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J Am Dent Assoc, Vol 139, No 9, 1173-1180.
© 2008 American Dental Association |
COVER STORY |
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Methods. In their study, the authors combined medical and dental claims data for 3,462 pregnant women in Minnesota with commercial dental insurance who had been pregnant between Jan. 1, 2004, and Dec. 31, 2005. The authors used McNemar pairwise comparisons, with each subject serving as her own control and her use of various dental services before pregnancy as her own baseline, to evaluate and compare the dental services used during and after pregnancy.
Results. During pregnancy, subjects’ use of several dental services—radiographs, restorative services, third-molar extractions and anesthesia—decreased significantly (P < .001) in comparison with their prepregnancy use. After pregnancy, subjects’ use of checkups, radiographs and restorative services showed significant increases (P < .001).
Conclusions. The significant decreases in use of these services during pregnancy and significant increases after pregnancy may suggest that these women and their dentists were using these services only conservatively during pregnancy or postponing their use altogether until after delivery.
Clinical Implications. This study’s findings may provide useful background information to medical and dental providers, health care plan administrators and policymakers as they consider recommendations regarding oral health care for women during pregnancy.
Key Words: Dental service use; pregnancy; oral health care during pregnancy
Abbreviations: ADA: American Dental Association.
Increasing evidence shows an association between poor oral health and adverse pregnancy outcomes. In recent years, for example, a number of studies have reported that periodontal disease during pregnancy is associated with an increased risk of premature delivery and low birth weight.1–3 Other studies have indicated that for women with periodontal disease, periodontal therapy may reduce the risk of delivering a preterm low–birth-weight infant.4–9 Hormonal changes occurring during pregnancy increase the risk of periodontal disease and other oral complications.10 For these reasons, it may become more important that pregnant women receive appropriate oral health care rather than delay the care until after delivery.
However, pregnant women are known to be less likely to receive dental care than the general female population.11–13 Financial barriers such as lack of dental insurance and low income have been identified as the most important factors.11–13 Other variables such as demographic characteristics (age, marital status, frequency of dental visits before pregnancy, education), perception (fear of certain aspects of dental care during pregnancy, lack of knowledge regarding the need for care) and dental providers’ attitude toward provision of care to pregnant patients (postponement of services until after delivery because of concerns about possible risks) also are found to be important factors.11–13
Many studies of pregnant populations have focused on these women’s access to and use of dental care during pregnancy and on identifying major barriers to their seeking oral health care.11–13 Because those studies were based on survey data consisting of self-reported or recall information—rather than on claims data regarding actual and specific types of dental services provided to these women, such as we used in our study—information on the various dental services used or comprehensive dental care received during pregnancy usually is not available. Additionally, little is known about the dental care women receive after pregnancy, which is of interest owing to the postponement of certain dental services until after delivery and the increased risks of dental problems (such as pregnancy gingivitis, swollen or bleeding gingiva, risk of decay associated with vomiting) or oral complications occurring during pregnancy. Therefore, we conducted a study to evaluate the comprehensive dental care received by women before, during and after pregnancy. To our knowledge, our study is the first of its kind.
We used dental claims submitted to Delta Dental of Minnesota for all dental services from 24 months before delivery through 12 months after delivery. Because women in the study had at least three years of continuous commercial dental coverage, the population was fairly homogenous and likely of a relatively high socioeconomic standing, thereby allowing us to eliminate financial barriers as impediments to accessing care. The purpose of our study was to evaluate and compare dental services used by women before, during and immediately after pregnancy. This study received approval from the institutional review board of the Minnesota Department of Health, St. Paul.
