Dental Care in California During Pregnancy

Lynn Walton-Haynes, DDS, MPH, is the dental program consultant, Office of Oral Health, California Department of Public Health. Conflict of Interest Disclosure: None reported.

Joanna Aalboe, RDH, MPH, is the health program manager and local programs statewide interventions unit chief, Office of Oral Health, California Department of Public Health. Conflict of Interest Disclosure: None reported.

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

ABSTRACT

Background: Dental visits during pregnancy can discover and address problems early, helping to prevent complications that can lead to adverse pregnancy outcomes. Dental care during pregnancy is safe and effective in improving and maintaining the oral health of mothers and children and should be accessible and equitable for all pregnant women.

Methods: To explore the prevalence of dental visits in California during pregnancy, we used recent data from the Maternal and Infant Health Assessment (MIHA) survey. MIHA is an annual, population-based survey of California-resident women with a live birth.

Results: Less than half (43%) of women in California with a live birth received a dental visit during their pregnancy. In California, disparities exist by age, race/ethnicity, geographic region, family income and education level.

Conclusion and practical implications: MIHA survey data show that disparities in utilization of dental services during pregnancy exist by age, race/ethnicity, geographic region, family income and educational levels. Dental professionals can work collectively with others to eliminate these disparities and advance oral health equity.

Keywords: Pregnancy, dental visit, prevention, oral health equity, oral health disparity, equity

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Dental care (preventive, diagnostic and restorative) during pregnancy is safe and effective in improving and maintaining the oral health of mothers and children. Practice guidelines on oral health care during pregnancy underscore this fact. [1–5] Addressing manageable problems early helps increase the safety of care by preventing dental disease complications that can lead to adverse pregnancy outcomes, such as preterm and lowweight birth, preeclampsia and gestational diabetes. [6,7] In addition, the mother’s oral health is one of the best predictors of their child’s oral health. [8] And yet less than half (43.9%) of California women with a live birth received a dental visit during their pregnancy. [9]

National and state efforts, such as the Maternal and Child Health Bureau-funded Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Initiative, have produced strategies to reduce oral disease in pregnant people and infants at high risk for oral disease by increasing access to and utilization of oral health care. [10] California’s PIOHQI pilot project in Sonoma County, which we discuss later in this paper, successfully improved utilization of oral health care. This paper highlights the MIHA data on dental visits by pregnant people and discusses steps that public health and dental health professionals can take to improve access to and utilization of oral health services during pregnancy.

Methods

We used data from the MIHA survey to explore the prevalence of dental visits during pregnancy in California. MIHA is an annual, population-based survey of California-resident women with a live birth. The survey is a collaborative effort of the Maternal, Child and Adolescent Health Division and the Women, Infants and Children Division in the California Department of Public Health (CDPH) and the Center for Health Equity at the University of California, San Francisco.

For dental visit data, there was a statewide sample size of 6,430 in 2017 and 6,131 in 2018. MIHA survey participants were sampled from the California Automated Vital Statistics System. Prevalence (%), 95% confidence interval (95% CI) and population estimates (rounded to the nearest hundred) are weighted to represent all women with a live birth. Population estimates are a two-year average (2017 and 2018).

Regional comparisons show whether the health indicator in the region was statistically different from the rest of the state (p-value < 0.05, chi-square test). Tables in this report were created by the Office of Oral Health using data prepared by the UCSF Center for Health Equity for the CDPH Maternal, Child and Adolescent Health Division. MIHA survey participants were asked, “During your most recent pregnancy, did you visit a dentist, dental clinic or get dental care at any other health clinic?” Women could report “Yes” or “No.”

Results

Forty-four percent (43.9%) of California women with a live birth received a dental visit during their pregnancy. [9]

TABLE 1 shows the variation in dental visits received during pregnancy for nine California geographical regions. Women in Los Angeles County, the San Joaquin Valley and southeastern California had a lower prevalence (39.3%, 36.8% and 31.1%, respectively) of receiving a dental visit during pregnancy than women in the rest of California.

TABLE 2 shows disparities in receipt of dental visits during pregnancy by insurance type, age, race/ethnicity, family income and educational level.

■ Only 35% of women with Medi-Cal prenatal health insurance received a dental visit during pregnancy.

■ Similarly, just 35% of women younger than 25 years of age received a dental visit during pregnancy.

