe systemic disease, those who used drugs that directly affect the salivary flow rate (e.g., antihypertensive, diuretic, psychotherapeutic, and antiarthritic medications), and those who used cigarettes or alcohol were excluded from the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data sources/measurement\u003c/h2\u003e \u003cp\u003eNew oral health questionnaire and assessment forms were developed based on the WHO\u0026rsquo;s reports [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] for this study. Questions were asked about participants\u0026rsquo; sociodemographic characteristics, systemic health conditions, eating habits, dental care routines, and oral and dental problems, and the data were recorded. Interviews with the participants and intraoral examinations were conducted by researchers OCD and FY, respectively. Additionally, the gestational weeks of pregnant women were queried, and they were assigned to study groups (1st trimester: 1\u0026ndash;12 weeks, 2nd trimester: 13\u0026ndash;26 weeks, 3rd trimester: 27th week to birth), while non-pregnant women were assigned to the control group. The recruitment of participants continued until the desired number was reached. To evaluate the salivary flow rate and pH, the unstimulated saliva of the participants was collected at least 1 hour after breakfast, between 10:00 and 11:00 in the morning, at 23\u0026deg;C at room temperature with 61.5% humidity for 5 minutes using the spitting method by researcher OCD. Before beginning the saliva collection process, those who felt hungry or thirsty were allowed to drink water and eat, but then they were asked to brush their teeth, and saliva collection started 1 hour later. During sample collection, individuals were allowed to sit in a comfortable position with their head forward and mouth slightly open, and they were asked not to speak. Samples were collected in sterile, dry, preweighed deionized glass test tubes. Analysis of pH was performed using a calibrated benchtop pH meter (Hanna Instruments\u0026reg;, HI 2211, Woonsocket, RI, USA) within half an hour of sample collection to prevent degradation of the saliva. The salivary flow rate was determined by the weight measurement method using sensitive scales (Shimadzu, AW220, Japan). To determine the net saliva amount, the tare weight of the container tube was subtracted from the saliva-filled gross weight and divided by 5, and the flow rate per minute was determined in g/min or l/min considering a salivary density equal to 1 g/cm\u003csup\u003e3\u003c/sup\u003e with an uncertainty of \u0026plusmn;\u0026thinsp;0.001 rpm (Flow rate\u0026thinsp;=\u0026thinsp;gross weight-bare weight/5 min). The obtained data were recorded. The salivary pH and flow rate measurements were made by a blind researcher (SEH) who was unaware of the subjects' groups.\u003c/p\u003e \u003cp\u003eThe caries experience and periodontal status of the participants were determined by the researcher (FY) who had undergone standardization and calibration training in accordance with the recommendations and criteria of the World Health Organization [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Caries experience was measured by the DMFT index (total number of decayed, missing, and filled teeth). The Community Periodontal Index (CPI) values used to determine periodontal health status were scored between 0 and 4 (0: healthy periodontal conditions; 1: gingival bleeding on probing; 2: calculus and bleeding; 3: periodontal pocket 4\u0026ndash;5 mm; and 4: periodontal pocket\u0026thinsp;\u0026ge;\u0026thinsp;5.5 mm).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Study size\u003c/h2\u003e \u003cp\u003eThe G*Power package program was used to perform a power analysis to determine the sample size. At the 95% confidence level, 80% power was obtained with at least 128 samples for f\u0026thinsp;=\u0026thinsp;0.3 effect size (n\u0026thinsp;=\u0026thinsp;32). In this context, we aimed to reach a minimum of 45 participants for each group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical methods\u003c/h2\u003e \u003cp\u003eThe collected data from all groups were imported to the Statistical Package for Social Sciences (SPSS) for Windows software, version 25.0 (IBM, Armonk, NY: IBM Corp.). Standard descriptive methods, such as the mean, standard deviation, median, frequency, minimum and maximum were applied to determine the characteristics of the sample. The data were first evaluated using the Kolmogorov‒Smirnov and Shapiro‒Wilk tests to evaluate distribution normality. The chi-square test was used to compare the categorical demographic variables among the groups. Because the distribution of the data did not meet the requirements for normality and homogeneity of variance, non-parametric Kruskal‒Wallis one-way analysis of variance by ranks and Mann‒Whitney U tests were used for multiple and pairwise comparisons, respectively. Spearman\u0026rsquo;s correlation coefficient was used to examine the correlation between continuous variables. The confidence interval was set to 95%, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Descriptive data\u003c/h2\u003e \u003cp\u003eThe sociodemographic characteristics, systemic health conditions, eating habits, dental care routines, and oral and dental problems of the participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 198 participants (51 women in the control group, 47 women in the 1st trimester group, 51 women in the 2nd trimester group, and 49 women in the 3rd trimester group) were included in this study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic data of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1st trimester\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2nd trimester\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3rd trimester\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.04\u0026thinsp;\u0026plusmn;\u0026thinsp;6.