Pregnancy is a very special and pleasant moment and stage for a woman. So maintaining the health of the body during pregnancy becomes an absolute thing for every pregnant woman to do (Anonymous, 2009, Fadavi et al, 2009) Public attention to women's health during pregnancy is increasing, but dental and oral health is often missed due to attention the assumption that pregnancy has nothing to do with the state of the oral cavity. Women often experience hormonal instability. causes an increase in the hormones estrogen and progesterone where both hormones can affect periodontal tissues such as gingival inflammation or gingivitis (Caranza FA. Newman MG, 2002) [22].

Gingivitis is a periodontal disorder that is often encountered when caused by plaque, namely the gingival edge will be clinically seen reddish to bluish red, enlarged gingival contours because of the adema and bleed easily when there are stimuli such as when eating and brushing teeth. Gingivitis can also be caused by systemic factors such as hormonal instability experienced by women during puberty, menstruation, and pregnancy. Gingivitis in pregnant women is called gingivitis gravidarum or pregnancy gingivitis.

The inflammatory response of pregnancy gingivitis becomes exaggerated with relatively little local irritation factor. Gingivitis depends on the level of oral hygiene of the patient as well as the role of the hormones estrogen and progesterone in periodontal tissue.

Pregnancy gingivitis or gingivitis gravidarum usually occurs in the 2nd and 3rd month of pregnancy, usually at the 8th week the severity of the peak is in the 8th month of pregnancy (week 32) decreases in the 9th month of pregnancy along with decreasing levels hormones in the body.2,6,8 Some studies state that the effect of hormonal changes will affect the dental health of pregnant women by 60% with 10-27% experiencing gum swelling. 9 Indonesian Dental Association notes gum inflammation is a problem of the mouth and teeth that often afflict pregnant women where 5-10% have swollen gums

In pregnancy, there is an increase in acid levels in the oral cavity, not to mention if pregnant women experience nausea and vomiting which can result in exposure to stomach acid in the teeth and gums. This can cause inflammation / gum disease and teeth, which can ultimately affect pregnancy and fetal development. (Adhi, 2009). These changes can affect the system in the body which will also affect the physiology of body parts including the oral cavity such as pain in periodontal tissue and also affect the emergence of gingivitis. (Pirie M, et al, 2007) [34]. Most complaints in the oral cavity of pregnant women are caused by hormonal changes. (Gaffield M.L. et al, 2001; Jiang P. et al, 2008)

Dental and oral diseases that occur during pregnancy are not only influenced by the pregnancy itself but are also influenced by the behavior of pregnant women which includes knowledge, attitudes and actions to maintain oral health.

Research conducted on pregnant women in Turkey by Ozen et al. (2012) stated that although 75% of respondents had knowledge of the relationship between pregnancy and periodontal disease, only 13.7% visited a dentist during pregnancy.

In the study of Hajikazemi et al. (2008) [12] conducted on pregnant women found that only 5.6% of respondents had a high level of knowledge, 30% of respondents behaved well toward health and 34.4% of respondents had good dental and oral health behavior. The results of this study indicate that the low behavior that includes knowledge, attitudes and actions of pregnant women towards the maintenance of oral health. The study found that the increased risk of low birth weight infants and fetal growth restriction was seen to be less if the disruption in the teeth and gums was mild. The risk becomes significant if the tooth disease is more severe. (IDAI, 2007) (Wrzosek T and Einarson A. 2009).

In the February 2006 issue of the Journal of Periodontology, proving the benefits of oral and dental health care for pregnant women, namely reducing the risk of pre-eclampsia (pregnancy poisoning) by 5 -8%, then the results of Academy of General Dentistry research show that pregnant women suffer health problems mouth and teeth (periodental desease) 3-5 times greater risk for delivering premature babies (less months). While pregnant women who suffer from gum infections, are 6 times more likely to deliver premature babies and babies born with low weight. Journal of Periodontology January 2006 edition states that, healing therapy for oral and dental health problems suffered by pregnant women, can reduce the birth rate of premature babies and babies born with low weight by 68%. The need for teaching and training for mothers who will become pregnant to maintain oral health. (Lydon-Rochelle M.T. et al, 2004).

