Introduction: Improving the Oral Health of Pregnant People

Jayanth V. Kumar, DDS, MPH, is the state dental director at the California Department of Public Health. Conflict of Interest Disclosure: None reported.

Renee Samelson, MD, MPH, is a professor of obstetrics and gynecology at Albany Medical College in Albany, New York. Conflict of Interest Disclosure: None reported.

Publication Policy Disclaimer The findings and conclusions in this article are those of the authors and do not necessarily represent the views or opinions of the California Department of Public Health or the California Health and Human Services Agency.

Good oral health habits and timely dental care protect a person’s health before and during pregnancy and can reduce the transmission of caries causing bacteria from mothers to their children. [1] The recently published report, “Oral Health in America: Advances and Challenges” further emphasizes the importance of early prevention and regular health care, including activities that promote oral health during preconception, pregnancy and the first three years of life because lifelong health determinants are established from the moment of conception. [2] The mother’s oral health status profoundly influences oral health outcomes in children. [3] In addition, providing timely educational information and dental care to pregnant people has been shown to reduce the risk for dental caries in their children. [4]

To promote oral health during pregnancy, the California Dental Association Foundation and the American College of Obstetricians and Gynecologists, District IX, developed the Perinatal Oral Health Practice Guidelines in 2010. [5] Since creating these guidelines, several initiatives have been undertaken at the national and state levels to ensure that health professionals and pregnant people know the importance and safety of receiving oral health care during pregnancy. [6,7] These initiatives include programs, policies, resources and training. For example, the federal Maternal and Child Health (MCH) Services Block Grant (Title V of the Social Security Act), a foundation for ensuring the health of our nation’s mothers, children and adolescents, including those with special health care needs, has established performance measures regarding preventive dental visits. [8] Also, the American Dental Association’s (ADA) Council on Advocacy for Access and Prevention has fostered efforts to make the profession aware of the importance and safety of providing oral health care throughout pregnancy. The American College of Obstetrics and Gynecology (ACOG) has also recommended oral health care during pregnancy and throughout the lifespan. Furthermore, an ACOG committee opinion has been revised to reinforce the importance of the “fourth trimester” and proposes a new paradigm for postpartum care, including chronic disease management. [9] In addition, the Association of State and Territorial Dental Directors has compiled a Best Practice Approach report to help achieve successful outcomes. Lastly, the Medi- Cal Dental Program’s Smile campaign has developed educational materials for pregnant people in California. Therefore, this issue of the Journal provides an opportunity to assess the progress made over the last decade and renew the state’s commitment to improving the oral health of pregnant people and children.

In their manuscript, Lynn Walton- Haynes, DDS, MPH, and colleagues reviewed the California Maternal and Infant Health Assessment (MIHA) data. Overall, they found that 43.9% of California people with a live birth had a dental visit during their pregnancy in 2017 and 2018. Before the publication of the California Perinatal Oral Health Practice Guidelines in 2010, the dental visit rate was 37.9%. Thus, the increase in the dental visit rate has only been modest during the last decade. Nationally, Lee et al. found that only about half of the people (51.7%) reported having at least one dental visit for a cleaning during their most recent pregnancy. [10] Consistent with the national data, the MIHA survey data also showed that disparities in the utilization of dental services during pregnancy exist by age, race/ethnicity, geographic region, income level, insurance status and educational levels. For example, the dental visit rates in 2017-2018 varied from a low of 31.1% in the southeastern California region to a high of 54.9% in the San Francisco Bay Area. Additionally, the dental visit rate among Medi-Cal beneficiaries varied from a low of 22.7% in San Bernardino County to a high of 73.3% in Sonoma County. In an analysis by the state, Lee et al. also noted that the proportion of Medicaidenrolled people who had a dental visit for a cleaning during pregnancy ranged from 19.6% in Maine to 51.1% in Washington. We must understand the reasons for such variation and address them to improve dental visit rates.

Dentistry can learn from California’s success in reversing the troubling trends in multiple measures of maternal health.

In their article, Katrina Holt, MPH, MS, RD, and Ruth Barzel, MA, describe the Health Resources and Services Administration’s Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative, launched nationally to improve the integration of preventive oral health care into primary care for pregnant people and infants, respectively. From 2013 through 2019, HRSA funded 16 demonstration projects as part of the PIOHQI initiative. The authors discuss many lessons learned from these projects, including making training modules available online to meet staff training needs, identifying educational messages and resources for professionals to use during visits and having oral health champions with relevant data to make a case for the importance of perinatal and infant oral health.