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.92\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.84\u0026thinsp;\u0026plusmn;\u0026thinsp;5.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.67\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.72 (kw\u0026thinsp;=\u0026thinsp;1.338)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMed (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (22\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (25\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (26\u0026ndash;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29 (23\u0026ndash;31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29 (24\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMin - max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026ndash;42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u0026ndash;42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (31.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.009* (cs\u0026thinsp;=\u0026thinsp;21.832)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (13.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (23.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (27.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 (38.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51 (25.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (62.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (44.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMSc-Phd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth assurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.821 γ\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (93.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44 (89.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e184 (92.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSystemic disease (non-severe)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (74.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (70.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40 (78.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e153 (77.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.31 (cs\u0026thinsp;=\u0026thinsp;3.583)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (25.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (29.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eThe use of drugs (that do not affect the flow of saliva)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (76.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (72.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45 (88.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41 (83.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e159 (80.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.192 (cs\u0026thinsp;=\u0026thinsp;4.738)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (16.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39 (19.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eTeeth brushing frequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 times a day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (48.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 (44.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e96 (48.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.452 (cs\u0026thinsp;=\u0026thinsp;8.838)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 times a day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (40.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23 (45.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than 1 per day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (22.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 (12.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 2 times a day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUsage of dental floss/interface brush\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (87.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44 (86.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45 (91.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e164 (82.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.004* (cs\u0026thinsp;=\u0026thinsp;13.229)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (13.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (8.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34 (17.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUsage of mouthwash\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (92.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43 (84.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43 (87.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e172 (86.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.532 (cs\u0026thinsp;=\u0026thinsp;2.199)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26 (13.