Improving Oral Health and Overall Health for Pregnant People and Infants

Katrina Holt, MPH, MS, RD, is the project director for the National Maternal and Child Oral Health Resource Center at Georgetown University. She is a fellow of the Academy of Nutrition and Dietetics. Conflict of Interest Disclosure: None reported.

Ruth Barzel, MA, is a senior editor/writer for the National Maternal and Child Oral Health Resource Center at Georgetown University. Conflict of Interest Disclosure: None reported.

ABSTRACT

Background: This article describes the Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative, launched to improve integration of preventive oral health care into primary care for pregnant women and infants.

Case description: Pregnancy is characterized by physiological changes that may adversely affect oral health and increase the risk for oral diseases. Hormonal and immunologic changes make pregnant women susceptible to oral health problems, which can have implications for infant oral health. The PIOHQI initiative worked to improve integration of preventive oral health care into primary care for pregnant women and infants.

Practical implications: Project findings provide promising evidence for efficacy of PIOHQI interventions.Keywords: Pregnant women, infants, oral health

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Pregnancy is a unique time of life characterized by complex physiological changes that may adversely affect oral health and increase risk for oral diseases. [1] Pregnancy can lead to oral health problems in women, including increased risk for tooth decay and gum disease. Several factors play a part in a pregnant person’s oral health: financing oral health care; women’s ability to access and utilize care; women’s knowledge, attitudes and behaviors; and workforce preparedness and willingness to provide oral health care to pregnant people.

Behavioral (e.g., vomiting, increased frequency of eating), hormonal and immunologic changes make pregnant people susceptible to oral health problems that can have implications for infant oral health. Local, systemic, genetic and environmental conditions can affect the formation of teeth throughout life. During pregnancy, maternal risk factors for tooth anomalies and developmental defects of the teeth include pregnancy problems, smoking and malnutrition. [2,3]

After pregnancy, a mother’s oral health is closely associated with her infant’s oral health. Mothers with high levels of the bacteria that cause tooth decay can transmit the bacteria to their infants. [4] The American College of Obstetricians and Gynecologists (ACOG) suggests that providing counseling on good oral health behaviors, promoting optimal oral hygiene and providing treatment during the perinatal period (i.e., pregnancy and the first year after birth) may reduce mother-to-child transmission, thereby preventing or delaying the onset of disease in the child while improving the mother’s oral health. 1 Despite this potential benefit, fewer than half of pregnant people received recommended preventive oral health services between 2012 and 2015. [5]

Because pregnant people may be receptive to changing health behaviors to improve their own health and the health of their unborn child, pregnancy is an opportune time to intervene. It is essential for pregnant people to receive appropriate and timely oral health care, including preventive, diagnostic and restorative treatment as well as education about how to maintain their own and their infant’s oral health. [6]

The lack of knowledge and understanding about perinatal oral health appears to cross demographic boundaries and is not limited to a single socioeconomic group. All women need to receive education about oral health changes during pregnancy, the importance and safety of oral health care while pregnant, how their oral health impacts their child’s oral health and the oral health care programs and coverage available in their state. They can also benefit from learning how eating healthy foods, practicing good oral hygiene and practicing other healthy behaviors will help keep them and their infant healthy. 6 Women may also need help with overcoming their fears about receiving oral health care in general as well as their concerns about the safety of receiving oral health care during pregnancy.

Medical professionals play a critical role in connecting oral health care and primary care, because they are often first to assess pregnant person’s and infants’ health and can promote oral health care. Incorporating oral health care (e.g., risk assessment, screening, education, anticipatory guidance and referral) into primary care is a promising strategy for reducing oral health disparities. [7]

Although adult dental services are available in all 50 states, some provide only emergency services.