We used McNemar pairwise comparisons, with each subject serving as her own control and the subject’s use of dental services before pregnancy as her own baseline, to compare the dental services used during and after pregnancy. We grouped data for comparison according to the following six-month periods:
We selected the six-month time interval for dental care evaluations in this study because biannual dental checkups and prophylaxes traditionally have been advocated by general dental practitioners and are covered by dental insurance plans for regular and preventive care. We excluded the last month before delivery from the six-month "during pregnancy" period and also the first month after delivery from the six-month "after pregnancy" period because it is well-known that women tend not to visit dental clinics in these two months. The primary reasons for this are that pregnant women find sitting in a dental chair during the last month before delivery very uncomfortable, and the increased responsibilities and time constraints of motherhood may prevent new mothers from scheduling dental appointments during the first month after delivery. Owing to these known physical, not social, reasons, we did not consider drop-in dental service use in this study.
We grouped the dental services assessed in this study according to the American Dental Association (ADA) dental service categories.14 We also grouped certain services within each category (for example, radiographs in the diagnostic category) to enable us to assess use of specific dental services; these are noted in parentheses. The categories were as follows:
Information on the various dental services used or comprehensive dental care received during pregnancy usually is not available.
METHODS
TOP
ABSTRACT
METHODS
RESULTS
DISCUSSION
CONCLUSION
REFERENCES
We combined medical and dental claims data for women with commercial insurance coverage for medical and dental care. Using medical claims data from Blue Cross Blue Shield of Minnesota (N.A.G. and E.P.B., unpublished data, November 2006), we identified 15,396 maternity cases by date of delivery from Jan. 1, 2004, through Dec. 31, 2005. We matched these cases with administrative records held by Delta Dental of Minnesota (now DeCare) using various combinations of subscribers’ identification numbers and members’ dates of birth, names and addresses. We included in the study only women who had been enrolled with Delta Dental of Minnesota continuously for 24 months before and 12 months after delivery. This resulted in a study population of 3,462 women.
RESULTS
TOP
ABSTRACT
METHODS
RESULTS
DISCUSSION
CONCLUSION
REFERENCES
The ages of these 3,462 subjects, calculated as the age at delivery date, ranged from 15 through 47 years, with a mean age of 32.1 years. The majority of the subjects, 70.0 percent, were between the ages of 25 and 34 years. Table 1
compares dental care use by these women in terms of having a dental visit or a dental checkup and prophylaxis. The results indicated that more than one-half of the subjects had dental visits or dental checkups and prophylaxes before, during and after pregnancy. During pregnancy, as compared with before pregnancy, subjects had a significant decrease in dental visits and no significant difference in dental checkups and prophylaxes. We found that after pregnancy, compared with before pregnancy, subjects had significantly more dental visits as well as dental checkups and prophylaxes.
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, among women younger than 25 years, only 47.3 percent had dental visits and 41.1 percent had dental checkups and prophylaxes before pregnancy. By contrast, well more than 50 percent of subjects in each of the remaining age groups (25–29 years, 30–34 years and 35 years or older) had visited the dentist or received dental checkups and prophylaxes before pregnancy. However, younger subjects (those in the groups aged 24 years and younger and 25–29 years) had dental checkups and prophylaxes significantly more frequently after pregnancy than before pregnancy, while older subjects (those in the groups aged 30–34 years and 35 years and older) showed no significant differences.
Table 2 provides a comparison of dental service use among women before, during and after pregnancy, according to ADA dental service category.14 Use of preventive dental care, such as dental prophylaxes, among women in the six-month before-, during- and after-pregnancy study periods was 56.7 percent, 56.1 percent and 59.5 percent, respectively. In terms of subjects’ receiving dental prophylaxes, there was no significant difference between the before-pregnancy and during-pregnancy rates and a significant increase after pregnancy. Subjects’ use of prosthodontic (both removable and fixed) and orthodontic services was not significantly different before, during and after pregnancy.
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After and before pregnancy. Comparing dental service use among subjects after and before pregnancy, we found significant increases in the receipt of diagnostic, preventive and restorative services. We found significant increases in the receipt of the following specific services: diagnostic—checkups and radiographs; preventive—prophylaxes; and restorative—placement of resin-based composite restorations.