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAcidic food with sugar consumed daily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 times a day or less than\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (80.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34 (69.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e144 72.7(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.237 (cs\u0026thinsp;=\u0026thinsp;8.009)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 times a day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31 (15.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 3 times a day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23 (11.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndispensable food or beverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (68.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (68.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34 (69.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e135 (68.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.993 (cs\u0026thinsp;=\u0026thinsp;0.092)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (31.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (31.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63 (31.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFeeling of dry mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (60.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (53.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37 (72.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27 (55.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e120 (60.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.191 (cs\u0026thinsp;=\u0026thinsp;4.751)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (39.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (46.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (27.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 (44.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78 (39.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical significance; S.D: standard deviation; Med (IQR): median (25th\u0026ndash;75th percentiles); min\u0026ndash;max: minimum\u0026ndash;maximum values; kw: Kruskal‒Wallis variance analysis; cs: chi-square test; γ: Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Main outcomes\u003c/h2\u003e \u003cp\u003eThe statistical comparisons of the DMFT index, CPI, unsitumulated salivary pH and flow rate between the study and control groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Furthermore, the CPIs of the pregnant women (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;1.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89, median (IQR)\u0026thinsp;=\u0026thinsp;2 (1\u0026ndash;2.5), minimum\u0026ndash;maximum\u0026thinsp;=\u0026thinsp;0\u0026thinsp;\u0026minus;\u0026thinsp;4) were significantly greater than those of the non-pregnant women (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u0026thinsp;=\u0026thinsp;1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92, median (IQR)\u0026thinsp;=\u0026thinsp;1.5 (0.75\u0026ndash;2), minimum\u0026ndash;maximum\u0026thinsp;=\u0026thinsp;0\u0026ndash;3) (p\u0026thinsp;=\u0026thinsp;0.027, z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.215, statistically significant, Mann-Whitney U test).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStatistical comparison of the DMFT index, CPI, and salivary data among groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1st trimester\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2nd trimester\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3rd trimester\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eDMFT Index\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003cp\u003e(kw\u0026thinsp;=\u0026thinsp;0.711)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMed (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (2\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (2\u0026ndash;5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emin - max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u0026ndash;23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026ndash;13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCPI Scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.169\u003c/p\u003e \u003cp\u003e(kw\u0026thinsp;=\u0026thinsp;5.042)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMed (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5 (0.75\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.25\u0026ndash;2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.75 (1\u0026ndash;2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (1\u0026ndash;2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emin - max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSalivary pH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.0001*\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(kw\u0026thinsp;=\u0026thinsp;43.170)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMed (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.08 (6.88\u0026ndash;7.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.81 (6.61\u0026ndash;7.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.66 (6.08\u0026ndash;6.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.62 (6.23\u0026ndash;6.79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emin - max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.11\u0026ndash;7.