A majority of dentists believe that perinatal oral health is important and are willing to provide oral health education and counseling during pregnancy. [8–10] However, their beliefs and treatment practices when caring for pregnant people vary significantly. Despite the benefits of receiving oral health care during pregnancy, oral health professionals often postpone providing care to pregnant people until after their delivery. [5]

In addition to a knowledgeable workforce, adequate reimbursement for oral health care is key to ensuring that pregnant people have access to care. Dental coverage in Medicaid is mandatory for children and adolescents ages 0 to 21 who are enrolled through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, which helps increase access to care. Pregnant adolescents up to age 21 can receive dental coverage through their state’s EPSDT program. However, states are not required to provide any dental coverage for adults.

Although adult dental services are available in all 50 states, some provide only emergency services. In addition, there is considerable variation among states in eligibility policies and scope of dental coverage for women during the perinatal period. In several states, pregnant people with low incomes are eligible for Medicaid dental coverage and thus have access to care that they don’t have during other periods of their lives. [11]

In 2011, the Health Resources and Services Administration (HRSA) in collaboration with ACOG, the American Dental Association and the National Maternal and Child Oral Health Resource Center (OHRC) convened an expert workgroup meeting that resulted in the landmark publication “Oral Health Care During Pregnancy: A National Consensus Statement.” Ultimately, the implementation of the guidance in the consensus statement should bring about changes in the health care delivery system and improve the standard of oral health care. [6]

From 2013 through 2019, HRSA funded the Perinatal and Infant Oral Health Quality Improvement (PIOHQI) initiative to define and implement evidencedbased models of care that would integrate preventive oral health care into primary care for pregnant people and infants.

Methods

The PIOHQI initiative funded 16 demonstration projects, which were intended to be unique and impactful and to meet local and community oral health needs. Three pilot projects — Connecticut, New York and West Virginia — were funded through 2018, and 13 expansion projects — Arizona, California, Colorado, Maine, Maryland, Massachusetts, Minnesota, New Mexico, Rhode Island, South Carolina, Texas, Virginia and Wisconsin — were funded through 2019. [12]

PIOHQI projects were able to accelerate progress by participating in a learning collaborative that provided peer-to-peer learning opportunities to share information about successes and challenges in common strategy areas. The learning collaborative was initially coordinated by the National Learning Network consortium, led by the Children’s Dental Health Project, which worked with the Association of Maternal and Child Health Programs, the Association of State and Territorial Dental Directors (ASTDD) and the FrameShift Group (2014 to 2017). Subsequently, support for the learning collaborative was transferred to the National Maternal and Child Center for Oral Health Systems Integration and Improvement consortium led by OHRC working in partnership with ASTDD (2017 to 2019). During this period, the learning collaborative also received support from the FrameShift Group. Technical assistance (TA) provided to the PIOHQI projects included monthly webinars, biannual meetings, a discussion list, a web portal and individualized technical assistance.

Outcomes

Throughout the initiative, PIOHQI projects engaged in numerous wide-ranging activities to reduce the prevalence of oral disease in pregnant people and infants at high risk for oral disease through improved access to and utilization of oral health care. While robust evidence for PIOHQI effectiveness is not available, project findings provide promising evidence for the efficacy of PIOHQI interventions.

“Ten Essential Public Health Services” and “Essential Public Health Services To Promote Oral Health in the United States” provide a strategic framework for many national programs, including the PIOHQI project. [13,14] Within the strategic framework, the PIOHQI project addressed the following essential services:

■ Assessing oral health status and implementing an oral health surveillance system.

■ Mobilizing community partners to leverage resources and advocate for/act on oral health issues.

■ Developing and implementing policies and systematic plans that support state and community oral health efforts.

■ Ensuring an adequate and competent public and private oral health workforce.

Assessing Oral Health Status: Massachusetts Department of Public Health

The Massachusetts project worked with early intervention sites in two communities to develop an oral health screening form for use during intake sessions and an oral health training module for staff. At the intake sessions, children who needed oral health care were referred to a dentist, and at the six-month follow-up visit, staff determined whether the child had a dental visit. Beginning in August 2018, 930 completed screening and referral forms were collected. Of the children screened, 81% had teeth, and of those, 85% were encouraged to make an appointment for a dental visit. Over a four-month period, the percentage of children who were seen by a dentist increased from 41% to 53%. The project successfully made the case, upon sharing findings with the state early intervention program, for incorporating oral health questions into its existing intake form, referring children to a dentist as needed and incorporating an oral health training module for staff onboarding.