Subjects were as likely before pregnancy as during pregnancy to receive prophylaxes as well as dental checkups.
Furthermore, it is of special interest to note that use of radiographs and restorative services declined significantly (P < .001) during pregnancy and increased significantly (P < .001) after pregnancy when compared with use before pregnancy. Specifically, the prevalence in receipt of radiographs dropped from 32.7 percent of subjects before pregnancy to only 2.9 percent during pregnancy, then increased to 53.9 percent after pregnancy. The proportion of subjects receiving restorative services also dropped from 16.8 percent before pregnancy to 9.0 percent during pregnancy, and it increased to 21.7 percent after pregnancy. Use of other services, such as anesthesia and oral surgeries, also showed significant declines (P < .001) during pregnancy, but no significant increases after pregnancy when compared with before-pregnancy use. For example, use of anesthesia dropped from 2.1 percent before pregnancy to almost zero during pregnancy and then rose to 1.8 percent after pregnancy. Oral surgeries, especially extractions of third molars, declined from 1.2 percent before pregnancy to 0.1 percent during pregnancy, then rose to 0.9 percent after pregnancy; extractions of teeth other than third molars had a relatively minor decline from 0.8 percent before pregnancy to 0.3 percent during pregnancy, then rose to 0.6 percent after pregnancy.
The dental services subjects used most frequently during pregnancy were prophylaxis and checkups—56.1 percent and 54.1 percent, respectively—followed by restorative services, at only 9.0 percent. Only 2.2 percent and 0.6 percent of women during pregnancy received emergency or problem-focused examinations and emergency treatment of dental pain, respectively.
The figure shows subjects’ monthly use of dental services from 24 months before delivery through 12 months after delivery. The proportion of subjects using any dental services and receiving prophylaxes remained relatively stable until the last month before delivery, when it dropped considerably (6.9 percent using any dental services and 5.4 percent receiving prophylaxes) and remained low the first month after delivery. The prevalence of use of dental services or receipt of prophylaxes then increased substantially, reaching the maximum (17.1 percent for dental services and 13.2 percent for prophylaxes) the second month after delivery. In the following six-month period from the second month through the seventh month after delivery, the monthly use of dental services and receipt of prophylaxes declined dramatically.
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The relationship between monthly patterns of receipt of radiographic examinations and prophylaxes revealed more clinical information of note: about one-half of the dental prophylaxis visits involved the making of radiographs for subjects before pregnancy, versus almost none of the visits during pregnancy, versus almost every such visit immediately after pregnancy. After the seven-months-after-delivery period, the relationship between the two services returned to what it had been before pregnancy.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Subjects were as likely before pregnancy as during pregnancy to receive prophylaxes as well as dental checkups. Dental checkups and prophylaxes were the two dental services most frequently used by this group of women. This high rate of use of preventive dental care during pregnancy might be a reflection of higher than average preventive dental service coverage and the relatively high economic standing of this group of subjects. Because pregnant women may be in greater need of preventive dental care, a higher use of preventive dental care during pregnancy might be expected. However, we did not observe this trend in this group.
About 60 percent of the subjects in this study received dental care in the six-month during-pregnancy study period, and during that period few subjects received restorative services (9.0 percent), emergency or problem-focused examinations (2.2 percent) or emergency treatment of dental pain (0.6 percent). These results differed from those of other studies,11–13 in which most women did not receive dental care during pregnancy and about one-half of those who sought dental care reported having dental problems.