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.71\u0026ndash;7.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.02\u0026ndash;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.2\u0026ndash;7.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSalivary Flow Rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;S.D.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003cp\u003e(kw\u0026thinsp;=\u0026thinsp;6.403)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMed (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49 (0.32\u0026ndash;0.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62 (0.45\u0026ndash;0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61 (0.42\u0026ndash;0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.47 (0.35\u0026ndash;0.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emin - max\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u0026ndash;1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u0026ndash;1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u0026ndash;2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.11\u0026ndash;1.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e*The difference between the data shown with different superscripts is statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); Kruskal‒Wallis test; S.D: standard deviation; Med (IQR): median (25th\u0026ndash;75th percentiles); min\u0026ndash;max: minimum\u0026ndash;maximum values.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Relationships between the salivary flow rate, pH, DMFT index and CPI among the groups\u003c/h2\u003e \u003cp\u003eThe correlations between the saliva flow rate and pH are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Statistically significant positive relationships were found between the control and 2nd trimester groups (r\u0026thinsp;=\u0026thinsp;0.473, p\u0026thinsp;=\u0026thinsp;0.001; r\u0026thinsp;=\u0026thinsp;0.324, p\u0026thinsp;=\u0026thinsp;0.02, respectively, Spearman correlation test). On the other hand, there was no relationship between the saliva flow rate and pH in the 1st trimester or 3rd trimester (r\u0026thinsp;=\u0026thinsp;0.211, p\u0026thinsp;\u0026gt;\u0026thinsp;0.160; r\u0026thinsp;=\u0026thinsp;0.180, p\u0026thinsp;\u0026gt;\u0026thinsp;0.215, respectively).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSignificant negative correlations were found between salivary pH and the DMFT index in the 1st trimester and 2nd trimester groups (r = -0.384, p\u0026thinsp;=\u0026thinsp;0.008; r = -0.284, p\u0026thinsp;=\u0026thinsp;0.043, respectively; Spearman correlation test). There was no correlation between salivary pH and the DMFT index in the 3rd trimester.\u003c/p\u003e \u003cp\u003eIn addition, no difference in the salivary flow rate, pH, DMFT index or CPI was detected among the other groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e Unstimulated saliva is one of the most important indicators of oral health since it reflects the function of the salivary glands at rest. When it is not stimulated, it is secreted intermittently throughout the day and reflects the physiological state of the oral cavity and the whole body [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, in this study, unstimulated saliva was used to examine salivary changes. However, various studies have examined both stimulated and unstimulated saliva in the literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Kullander and Soneson [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Migliario et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported that salivary pH decreased during pregnancy. Rockenbach et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] reported that the pH of unstimulated saliva during pregnancy was 6.7, while it was 7.5 in non-pregnant women. Similarly, in this study, the pH of unstimulated saliva was 7.08 for the control group and 6.81, 6.66, and 6.62 for the 1st, 2nd, and 3rd trimester groups, respectively. This situation can be explained as follows. During gastroesophageal reflux, which is commonly observed in pregnancy, there is a decrease in salivary pH due to the relationship between pH and the volume of saliva and the esophagus [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Some investigators have reported lower salivary pH as a result of the effect of progesterone on plasma bicarbonate levels during pregnancy [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Increased frequency of eating, differences in oral hygiene habits, and taste changes may also be reasons for lower salivary pH during pregnancy [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It was also reported that the decrease in pH was directly related to the saliva collection method [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Differences in pH were not significant in stimulated saliva in the third trimester compared to the first, whereas a significant association and decreased heterogeneity were reported in unstimulated saliva in all trimesters compared to the control [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Similarly, in this study, the unstimulated salivary pH values of all study groups were lower than those of the control group, but statistical similarity was found between the study groups.