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J Am Dent Assoc, Vol 140, No 2, 211-222.
© 2009 American Dental Association
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RESEARCH

Providing Dental Care to Pregnant Patients

A Survey of Oregon General Dentists



Colleen E. Huebner, PhD, MPH, Peter Milgrom, DDS, Douglas Conrad, PhD and Rosanna Shuk Yin Lee, MA


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 References
 
Background. A growing number of studies and reports indicate preventive, routine and emergency dental procedures can be provided safely to pregnant patients to alleviate dental problems and promote oral health of mothers and children.

Methods. In 2006 and 2007, the authors conducted a survey of 1,604 general dentists in Oregon. The survey asked dentists about their attitudes, beliefs and practices regarding dental care for pregnant patients. The authors compared the responses with 2006 guidelines from a New York State Department of Health expert panel.

Results. The response rate was 55.2 percent. Most respondents (91.7 percent) agreed that dental treatment should be part of prenatal care. Two-thirds of respondents (67.7 percent) were interested in receiving continuing dental education (CDE) regarding the care of pregnant patients. Comparisons of self-reported knowledge and practice with the aforementioned guidelines revealed several points of difference; the greatest regarded obtaining full-mouth radiographs, providing nitrous oxide, administering long-acting anesthetic injections and use of over-the-counter pain medications.

Conclusions. Dentists need pregnancy-specific education to provide up-to-date preventive and curative care to pregnant patients. The results of the study identified specific skills and misinformation that could be addressed through CDE.

Clinical Implications. Comprehensive dental care provided during pregnancy is needed to ensure the oral health of all women at risk of experiencing pregnancy-specific problems, as well as the prevention of early childhood caries.

Key Words: Access to care; aspirin; dental care; pregnancy; prenatal care; vulnerable populations; women’s health; continuing education programs

Abbreviations: CDE: Continuing dental education. • ECC: Early childhood caries. • FDA: Food and Drug Administration. • NSAIDs: Nonsteroidal anti-inflammatory drugs.

During the past 13 years, there has been increasing interest in the oral health of pregnant patients. One reason is the reported association between maternal periodontal infection during pregnancy and obstetric complications including preeclampsia1 and premature birth.2,3 The possibility that periodontal disease is associated with preterm birth has led to several intervention studies, with mixed results.4–8 One explanation for the inconsistent findings is that periodontal therapy provided after the systemic inflammation is established may occur too late to reduce the risk of experiencing adverse birth outcomes.9

A second reason for interest in oral health and pregnancy is a concern for women’s health as a goal in itself.10–13 Even among healthy women, the physiological changes that accompany pregnancy can lead to gingivitis, periodontitis and benign lesions (pregnancy tumors).14,15 Hormonal changes, along with modifications in diet and frequency of eating can increase the risk of developing tooth decay.14 Preventive care and dental treatment can be provided safely during pregnancy,2,15–18 yet, as reported by a four-state study, many women do not receive this type of care.19 Additionally, dental care during pregnancy may decrease early childhood caries (ECC) if it includes anticipatory guidance about infant oral health and ways to reduce early transmission from mother to infant of the bacteria that lead to ECC.20–22

In the past decade, professional associations and governmental agencies have issued practice recommendations, policy briefs and fact sheets with the goal of raising public and professional awareness of the oral health needs of pregnant patients and improving oral health care provided during pregnancy and early childhood.23–25 In 2006, for example, guidelines for medical and dental professionals were codified by an expert panel convened by the New York State Department of Health.26

Even among healthy women, the physiological changes that accompany pregnancy can lead to gingivitis, periodontitis and benign lesions.

We conducted a statewide survey of general dentists’ attitudes, beliefs and practices regarding treatment and anticipatory guidance for pregnant patients that was intended to contribute to these efforts by adding a snapshot of the practices in one state and by identifying additional topics for dental education regarding pregnancy and oral care.


   SUBJECTS, MATERIALS AND METHODS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 References
 
Survey population, materials and methods. We used the Tailored Design Method27 to survey general dentists in Oregon. We mailed questionnaires in December 2006 to 1,604 dentists who we identified by means of the American Dental Association’s master file of members and nonmembers. We mailed the questionnaire only to practitioners in solo or partnership practices, associates or employee dentists in incorporated or unincorporated practices, or employees in state-run or federally run clinics.