Research on the occurrence of gingivitis in pregnant women called Pregnancy gingivitis or inflammation of the gums conducted by Retnoningrum (2006), at Karyadi Hospital Semarang stated that pregnant women have a risk factor for babies born with low birth weight (BBRL), at 8.75 times compared to pregnant women who do not experience gingivitis. Oral mucosal lesions are more common in pregnant women than non-pregnant women. According to Jefoat research (in Ernawati 2008) produced that pregnant women who suffer from gingivitis, the risk of having premature babies with low birth weight (LBW) of 4.45-7.07 times higher than in mothers with healthy gingival conditions.

Maintenance of oral health will reduce the incidence of gingivitis during pregnancy. According to research conducted by Santoso et al. In 2009, periodontal diseases such as untreated gingivitis in pregnant women was one of the risk factors for a low birth weight (LBW) baby. The results of data analysis showed that respondents with poor oral hygiene had 2.55 times the risk of giving birth to LBW babies less months compared to respondents with good oral hygiene. Therefore dental care in pregnant women is very important. As a study conducted by Pujiastuti and Praharani (2005) where the results are an increase in the severity of gingivitis during pregnancy which is worst in the third trimester.

Research conducted by Erawati, Anastasia and Sukmadara (2016), results in a significant correlation between the level of dental and oral hygiene in pregnant women and the severity of gingivitis in pregnant women in the third trimester compared to the third trimester significantly.

The Basic Health Research (Riskesdas, 2013) of the Bali Convention area stated that the prevalence of dental and oral health problems reached 25.1% mostly suffered by women and in the riskesdas it was also stated that an average of 32 women in the Bali area suffered from sores.

Puskesmas is one of the centers for public health services that provides curative, preventive, promotive and rehabilitative services. As a leading health care facility that provides services to pregnant women and oral health.

This type of research is a clinical observational study using a cross sectional study method, when and where the study was conducted starting in July-August 2018 conducted at the Polygigi and Polyclinic MCH Puskesmas in the working area of the Denpasar City Puskesmas which includes 11 Puskesmas Ie: Puskesmas I, II, III, IV South Denpasar, Health Center I, II West Denpasar, Health Center I, II East Denpasar, Health Center I, II, III North Denpasar.

The population in this study were all pregnant women who came for their pregnancy check up at the Puskesmas in the working area of Denpasar City Health Office with samples of pregnant women who met the inclusion criteria and were found when the study took place at the KIA polyclinic for 810 people in 2018

Frequency Distribution of Respondents Based on the Relationship of Oral Hygiene Level (OHI-S) with Gingival Status

Table 3Frequency Distribution of Respondents Based on the Relationship of Oral Hygiene Level (OHI-S) with Gingival Status