\u003c/p\u003e \u003cp\u003eWhen changes in the salivary flow rate during pregnancy are evaluated in studies, different results emerge. While some researchers have reported a decrease in the salivary flow rate during pregnancy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], others have reported an increase [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this study, it was determined that there was no significant difference between the salivary flow rates of pregnant and non-pregnant women. Similarly, another study reported no statistically significant difference in salivary phosphate, pH, buffering capacity, flow rate, or DMFT index among all trimesters compared with the control and concluded that the stimulated salivary flow rate increased in the third trimester of pregnancy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This result is inconsistent with the results of other studies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These differences can be explained by the small sample sizes, the assessment of parotid gland salivary secretion, and the variation in salivary content among normal individuals. In addition, it has been reported that there may be an increase in the stimulated salivary flow rate due to the presence of estrogen receptor-beta in the oral epithelium and salivary glands of individuals receiving hormone therapy [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] or the effect of estrogen [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this study, however, since the unstimulated salivary flow rate was evaluated, there may not have been a similar estrogen effect; therefore, the salivary flow rate between the groups may have been similar.\u003c/p\u003e \u003cp\u003eThe salivary flow rate has a regulating effect on the pH of saliva [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Veenendaal et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] reported that sialorrhea or pregnancy ptyalism is a recurrent symptom in pregnant women. This can be attributed to the increase in the salivary flow rate to suppress this acidic environment due to the body\u0026rsquo;s defense system and decreasing intraoral pH due to severe nausea and vomiting. This condition is called \u0026ldquo;hyperemesis gravidarum\u0026rdquo; and is observed predominantly in female fetuses, fetuses with lower birth weights, and fetuses with shorter gestational ages at birth.\u003c/p\u003e \u003cp\u003eAlthough an increase in the probability of being affected by caries during pregnancy seems to be generally accepted, some conflicting results have been reported in the literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. According to Quock [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], changes in the structure and quality of saliva, pH, flow rate, and time play important roles in caries formation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and the greatest changes occur in the 3rd trimester of pregnancy [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In fact, since the experience of caries is a long-term and multifactorial etiological condition, it cannot be said that the amount of caries affecting individuals increases only according to their pregnancy period. To arrive at a more precise conclusion, further studies with more comprehensive and larger sample sizes are needed. In this study, there was no statistically significant difference between the DMFT values of the study and control groups. Past studies have also reported that no significant change in the DMFT index is expected during pregnancy [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, there was no statistically significant difference in the DMFT index between the control group and pregnant women at different gestational ages. For this reason, this study evaluated the relationships between salivary pH, salivary flow rate, and DMFT. There was a significant negative association between pH and the DMFT index for the 1st and 2nd trimester groups. The decrease in salivary pH from the 1st trimester to the 2nd trimester can be explained by the increase in caries exposure and DMFT. Although individuals in the 3rd trimester in this study had the lowest pH values, the lack of a relationship between pH and DMFT in the 3rd trimester group may have been due to the predominance of other caries-causing factors in this group. Therefore, the decrease in pH during caries formation should not be ignored. Similarly, Kamate et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] reported that the decrease in saliva pH continued in the postpartum period, and these changes were reflected in the increase in the DMFT index. When the effect of the salivary flow rate on DMFT was evaluated in past studies, no relationship was found between the two parameters [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Birkhed and Heintze [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and Russell et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] suggested that there was no linear relationship between the salivary flow rate, DMFT/DMFS index, and dental caries activity. Mandel [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and Russell et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] reported that there was only a weak or no correlation between the saliva secretion rate and caries incidence. Similarly, no relationship was found between the flow rate and DMFT in this study.