The survey included 54 questions developed by the study team or drawn from previous studies.28,29 In the survey, we asked for demographic information about the dentists and their patients and assessed dentists’ attitudes, beliefs and practices about preventive care, routine and emergency treatment, and prescribing medications to pregnant patients. To differentiate knowledge from current practice, we asked two sets of questions about eight routine procedures: performing scaling and root planing, obtaining a single periapical radiograph, obtaining full-mouth radiographs, performing a single tooth extraction, performing endodontic therapy, placing resin-based composite restorations, administering local anesthetic injections and providing nitrous oxide. The first question was "During which period of pregnancy do you believe it is appropriate to provide each of the following?" The second question was "How often do you perform each of the following procedures on pregnant women currently?"

We asked additional questions to determine dentists’ knowledge about providing five procedures in emergencies: extracting a tooth, opening and broaching (to relieve pain), incising and draining an abscess, placing a temporary restoration and administering an injection of a long-acting anesthetic. Six questions asked how often dentists prescribed or recommended pharmaceuticals to patients to control pain or treat infection. We asked specifically about acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, codeine or other narcotics (for example, hydrocodone), an antiseptic agent (chlorhexidine gluconate [PerioChip, Dexcel Pharma Technologies, Hadera, Israel]) and doxycycline hyclate (Periostat, CollaGenex Pharmaceuticals, Fort Worth, Texas).

To examine the effects of recent recommendations and reports regarding oral health care of pregnant patients, we asked the year in which dentists received their dental degrees, about receipt of continuing dental education (CDE) regarding pregnancy-related topics, and whether the dental procedures they provided to pregnant patients differed from how they practiced in the period 1999 through 2002. We chose the 1999-through-2002 period because it is the recent past but before the publication of highly visible position statements such as the American Academy of Periodontology’s 2004 statement regarding managing the periodontal care of pregnant patients.30 Finally, we asked dentists about their interest in receiving patient education materials or receiving CDE. The Institutional Review Board of the University of Washington approved the study. We included the elements of informed consent in the cover letter that accompanied the survey.

Analysis. We used statistical software (Stata, Version 9, StataCorp, College Station, Texas) to summarize respondents’ answers to the survey questions. We compared their responses to the guidelines for oral health professionals provided by the New York State Department of Health.26 According to these guidelines, dental care is safe and effective during pregnancy. The guidelines encourage dentists to provide dental and periodontal examinations and state that needed diagnosis, radiographs and treatment measures can be administered to patients at any time. The guidelines do not differentiate routine from emergency care, stating "needed oral treatment should be provided any time during the pregnancy."26(p26) If the guidelines did not address the use of a particular agent or drug, we referred to U.S. Food and Drug Administration (FDA) drug warnings and cautions available in relevant published texts,31–33 as well as a 2006 article by Turner and colleagues.34 The FDA’s categories for drug use in pregnancy range from A (adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities in any trimester of pregnancy) to D (adequate well-controlled or observational studies in pregnant women have demonstrated a risk to the fetus; however, the benefits of therapy may outweigh the potential risk).35 There also is a category X (adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities; the use of the product is contraindicated in women who are or may become pregnant) that comes after category D.

A total of 85.7 percent of dentists surveyed reported they provide oral hygiene instruction to pregnant patients often and another 10.6 percent reported doing so sometimes.

We used logistic regression to identify whether dental education was associated with attitudes, knowledge or practices consistent with the guidelines. In our analyses, we considered two aspects of education. The first was years since graduation from dental school, in which a categorical variable code of 1 indicated graduation within the previous 10 years and a code of 0 indicated graduation 11 or more years previous. The second was a report of receiving CDE in periodontal disease during pregnancy or oral hygiene for pregnant patients, in which a code of 1 indicated attending either type of course and a code of 0 indicated no course. Learning if more recent graduates or dentists who received CDE about pregnancy-specific topics are more likely to describe using preferred practices has implications for dental school curricula and future CDE. We included sex (male versus female) in the model to learn if female dentists might have a different approach than males to pregnancy care, possibly based on personal experience rather than professional training.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 References
 