In our study, younger subjects exhibited much lower rates of dental care use than did older subjects. However, only younger subjects had significantly more frequent dental checkups and prophylaxes after pregnancy than before pregnancy. The fact that younger women tend to have healthier teeth than do older women15,16 could lead those women to perceive less need for dental care and could explain their low frequency of dental care use before pregnancy. The increases in dental checkups and prophylaxes after pregnancy versus before pregnancy could be attributed to several factors:
The significant reduction (P < .001) in the prevalence of subjects receiving radiographs, third-molar extractions and anesthesia services during pregnancy may indicate that these pregnant women and their dentists likely were following the ADA recommendations to avoid or postpone these elective services or use them only conservatively during pregnancy.17 These women also exhibited a significant decrease in use of restorative services during pregnancy and a significant increase in use of those services after pregnancy, perhaps suggesting that they had postponed certain nonurgent treatment services until after delivery.
Periodontal services were rarely used among this population of women with comparatively younger age; we found that only 1.7 percent, 1.0 percent and 1.8 percent of women received periodontal services before, during and after pregnancy, respectively. Most pregnant women need only prophylaxes to maintain periodontal health. Among the few in our cohort who needed more intense periodontal treatments, use of these services showed a significant drop during pregnancy. Periodontal treatments have been recommended as a preventive dental treatment for pregnant women with moderate-to-severe periodontal diseases. We also note the significant (P = .024), but not highly significant, decline in the use of fluoride treatments during pregnancy. The use of fluoride treatments among subjects before, during and after pregnancy was low (only about 2.6–3.8 percent of subjects), possibly owing to Minnesota’s fluoridated public water supply and to their use of many fluoridated products, such as toothpaste, dental floss and some bottled water.
Subjects were as likely to receive preventive dental care during pregnancy as before pregnancy.
The relationship between the monthly receipt of dental radiographs and dental prophylaxis in our cohort revealed the impact of dental insurance coverage on these services: about one-half of the dental prophylaxis visits involved the provision of radiographs for women before pregnancy as well as after seven months postdelivery, because dental insurance plans generally provide coverage for biannual prophylaxes and annual dental radiographs. While women avoided receiving radiographs during pregnancy, they appeared to compensate for this after delivery, as we found that nearly every postdelivery dental prophylaxis visit included a radiograph.
About 60 to 75 percent of pregnant women experience "pregnancy gingivitis,"17 which correlates with an increased sensitivity to dental plaque that can be found among pregnant women.10 Women who have gingivitis before pregnancy are more likely to experience a worsening of the condition during pregnancy. If gingivitis is left untreated, it can develop into severe periodontal disease, leading to bone loss around the teeth. In this study population, only 1 percent or less of the subjects used gingivitis-related services and we did not find the use of gingivitis-related services to be significantly different for women before, during and after pregnancy. This low rate of using gingivitis-related services could be attributed to the relatively young age of this study population (mean age, 32 years). Although gingivitis is a common problem among pregnant women, dental prophylaxis and excellent home care during pregnancy usually will control it. From the population’s stable use of dental prophylaxes during pregnancy, one can assume that this population had relatively good home care during pregnancy and that gingivitis-related problems decreased after pregnancy for most women, explaining the lack of any significant increases in use of gingivitis-related services during and after pregnancy.
Even though we found the use of basic restorative services, such as resin-based composite restorations, to be significantly increased among subjects after pregnancy versus before pregnancy, we found that subjects’ postpregnancy use of complex clinical services—such as major restorative services, endodontic treatment, periodontic treatment, provision of removable and fixed prosthodontic restorations and oral surgery services—was not significantly different from their prepregnancy use.
This study does have some limitations. Of the 15,396 maternity cases we identified by date of delivery during 2004 and 2005 using medical claims data, 3,462 matched to dental claims data and involved at least three years of continuous commercial dental coverage. We relied on the continuous dental benefits coverage in the study period to enable us to evaluate and compare the dental services subjects used before, during and after pregnancy, when financial barriers were eliminated as impediments to accessing dental care. Therefore, our study population likely is of a relatively higher socioeconomic standing and may not represent dental care use among pregnant women in the general U.S. population.
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CONCLUSION |
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FOOTNOTES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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