\u003c/p\u003e \u003cp\u003eFemale sex hormones (estrogen, progesterone, and human gonadotropin) secreted mainly by the placenta are responsible for physiological changes during pregnancy, such as changes in saliva flow, composition, pH, and hormone levels. During pregnancy, conditions such as gingival bleeding, increased gingival infection, and periodontal pocket formation, known as pregnancy gingivitis, may occur without specific plaque accumulation [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Although it is thought that this condition is due to hormonal changes, its etiology is still unclear [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Gestational gingivitis usually begins to appear in the 1st trimester of pregnancy [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In the literature, an increase in the CPI score has been reported, reflecting the worsening of the periodontal condition with the progression of pregnancy [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In this study, a numerical increase was observed in CPI scores from the 1st to the 3rd trimester, similar to prior studies. At the same time, the CPI scores of pregnant women were found to be significantly greater than those of non-pregnant women.\u003c/p\u003e \u003cp\u003eIn this study, changes in the salivary flow rate and pH were evaluated as the causes of dental caries and periodontal diseases encountered during pregnancy. However, these two diseases are the most common oral diseases worldwide and are multifactorial. Changes in environmental factors such as sociodemographic characteristics, physiological individual factors, and general systemic health make individuals prone to oral diseases. Although pregnancy alone is not effective, it is among the etiological factors that causes oral and dental diseases. Observational studies with a larger number of participants need to be conducted, taking into account factors other than salivary variables that may be effective in treating oral and dental diseases during pregnancy.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn this study, a significant decrease in the salivary pH of pregnant women was detected, while no significant difference in the salivary flow rate was detected between the control and study groups. The periodontal health of pregnant women was worse than that of non-pregnant women. During pregnancy, factors such as changing oral hygiene habits, eating habits, hormonal status, and salivary characteristics directly or indirectly affect oral and dental health. It is important to determine the cause of oral and dental health problems, which are more common in this period, in terms of establishing prevention and treatment protocols suitable for etiological factors. The data obtained from this study are important in terms of the formation of healthy individuals with healthy mothers and their babies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDMFT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Total number of decayed, missing, and filled teeth\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCPI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Community Periodontal Index\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki.\u0026nbsp;Ethical approval was received for this research from the Ethics Committee of Health Sciences\u0026nbsp;of\u0026nbsp;Mugla Sitki Kocman\u0026nbsp;University (Report no:\u0026nbsp;2021/21-VII). Written\u0026nbsp;informed consent was\u0026nbsp;obtained from the participants before\u0026nbsp;they\u0026nbsp;participated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFY: Conceptualization (equal); data curation (equal); formal analysis (lead); investigation (equal); visualization (equal); writing \u0026ndash; original draft preparation (lead). OCD: Conceptualization (equal); data curation (equal); investigation (equal); visualization (equal); writing \u0026ndash; original draft preparation (supporting). SEH: Conceptualization (equal); data curation (equal); investigation (equal); visualization (equal); writing \u0026ndash; review and editing. BK: Conceptualization (equal); methodology (supporting); resources (equal); validation (equal); AD: Conceptualization (equal); methodology (lead); resources (equal); supervision (lead); validation (equal). All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participants for their cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSilness J, L\u0026ouml;e H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. \u003cem\u003eActa Odontol Scand.\u003c/em\u003e 1964;22:121-35.\u003c/li\u003e\n\u003cli\u003eKateeb E, Momany E. Dental caries experience and associated risk indicators among Palestinian pregnant women in the Jerusalem area: a cross-sectional study. \u003cem\u003eBMC Oral Health.\u003c/em\u003e 2018;18:1-8.\u003c/li\u003e\n\u003cli\u003eKamate WI, Vibhute NA, Baad RK. Estimation of DMFT, salivary streptococcus mutans count, flow rate, pH, and salivary total calcium content in pregnant and non-pregnant women: a prospective study. \u003cem\u003eJ Clin Diagnostic Res.\u003c/em\u003e 2017;11:ZC147.\u003c/li\u003e\n\u003cli\u003eBahri Binabaj N, Bahri Binabaj N, Iliati HR, Salarvand S, Mansoorian MR. Assessment of DMFT index in pregnant women and its relationship with knowledge, attitude and health behaviors in terms of oral and dental cares (Mashhad-2009). \u003cem\u003eIran J Obstet Gynecol Infertil\u003c/em\u003e. 2012;15:15-21. [In Arabic, English abstract]\u003c/li\u003e\n\u003cli\u003eSrinivas SK, Parry S. Periodontal disease and pregnancy outcomes: time to move on? \u003cem\u003eJ Womens Health\u003c/em\u003e 2012;21:121-5.