In table 3 respondents based on moderate OHI-S criteria, most experienced mild gingivitis 169 (92.3%), while OHI-S both mostly experienced mild gingivitis and normal gingiva. Whereas with poor OHI-S, most experienced moderate criteria gingivitis. Relationship of Oral Hygiene Level (OHI-S) with Gingival Status with chi-Square test results obtained p = 0,000 less than significant level α = 0.05, so it can be concluded that there is a significant relationship between the level of oral hygiene (OHI-S) with status gingiva during pregnancy. This research shows that there is a relationship between the level of oral hygiene with gingival status where although the respondents have a good oral hygiene status, they still experience gingival disorders even in mild criteria.This condition is caused during pregnancy when hormonal changes occur, the hormones estrogen and progesterone. These hormonal changes in pregnant women can cause a variety of complaints to pregnant women such as nausea, vomiting, and toothache so that pregnant women ignore oral and dental hygiene. This study is in accordance with the opinion of Prawirohardjo (2010) in which pregnant women occur physiological changes wherein a number of hormones have increased such as estrogen and progestron levels have an impact on the entire body including the oral cavity so also in the saliva of pregnant women during pregnancy. The results of this study are in line with the results of research conducted by Wardhani in 2012 [43] showing a relationship between the level of oral hygiene of a pregnant woman with her gingival status ie the worse the level of oral hygiene of a pregnant woman, the worse her gingival status will be. From the research that has been done this shows that the oral hygiene status of pregnant women will affect the severity of gingivitis. Although the severity of gingivitis is influenced by oral hygiene conditions, the increase in the severity of gingivitis that occurs in pregnant women is influenced by hormonal factors. This is because the increase in hormones in pregnant women peaks in the third trimester of pregnancy. Research conducted by Wardhani (2012) [43] shows a relationship between the level of oral hygiene of pregnant women with their gingival status, the worse the oral hygiene level of pregnant women, the worse their gingival status is. This is supported by research conducted by Hartati et al (2011) [10] who found that pregnant women with plaque on their teeth had more gingivitis compared to women with no plaque on their teeth. Research conducted by Rintoko (2005) [36] also stated the level of oral hygiene affected the occurrence of gingivitis in pregnant mother.

The severity of gingivitis peaks at 8 months gestation and decreases at 9 months gestation, with the same pattern of plaque accumulation. Some researchers report the greatest severity of gingivitis occurs in the second and third trimesters. Reduction in the severity of gingivitis can occur after 2 months postpartum and after one year the condition of the gingiva can return to normal, can be compared with the condition of women who are not pregnant. However, gingiva will not return to normal if local factors are not removed.

Frequency Distribution of Respondents Based on Relationship between Gingival Status and Pregnancy Trimester.

Table 4. Distribution of Respondent Frequencies Based on the Relationship between Gingival Status and Pregnancy Trimester

Table 4 In trimester 1, II, III, most of them experienced mild inflammation, namely (88.0%) and 87.4% and 86%. There was a significant relationship between gingival status and gestational age because of the chi-square test, the significance value = 0.002 <of α = 0.05, bivariate analysis between gestational age with gingival health status, obtained the most gingival status results in mild gingivitis status both in trimester I (88.0%), in trimester II mild gingivitis status (87.4%), as well as in the third trimester, mild gingivitis status (81.1%). In this study, there was no status of severe gingivitis which showed that gingivitis was different in all samples even though the degree of oral hygiene (OHI-S) was good.These results are in accordance with the theory which states that pregnancy can trigger gingivitis even though the respondent's oral cavity is good (Carranza, 2002) [23].