Throughout the initiative, PIOHQI projects engaged in numerous wide-ranging activities to reduce the prevalence of oral disease.

Mobilizing Community Partners: Children’s Hospital of Wisconsin

The Wisconsin project integrated oral health education, preventive care and referral to a dentist into a prenatal care coordination (PNCC) program and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Process-level data collected from six implementation sites were analyzed to identify strategies to increase utilization of oral health care and key educational messages that resonated with the target population. Two of the six sites had a dental clinic as a partner for referrals. At one of the two sites, 25% of pregnant people enrolled in the PNCC program needed to see a dentist, and 66% of those who received a referral to a dentist at the clinic completed the appointment. At the other site, 40% of pregnant people enrolled in WIC needed to see a dentist, and 50% of those who received a referral to see a dentist at the dental clinic completed the appointment.

Two models emerged: 1) closed-loop referral (i.e., following a referral from a primary care practice to a dental clinic, the dental clinic communicates with the primary care practice about the pregnant people) for an appointment for a dental visit and 2) integrated preventive oral health services.

West Virginia Department of Health and Human Resources

The West Virginia project collaborated with its four managed care organizations to provide incentives to OB-GYNs to promote oral health care for pregnant people ($25 per member for a completed dental visit) and incentives to pregnant people to use the services offered ($25 per visit for up to two visits through 60 days postpartum).

Developing and Implementing Policies and Systematic Plans: California Department of Public Health

The California project worked with a consortium of health centers to increase the dental visit rate for infants. Petaluma Health Center used a multipronged approach, including oral health education for the medical team, building a coordinated scheduling system between the medical and dental electronic health record systems, creating standard protocols to identify infants eligible for dental visits and providing incentives to medical assistants for increasing the number of dental appointments for infants. Over a 21-month period, the number of infants with a well-child visit who visited the dentist by age 12 months rose from 68 to nearly 200 per month, and the number of surgery center referrals for dental procedures and the rate of tooth decay for children who received care fell.

Colorado Department of Public Health and Environment Oral Health Program: Cavity Free at Three

The Colorado project tested promising practices to integrate prenatal oral health screening, education and referral to oral health professionals into health care delivery systems that serve populations at high risk for oral disease, launching the pilot in two health centers and later expanding to private clinics. Project components consisted of clinical training for staff, a quality improvement approach to test strategies to increase access to oral health care and development of referral systems between oral health professionals and medical professionals. Preliminary results indicated that integrating prenatal screening, education and referral into health care delivery systems resulted in approximately four times as many patients receiving oral health care during pregnancy.

MaineHealth

The Maine project worked on a statewide pilot to integrate oral health screenings, risk assessments and referrals into prenatal medical visits. The project trained over 324 staff from 15 OB-GYN and family medicine sites to increase their awareness about the importance of prenatal oral health. Eighty-seven percent of pregnant people (1,093) at the sites received an assessment. Ten of the 15 sites exceeded the assessment goal of 80%.

The California project worked with a consortium of health centers to increase the dental visit rate for infants.

Maryland Department of Health and Mental Hygiene, Office of Oral Health

The Maryland project, with assistance from an interprofessional steering committee, produced “Oral Health Care During Pregnancy: Practice Guidance for Maryland’s Prenatal and Dental Providers.” Selected content was adapted from “Oral Health Care During Pregnancy: A National Consensus Statement.” The document provides recommendations and resources for prenatal care and oral health professionals to increase utilization of oral health care and improve the oral health of pregnant people and infants throughout the state. The document was mailed to about 7,600 dentists, dental hygienists, OB-GYNs and nurse midwives and sent electronically to numerous academic institutions, provider organizations and public health programs in Maryland.