\u003c/li\u003e\n\u003cli\u003eWu M, Chen SW, Jiang SY. Relationship between gingival inflammation and pregnancy. \u003cem\u003eMediators Inflamm.\u003c/em\u003e 2015;2015.\u003c/li\u003e\n\u003cli\u003eLaine MA. Effect of pregnancy on periodontal and dental health. \u003cem\u003eActa Odontol Scand\u003c/em\u003e 2002;60:257-64.\u003c/li\u003e\n\u003cli\u003eSelwitz RH, Ismail AI, Pitts NB. Dental caries. \u003cem\u003eThe Lancet\u003c/em\u003e. 2007;369:51-9.\u003c/li\u003e\n\u003cli\u003eRio R, Azevedo \u0026Aacute;, Sim\u0026otilde;es Silva L, Marinho J, Silva MJ, Sampaio Maia B. The biochemistry of saliva throughout pregnancy. \u003cem\u003eMed Express\u003c/em\u003e 2015;2:M150506.\u003c/li\u003e\n\u003cli\u003eLaine M, Tenovuo J, Lehtonen O-P, Ojanotko Harri A, Vilja P, Tuohimaa P. Pregnancy- related changes in human whole saliva. \u003cem\u003eArch Oral Biol.\u003c/em\u003e 1988;33: 913-7.\u003c/li\u003e\n\u003cli\u003eLaine M, Pieniha\u0026Egrave;kkinen K. Salivary buffer effect in relation to late pregnancy and postpartum. \u003cem\u003eActa Odontol Scand\u003c/em\u003e. 2000;58:8-10.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Oral Health Surveys. In: Basic methods. Geneva: WHO, 1997: 10-51.\u003c/li\u003e\n\u003cli\u003eYousefi M, Parvaie P, Riahi SM. Salivary factors related to caries in pregnancy: a systematic review and meta-analysis. \u003cem\u003eJ Am Dent Assoc\u003c/em\u003e 2020;151:576-88.\u003c/li\u003e\n\u003cli\u003eNaveen S, Asha M, Shubha G, Bajoria A, Jose A. Salivary Flow rate, pH and buffering capacity in pregnant and non pregnant women-A comparative study. \u003cem\u003eJMED Res\u003c/em\u003e 2014;2014:1- 7.\u003c/li\u003e\n\u003cli\u003eEdgar W, Dawes C, O\u0026apos;Mullane D. Saliva and oral health. 4th ed. Suffolk: Stephen Hancocks Limited; 2012.\u003c/li\u003e\n\u003cli\u003eSalvolini E, Di Giorgio R, Curatola A, Mazzanti L, Fratto G. Biochemical modifications of human whole saliva induced by pregnancy. \u003cem\u003eBJOG: Int J Obstet Gynecol.\u003c/em\u003e 1998;105:656-60.\u003c/li\u003e\n\u003cli\u003eKarnik AA, Pagare SS, Krishnamurthy V, Vahanwala SP, Waghmare M. Determination of salivary flow rate, pH, and dental caries during pregnancy: A study. \u003cem\u003eJ Indian Acad Oral Med Radiol\u003c/em\u003e 2015;27:372.\u003c/li\u003e\n\u003cli\u003eKullander S, Sonesson B. Studies on saliva in menstruating, pregnant and post- menopausal women. \u003cem\u003eEur J Endocrinol.\u003c/em\u003e 1965;48:329-36.\u003c/li\u003e\n\u003cli\u003eMigliario M, Bindi M, Surico D, et al. Changes in salivary flow rate and pH in pregnancy. \u003cem\u003eEur Rev Med Pharmacol Sci\u003c/em\u003e 2021;25:1804-10.\u003c/li\u003e\n\u003cli\u003eRockenbach MI, Marinho SA, Veeck EB, Lindemann L, Shinkai RS. Salivary flow rate, pH, and concentrations of calcium, phosphate, and sIgA in Brazilian pregnant and non-pregnant women. \u003cem\u003eHead Face Med\u003c/em\u003e. 2006;2:1-5.\u003c/li\u003e\n\u003cli\u003eBody C, Christie JA. Gastrointestinal diseases in pregnancy: nausea, vomiting, hyperemesis gravidarum, gastroesophageal reflux disease, constipation, and diarrhea. \u003cem\u003eGastroenterol Clin.\u003c/em\u003e 2016;45:267-83.\u003c/li\u003e\n\u003cli\u003eCaruso AA, Del Prete S, Ferrara L, et al. Relationship between gastroesophageal reflux disease and pH nose and salivary: proposal of a simple method outpatient in patients adults. \u003cem\u003eOpen Med\u003c/em\u003e. 2016;11:381-6.\u003c/li\u003e\n\u003cli\u003eSonbul H, Ashi H, Aljahdali E, Campus G, Lingstr\u0026ouml;m P. The influence of pregnancy on sweet taste perception and plaque acidogenicity. \u003cem\u003eMatern Child Health J\u003c/em\u003e. 2017;21:1037-1046.\u003c/li\u003e\n\u003cli\u003eDolić O, Obradović M, Kojić Ž, Sukara S. Caries risk assessment in pregnant women using cariogram. \u003cem\u003eSrp Arh Celok Lek\u003c/em\u003e. 2017;145:178-83.\u003c/li\u003e\n\u003cli\u003eOzturk L, Aky\u0026uuml;z S, Garan A, Yarat A. Salivary and dental-oral hygiene parameters in 3rd trimester of pregnancy and early lactation: The effect of education. \u003cem\u003eMarmara Dent J\u003c/em\u003e. 2013;1:1-8.\u003c/li\u003e\n\u003cli\u003eGonz\u0026aacute;lez M, Montes de Oca L, Jim\u0026eacute;nez G. Changes in saliva composition of pregnant and non-pregnant patients. \u003cem\u003ePerinatol Reprod Hum\u003c/em\u003e 2001;15:195-201.\u003c/li\u003e\n\u003cli\u003eD\u0026apos;Alessandro S, Curbelo H, Tumilasci O, Tessler J, Houssay A. Changes in human parotid salivary protein and sialic acid levels during pregnancy. \u003cem\u003eArch Oral Biol.\u003c/em\u003e 1989;34:829-31.\u003c/li\u003e\n\u003cli\u003eKivel\u0026auml; J, Laine M, Parkkila S, Rajaniemi H. Salivary carbonic anhydrase VI and its relation to salivary flow rate and buffer capacity in pregnant and non-pregnant women. \u003cem\u003eArch Oral Biol.\u003c/em\u003e 2003;48:547-51.\u003c/li\u003e\n\u003cli\u003eSaluja P, Shetty V, Dave A, Arora M, Hans V, Madan A. Comparative evaluation of the effect of menstruation, pregnancy and menopause on salivary flow rate, pH and gustatory function. \u003cem\u003eJ Clin Diagnos Res\u003c/em\u003e. 2014;8:ZC81.