In this study the results obtained in the level of oral hygiene of pregnant women mostly experienced gingival status with mild gingivitis criteria both in respondents with OHI-S creteia both experienced gingival inflammation with mild creteria as much (81.3%), and the most respondents with OHI-S status is experiencing mild gingivitis (92.3%). The remaining minority of respondents with good, moderate and bad OHI-S status have moderate gingivitis. This research shows that there is a relationship between the level of oral hygiene with gingival status where although the respondents have a good oral hygiene status, they still experience gingival disorders even in mild criteria. This condition is caused during pregnancy when hormonal changes occur, the hormones estrogen and progesterone. These hormonal changes in pregnant women can cause a variety of complaints to pregnant women such as nausea, vomiting, and toothache so that pregnant women ignore oral and dental hygiene. This study is in accordance with the opinion of Prawirohardjo (2010) [33] in which pregnant women occur physiological changes wherein a number of hormones have increased such as estrogen and progestron levels have an impact on the entire body including the oral cavity so also in the saliva of pregnant women during pregnancy. The study is also in accordance with the results of Riskesdas 2007 which stated that the Indonesian population experienced dental and oral health problems namely caries and periodontal diseases such as gingivitis including pregnant women (MOH RI. 2007) The results of this study are in line with the results of research conducted by Wardhani in 2012 [43] showing the existence of the relationship between the level of oral hygiene of pregnant women with its gingival status is the worse the level of oral hygiene of pregnant women, the worse the status of the gingiva. From the research that has been done this shows that the oral hygiene status of pregnant women will affect the severity of gingivitis. Although the severity of gingivitis is influenced by oral hygiene conditions, the increase in the severity of gingivitis that occurs in pregnant women is influenced by hormonal factors. This is because the increase in hormones in pregnant women peaks in the third trimester of pregnancy. This is in accordance with the results of research from Dika Fitria W (2014) [43] with the title of the relationship between the level of oral hygiene with gingival status in pregnant women in the working area of ​​Sumber Sari Health Center, Sumbersari District of Jember based on the results of the Pearson correlation test, the significance value is 0.002; The significance values ​​obtained were all below 0.05 (p <0.05), so it can be concluded that in all trimesters there was a significant relationship between the level of oral hygiene and gingival status in pregnant women. Research conducted by Wardhani (2012) [43] shows a relationship between the level of oral hygiene of pregnant women with their gingival status, the worse the oral hygiene level of pregnant women, the worse their gingival status is. This is supported by research conducted by Hartati et al (2011) who found that pregnant women with plaque on their teeth had more gingivitis compared to women with no plaque on their teeth. Research conducted by Rintoko (2005) [36] also stated the level of oral hygiene affected the occurrence of gingivitis in pregnant mother. The severity of gingivitis peaks at 8 months gestation and decreases at 9 months gestation, with the same pattern of plaque accumulation. Some researchers report the greatest severity of gingivitis occurs in the second and third trimesters. Reduction in the severity of gingivitis can occur after 2 months postpartum and after one year the condition of the gingiva can return to normal, can be compared with the condition of women who are not pregnant. However, gingiva will not return to normal if local factors are not removed.

Frequency Distribution of Respondents Based on the Relationship between Gingival Status and Education

Table 5. Distribution of Respondent Frequencies Based on the Relationship between Gingival Status and Education

In table 5, where the majority of respondents who were educated in high school or junior high school experienced mild gingivitis which was 83.0% and 87.5% and none had severe gingivitis. Chi-square statistical test p = 0.000 means the significance value = 0.000 is smaller than the significant level α = 0.05, so it can be concluded that there is a significant relationship between education level and gingival status during pregnancy. Meaning the results of this study indicate that there is a relationship between status gingiva and education level in pregnant women in the working area of Denpasar City Health Center because the significance value is smaller 0.05, it can be seen that the significance value of the Chi Square test.Based on the overall results of research on the relationship between the status of periodontal disease and the level of education in pregnant women in the Work Area of ​​Welahan Health Center in Jepara Regency, by Danny Setiawan Nugraha (2017) there is a relationship between the level of education and status of periodontal disease in pregnant women in the Work Area of ​​the Welahan District Health Center. Jepara This can be proven by the results of the Chi-Square test (significance value 0.039) which shows the close relationship between the level of education with periodontal status in pregnant women. Education influences knowledge, while knowledge will have an impact on behavior and understanding of the health of teeth and mouth, and indirectly have an impact on the health of periodontal disease. The results of this study are in line with research conducted by Sunita Bamanikar and Liew Kok Kee (2013), with the title Knowladge, Attitude and Practice of Oral and Dental Healthcare in Pregnant Women. The results of the study stated that there was a relationship between education level and periodontal status in pregnant women in various trimisters. From the research results, pregnant women in the first trimister were found as many as 26.9% of the samples had normal (healthy) periodontitis status, while in the second trimister it was found as many as 31.2% of the samples had mild periodontitis status, and in pregnant women in the third trimister found as many as 40.9% of the sample had moderate periodontal status. From the sample it was also found that from a sample of 40.9% who had moderate periodontal status, most of them had quite a low education. Periodontal disease is an inflammatory disease or damage to the supporting tissues of the teeth caused by local factors, namely bacterial plaque. who do not yet know about the importance of maintaining dental health during the pregnancy period due to the rush of working mothers so they do not have time to visit the dental clinic and are only busy examining pregnancy, also preparing for the birth of their babies so that they neglect care of the oral cavity. Likewise, even though most of the respondents work, but because most of them have a high school education or equivalent so their income is only to meet routine needs so that ignoring dental care is considered expensive and does not become a major priority.