■ Black women and Latina women had a lower prevalence (33% and 37%, respectively) of receiving a dental visit during pregnancy than women overall.

Women with lower incomes and those with less than a college degree had significantly lower prevalence of receiving a dental visit during pregnancy than women overall.

Discussion

The data presented above underscore that much work is needed to improve access to and utilization of oral health care during pregnancy. The CDPH California Oral Health Plan 2018–2028 (plan) provides a roadmap for oral health improvements and equity for all Californians over the course of a 10-year period. The plan offers a structure for collective action to assess and monitor oral health status and disparities, prevent oral diseases, increase access to dental services, promote best practices and advance evidence-based policies.

Working with the California Oral Health Plan Advisory Committee, the Office of Oral Health created the California Partnership for Oral Health Plan (partnership). With a vision of “oral health equity and well-being for all Californians,” the partnership promotes a public health approach to California’s oral health needs and enables partners to work together to achieve the goal of the plan. The partnership includes a diverse group of stakeholders from state and local government, academic institutions, foundations, professional organizations and community health champions.

One key strategy to increase oral health care during pregnancy is to enhance the integration of oral health and primary medical care. This was successfully demonstrated in the Sonoma County PIOHQI pilot project, which used a multipronged approach: Oral health education for the medical team, a coordinated scheduling system between the medical and dental electronic health record systems, standard protocols to identify infants eligible for dental visits and incentives to medical assistants for increasing the number of infant dental appointments. All of these strategies led to an increase of infant visits from 10.7% to 45.5% over a 21-month period. [11] Leveraging funding from the California Healthcare, Research and Prevention Tobacco Act of 2016, the CDPH Office of Oral Health and the local oral health programs are planning or already implementing medical-dental integration approaches to increase dental visits during pregnancy.

Dental health professionals are trusted members of their communities and as champions of oral health can serve a vital role to increase understanding of the importance of receiving oral health care during pregnancy. Utilizing available resources such as the Oral Health Literacy Toolkit, the oral health care team can maximize the opportunity to communicate effectively with their patients and communities. Dental health professionals also can partner with prenatal providers, hospitals and First 5 organizations to inform and educate the public. The First 5 parenting guide stresses the importance of oral health during pregnancy.

As we work to achieve oral health equity, we must ensure that everyone has access to oral health care. Health equity is defined as “the absence of systemic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages.” [12] In California, data show disparities exist by age, race/ethnicity, geographic region, family income and educational level.

California has made significant improvements to the Medi-Cal Dental Program. To increase dental visit rates, the Smile, California campaign has created brochures and flyers. [13] Recently, Medicaid extended postpartum coverage from 60 days to one year. This, along with increasing the number of health professionals who accept Medi-Cal beneficiaries in their practice, could increase the opportunity for women to receive oral health care during pregnancy. Through participation with state and local oral health program initiatives, dental organizations, community groups and others, dental health professionals can play a significant role toward achieving oral health equity.

Conclusion

MIHA survey data show that disparities in utilization of dental services during pregnancy exist by age, race/ ethnicity, geographic region, family income and educational level. Dental professionals can work collectively with others to eliminate these disparities and advance oral health equity.

ACKNOWLEDGMENT The authors thank the Maternal and Infant Health Assessment Project Team at the California Department of Public Health, Maternal, Child and Adolescent Health Division and University of California San Francisco, Center for Health Equity (cdph.ca.gov/ miha) for preparing the data used in this article. The authors also thank Karen Jacoby, health program specialist, Office of Oral Health, California Department of Public Health, for the editorial assistance.

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9. California Department of Public Health. Maternal and Infant Health Assessment (MIHA) survey data, 2017and 2018.

10. Lorenzo S, Goodman H, Stemmler P, Holt K, Barzel R, eds. 2019. The Maternal and Child Health Bureau-Funded Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Initiative 2013–2019: Final Report. Washington, D.C.: National Maternal and Child Oral Health Resource Center.

11. Association of State and Territorial Dental Directors. California Infant Dental Visit Quality Improvement Projects, ASTDD Best Practice Report. December 2019.

12. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003 Apr;57(4):254–8. doi: 10.1136/jech.57.4.254.

13. Smile, California. Partners and Providers. Accessed Jan. 31, 2022.

THE CORRESPONDING AUTHOR, Lynn Walton- Haynes, can be reached at Lynn.Walton-Haynes@cdph.ca.gov.