\u003c/li\u003e\n\u003cli\u003eEliasson L, Carl\u0026eacute;n A, Laine M, Birkhed D. Minor gland and whole saliva in postmenopausal women using a low potency oestrogen (oestriol). \u003cem\u003eArch Oral Biol\u003c/em\u003e. 2003;48:511-7.\u003c/li\u003e\n\u003cli\u003eValimaa H, Savolainen S, Soukka T, et al. Estrogen receptor-beta is the predominant estrogen receptor subtype in human oral epithelium and salivary glands. \u003cem\u003eJ Endocrinol\u003c/em\u003e 2004;180:55-62.\u003c/li\u003e\n\u003cli\u003eVeenendaal MV, van Abeelen AF, Painter RC, van der Post JA, Roseboom TJ. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta‐analysis. \u003cem\u003eBJOG: Int J Obst Gynecol\u003c/em\u003e. 2011;118:1302-13.\u003c/li\u003e\n\u003cli\u003eQuock RL. Dental caries: a current understanding and implications. \u003cem\u003eJ Nat Sci.\u003c/em\u003e 2015;1:27.\u003c/li\u003e\n\u003cli\u003eBirkhed D, Heintze U. Salivary secretion rate, buffer capacity, and pH. In: Tenovuo JO, editor. Human saliva: clinical chemistry and microbiology. Florida: CRC press; 2021. p:25-74.\u003c/li\u003e\n\u003cli\u003eRussell JI, MacFarlane TW, Aitchison TC, Stephen KW, Burchell CK. Caries prevalence and microbiological and salivary caries activity tests in Scottish adolescents. \u003cem\u003eCommunity Dent Oral Epidemiol\u003c/em\u003e. 1990;18:120-5.\u003c/li\u003e\n\u003cli\u003eMandel ID. The role of saliva in maintaining oral homeostasis. \u003cem\u003eJ Am Dent Assoc.\u003c/em\u003e 1989;119:298-304.\u003c/li\u003e\n\u003cli\u003eL\u0026ouml;e H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. \u003cem\u003eActa Odontol Scand\u003c/em\u003e.1963;21:533-51.\u003c/li\u003e\n\u003cli\u003eVogt M, Sallum AW, Cecatti JG, Morais SS. Factors associated with the prevalence of periodontal disease in low-risk pregnant women. \u003cem\u003eReprod Health.\u003c/em\u003e 2012;9:1-8.\u003c/li\u003e\n\u003cli\u003eCarrillo‐de‐Albornoz A, Figuero E, Herrera D, Bascones‐Mart\u0026iacute;nez A. Gingival changes during pregnancy: II. Influence of hormonal variations on the subgingival biofilm. \u003cem\u003eJ Clin Periodontol.\u003c/em\u003e 2010;37:230-40.\u003c/li\u003e\n\u003cli\u003eTilakaratne A, Soory M, Ranasinghe A, Corea S, Ekanayake S, De Silva M. Periodontal disease status during pregnancy and 3 months post‐partum, in a rural population of Sri‐Lankan women. \u003cem\u003eJ Clin Periodontol.\u003c/em\u003e 2000;27:787-92.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Periodontal diseases, Dental caries, Saliva, Pregnant woman","lastPublishedDoi":"10.21203/rs.3.rs-4730123/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4730123/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eThe frequent occurrence of dental caries and periodontal diseases in women during pregnancy may be due to many factors, such as salivary variables. The aim of this study was to evaluate the effects of pregnancy on salivary pH, flow rate, the DMFT index, and CPI sores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A total of 198 volunteers (pregnant in different trimesters and non- pregnant) were included. Data about sociodemographic characteristics and dental and systemic health conditions were recorded. Unsitumulated saliva samples were collected for 5 minutes via the spitting method. The pH of the saliva was measured by a portable pH meter. The salivary flow rate was determined by the weight measurement method. The DMFT index and CPI were determined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e There were significant differences between the pH values of the control and study groups (p \u0026lt; 0.05). There was no difference among the salivary flow rates of the study and control groups. The mean CPI of pregnant women was significantly greater than that of non-pregnant women (p \u0026lt; 0.05), while the DMFTs were similar among all groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePregnancy causes a direct decrease in unsitumulated salivary pH and an increase in periodontal disease. It also negatively affects oral and dental health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Clinical Trials-ID: NCT06343337; Registration Date: 04.01.2024.\u003c/p\u003e","manuscriptTitle":"The effects of pregnancy on oral health, salivary ph and flow rate","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-22 18:09:24","doi":"10.21203/rs.3.rs-4730123/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-31T11:10:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-30T14:01:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-30T13:58:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-07-12T12:01:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb54d69c-353c-4c3a-85b9-07846bf41c87","owner":[],"postedDate":"August 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:04:41+00:00","versionOfRecord":{"articleIdentity":"rs-4730123","link":"https://doi.org/10.1186/s12903-024-05057-0","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2024-10-25 15:58:05","publishedOnDateReadable":"October 25th, 2024"},"versionCreatedAt":"2024-08-22 18:09:24","video":"","vorDoi":"10.1186/s12903-024-05057-0","vorDoiUrl":"https://doi.org/10.1186/s12903-024-05057-0","workflowStages":[]},"version":"v1","identity":"rs-4730123","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4730123","identity":"rs-4730123","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}