Rhode Island Department of Health

The Rhode Island project worked with two health centers to test and track ways to increase referrals for pregnant people between medical practices and oral health practices. Strategies tested included conducting oral health training with medical and front office staff, regularly identifying and sharing lists of pregnant people with oral health staff and incorporating oral health into organizational strategic and incentive plans. At one health center, the percentage of pregnant people receiving oral health care increased from 14% to 31% during the project period. A dental hygienist worked with private medical practices to integrate oral health risk assessment, fluoride-varnish application and referral into practice workflow. Fluoride-varnish application rates in these medical practices increased from 4% to 10% during the project period for children ages 2 and under who were enrolled in Medicaid.

Ensuring Adequate and Competent Workforce: Children’s Dental Services (Minnesota)

The Minnesota project used workforce innovations, such as collaborative practice dental hygienists, advanced dental therapists and teledentistry, to expand oral health care access for pregnant people and infants, particularly in WIC clinics and early childhood programs located in rural and remote areas. The workforce innovations enabled more cost-efficient use of staff to provide care to more pregnant people and infants while decreasing per-patient costs.

Northern Arizona University

The Arizona project analyzed the state’s 2016 and 2017 Medicaid dental claims data to understand Arizona’s oral health workforce capacity and its impact on access to and utilization of oral health care. After completing the analysis, project staff developed infographics to help partners advocate for legislative change, including the addition of an adult emergency dental benefit passed in 2018 and a pregnant person’s benefit passed in 2019.

South Carolina Department of Health and Environmental Control

The South Carolina project collaborated with the South Carolina Department of Health and Human Services to establish a dental periodicity schedule and fluoride-varnish reimbursement policy to allow nonoral health professionals in primary care settings to receive reimbursement for fluoride-varnish applications up to four times a year, doubling allowed applications for children at risk for tooth decay who benefit from increased application frequency (every three to four months). The change resulted in a statewide increase in fluoride-varnish applications among infants and children from birth through age 4 from 15,207 applications in 2016 to 18,439 in 2018.

Lessons Learned

The PIOHQI projects revealed important lessons about how to increase access to and utilization of oral health care for pregnant people and infants at high risk for oral disease. Many of these lessons are applicable to organizations providing oral health care as well as to those striving to increase access to and utilization of overall health care.

Participating in a learning collaborative contributed to the project’s success.

Specific lessons learned through the projects included the following: [15]

■ Securing a commitment from leadership is important to achieving project goals and cultivating and sustaining leadership’s interest and engagement.

■ Making training modules available online (versus offering trainings in person only) is necessary to meet staff training needs. In addition, identifying educational messages and resources for professionals to use during visits is essential in light of workload challenges for both primary care professionals and social services professionals.

■ Focusing community outreach with a direct connection to health professionals enables measurement of outcomes by determining the number of patients who received oral health care.

■ Processes and procedures must be adapted locally to enable functionality at individual sites — a one-size-fits-all approach does not work.

■ Policy change comes about slowly, and it is important to be ready when an opportunity for change presents itself. Having oral health champions with relevant data to make the case for the importance of perinatal and infant oral health is essential to effect change.

■ Developing practice guidance can be very time-consuming. It may be more efficient to adapt existing guidance rather than starting from scratch.

■ Data are necessary for monitoring the impact of project activities. Evidence can be used to advocate for increased funding.

■ Participating in a learning collaborative contributed to the project’s success.

■ Securing funding and technical assistance, such as that provided by HRSA, is necessary to conduct any work in this area.

Success stories from the PIOHQI initiative mark the beginning of a roadmap that key federal, state and local stakeholders can follow, but the journey has only begun. More work is needed if further progress in improving perinatal and infant oral health is to be made.

FUNDING The authors received financial support for the development of this article from the Health Resources and Services Administration, grant no. U44MC30806.

ACKNOWLEDGMENTS The authors acknowledge Pamella Vodicka, MS, RD, captain, U.S. Public Health Service, Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, and Maria Teresa Canto, DDS, MS, MPH, dental officer, Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, for their helpful comments on drafts of this article.

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THE CORRESPONDING AUTHOR, Katrina Holt, MPH, MS, RD, can be reached at kholt@georgetown.edu.