Frequency Distribution of Respondents Based on the Relationship between the level of dental and oral hygiene (OHI-S) with gestational age

Table 6. Distribution of Respondent Frequencies Based on the Relationship between the level of dental and oral hygiene with gestational age

Table 6 based on the relationship between OHIS and gestational age, most in the second and third trimesters have OHI-S with moderate criteria. Based on statistical tests by means of chi-square, the results are p = 0,000 which means the significance value = 0,000 is less than the significant level α = 0.05, so it can be concluded that there is a significant relationship between OHI-S and trimester of pregnancy

Frequency Distribution of Respondents Based on the Relationship between the level of dental and oral hygiene with Gingival Status

Table 7. Frequency Distribution of Respondents Based on the Relationship between the level of dental and oral hygiene with Gingival Status

Table 7 shows the majority of respondents with moderate OHI-S with gingival status with mild gingivitis criteria. There is a significant relationship between OHI-S with gingival status during pregnancy, based on chi-square results obtained p = 0,000, which means the significance value = 0,000 is less than the significant level α = 0.05,

Frequency Distribution of Respondents Based on the Relationship between Gingival Status and Employment

Table 8. Distribution of Respondent Frequencies Based on Relationship of Gingival Status with Work

Table 8, most respondents both working and not working experience gingivitis with mild criteria. Based on the Chi Square statistical test obtained p = 0.002, which means that the significance value = 0.000 is less than the significant level α = 0.05, so it can be concluded that there is a significant relationship between gingival status. respondents who already have good knowledge about oral health care, because by working they get a lot of information both formally and informally through print and electronic media. This might be due to the respondents' awareness about the importance of maintaining oral health, especially during pregnancy. Information obtained by pregnant women regarding the maintenance of oral health will also affect the level of knowledge.

Most respondents have high school / equivalent education, namely 153 people, 53 people junior high school (19.3%), 32 elementary school students while academy 14 people (5.1%) and only 23 people (8.4%) scholars. This is a sign that the respondent understands the importance of pregnancy, which is a productive period for pregnancy and childbirth. According to the authors, this shows that the majority of respondents in this study already have an awareness of the importance of continuing education. Education has an important role in improving living standards. Generally the level of welfare is very dependent on the level of one's education. Besides education is closely related to knowledge so that it will affect one's behavior including in the utilization of health services. This is in accordance with scientific opinion that is a tiered education system is expected to be able to increase individual knowledge through a certain mindset (Gunarsa, 2001). The higher a person's education, the easier it is to receive information so the more knowledge he has. Conversely, a lack of education will be more difficult in perceiving and inhibiting the development of maternal attitudes towards newly introduced values, such as the importance of ANC visits during pregnancy. Appropriate management by counseling so that mothers are more understanding about the importance of ANC in pregnant women, especially in the third trimester so that they can change their behavior to conduct ANC regularly (Nursalam and Siti Parian; 2001) [30]

This result is also in accordance with the study of Hendroyoto et al (2013) where most of the respondents had a high school education of 33 people (60%), out of 55 people who examined gingivitis in pregnant women at the Tumiting Menado Health Center

Frequency distribution of respondents by type of work most of the respondents work status 139 (50.5%) both as entrepreneurs, civil servants while the remaining 136 people (49.5%) as housewives. This means that by working, mothers can socialize with others and can get information and experience from the environment so that they have more knowledge than mothers who do not work. Even though the majority of respondents in this study had the latest tertiary education and high school, respondents who already had good knowledge of dental and oral health care, because by working they got a lot of information both formally and informally through print and electronic media. This might be due to the respondents' awareness about the importance of maintaining oral health, especially during pregnancy. Information obtained by pregnant women regarding the maintenance of oral health will also affect the level of knowledge.

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