In their article, Rachel Anderson, BS, and Hugh Silk, MD, MPH, propose a more upstream approach by addressing oral health needs in the preconception phase. They cite studies to show that people with periodontal disease take longer to conceive. Further, treating periodontal disease during pregnancy may be too late to affect the disease-related inflammatory cascade that has already set in. Therefore, they recommend a multidisciplinary approach involving dental and medical professionals providing consistent messaging and synergistic care during the preconception period. This approach would require medical-dental integration, training and incentives to foster clinical practice changes.

Dentistry can learn from California’s success in reversing the troubling trends in multiple measures of maternal health. In an article in the journal Health Affairs, Main, Markow and Gold described how the California Maternal Quality Care Collaborative was formed as a public-private partnership to address maternal mortality and morbidity in California. [11] According to the authors, while the U.S. maternal mortality rate has worsened in the 2010s, California cut its rate nearly in half, from 13.1 per 100,000 live births, on average, in the baseline period of 2005-09 to a threeyear average of 7.0 during 2011-13. The state’s rate had become comparable to the average rate in Western Europe (7.2 per 100,000). They identified several key steps, including linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives and implementing a series of datadriven, large-scale quality improvement projects. Similar health care and public health partnerships can increase dental visit rates during pregnancy and help eliminate disparities in dental care utilization among pregnant people.

California is committed to providing health insurance coverage for all pregnant people. The Medi-Cal Dental Program covers dental services during pregnancy and 60 days postpartum, and effective April 1, the postpartum period extends to 12 months. In 2019, there were 446,479 live births in California, about oneeighth of the national births. Medicaid pays for slightly less than half of all births nationally, thus playing a pivotal role in delivering maternity-related services for pregnant people. As part of the national PIOHQI demonstration project, the California Department of Public Health, Office of Oral Health partnered with the Sonoma County Department of Health Services’ Dental Health Program and six community health centers integrated oral health and primary care. The strategies included taking an inventory of Local Health Jurisdiction assets to enlist various programs, hosting educational seminars to foster collaboration, sharing best practices and forming a Community of Practice (CoP) to implement quality improvement initiatives. As a result, the MIHA data showed that the dental visit rate in the 2017-18 cycle was 73.3% and 61.6% among Medicaid beneficiaries and privately insured pregnant people, respectively. With an estimated number of 50,000 active dentists and dental hygienists in California, there is an adequate dental workforce to address the need of every pregnant person. Therefore, initiatives like the Sonoma project demonstrate that remarkable improvements can be achieved through the concerted efforts of partner organizations.

REFERENCES

1. Oral Health Care During Pregnancy Expert Workgroup. 2012. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center.

2. U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research. Oral Health in America: Advances and Challenges. Bethesda, Md.

3. Fisher-Owens SA, Gansky SA, Platt LJ, et al. Influences on children’s oral health: A conceptual model. Pediatrics 2007 Sep;120(3):e510–20. doi: 10.1542/peds.2006-3084.

4. Meyer K, Geurtsen W, Gunay H. An early oral health care program starting during pregnancy: Results of a prospective clinical long-term study. Clin Oral Investig 2010 Jun;14(3):257–64. doi: 10.1007/s00784-009-0297-x. Epub 2009 Jun 17.

5. CDA Foundation. Oral Health During Pregnancy and Early Childhood: Evidence‐Based Guidelines for Health Professionals. 2010.

6. Barzel R, Holt K. Promoting Oral Health During Pregnancy: Update on Activities — October 2021. National Maternal and Child Oral Health Resource Center. Washington, D.C.

7. National Maternal and Child Oral Health Resource Center. Promoting Oral Health During Pregnancy: Update on Activities — May 2020. Washington, D.C.

8. MCH Evidence. Preventive Dental Visit (Oral Health). Evidence Tools.

9. Optimizing Postpartum Care. ACOG Committee Opinion 736. American College of Obstetrics and Gynecologists. Obstet Gynecol 2018 May;131(5):e140–e150. doi: 10.1097/AOG.0000000000002633.

10. Lee H, Tranby E, Shi L. Dental visits during pregnancy: Pregnancy risk assessment monitoring system analysis 2012–2015. JDR Clin Trans Res 2021 Jul 29;23800844211028541. doi: 10.1177/23800844211028541. Online ahead of print.

11. Main EK, Markow C, Gould J. Addressing Maternal Mortality and Morbidity in California Through Public-Private Partnerships. Health Aff (Millwood) 2018 Sep;37(9):1484– 1493. doi: 10.1377/hlthaff.2018.0463.

THE CORRESPONDING AUTHOR, Jayanth V. Kumar, DDS, MPH, can be reached at jayanth.kumar@cdph.ca.gov.