Respondents and characteristics of their dental practices. The total number of eligible dentists was 1,502, and 829 surveys were completed, resulting in a valid response rate of 55.2 percent. We found no systematic differences in terms of age or years since graduation from dental school between respondents and nonrespondents. Respondents’ mean age was 47 years (SD = 13) and 43.2 percent were younger than 45 years; 82.7 percent were male (Table 1Go). A total of 31.5 percent had received their dental degrees in the preceding 10 years, and the remainder had received their degrees 11 or more years previous. A total of 34.0 percent of respondents reported having received CDE about "periodontal disease of pregnant women," 28.0 percent reported having received CDE about "oral hygiene for pregnant women," and 43.9 percent reported having received CDE about "early childhood caries." The most common employment situation was sole proprietor (42.2 percent), followed by working in an incorporated dental practice as a shareholder owner (14.6 percent) or associate (12.9). The respondents reported seeing an average of 52 patients in a typical week, most of whom had private dental insurance. Three-quarters (74.9 percent) of respondents reported that more than 50 percent of their patients were younger than 45 years.


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  		TABLE 1 Survey respondents’ characteristics (N = 829).

 
Provision of patient education about pregnancy-related topics. A total of 85.7 percent reported they provide oral hygiene instruction to pregnant patients often and another 10.6 percent reported doing so sometimes. Similarly, 82.6 percent talked with more than 75 percent of their pregnant patients about periodontal disease. Fewer (45.1 percent) talked with their pregnant patients about caries transmission from mother to child and ECC. A total of 57.1 percent provided patients with educational brochures regarding oral health care and pregnancy. More respondents provided brochures regarding children’s oral health; the most common topic was oral hygiene (67.0 percent).

Attitudes and beliefs toward behavior counseling and treatment of pregnant patients. Respondents’ attitudes and beliefs are summarized in Table 2Go. Most (91.7 percent) agreed that dental treatment should be part of prenatal care. A total of 85.6 percent agreed that pregnant patients were more likely to seek dental care if their physicians recommend it; however, 79.5 percent disagreed with the statement that physicians are better able than dentists to counsel pregnant patients about oral health. Two-thirds (66.6 percent) disagreed that their practices were too busy to add counseling about oral hygiene to pregnant patients; 20.0 percent neither agreed nor disagreed, and 11.3 percent agreed their practices were too busy to add this counseling. Nearly all (94.9 percent) agreed counseling about periodontal disease and premature birth was important for the mother’s and child’s health, and 81.1 percent said it was worth their time to discuss with pregnant patients how tooth decay in the mother could affect the child’s dental health. A total of 77.2 percent were confident in their skills to counsel pregnant patients, 14.2 percent were neutral in their self-assessment, and 7.1 percent reported they did not have the needed skills. A total of 86.1 percent disagreed with the statement "There is little I can do to affect pregnant patients’ oral hygiene."


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  		TABLE 2 Oregon general dentists’ attitudes and beliefs toward behavioral counseling and treatment for pregnant patients (N = 829).

 
Two beliefs emerged from our findings as potential barriers to counseling. The first finding was that 71.2 percent of respondents said insurance plans do not compensate adequately for time spent to counsel pregnant patients; related to this, 39.6 percent agreed that patients’ out-of-pocket cost for counseling could be a barrier. The second finding was that 41.5 percent said they were concerned about being sued if something goes wrong with a patient’s pregnancy.

Two-thirds (67.7 percent) reported interest in receiving CDE on care for pregnant patients. Eighty percent expressed interest in learning how to talk with patients about oral health care during pregnancy, and 89.2 were interested in receiving patient-directed educational materials about care during pregnancy.

Knowledge and practice of providing routine dental care to pregnant patients. The most common response about the timing of routine care was that it should be provided in the second trimester (Table 3Go,26 page 216). Obtaining full-mouth radiographs was the procedure for which respondents’ beliefs differed most from the recommendation that a full-mouth radiograph can be obtained from a pregnant patient if necessary; 54.0 percent said they believed it was never appropriate to obtain a full-mouth radiograph, and 60.1 percent said they never did so in practice. In contrast, 2.7 percent believed it was never appropriate to provide a single periapical radiograph, and 5.1 percent reported never doing so in practice. In response to our questions about administering local anesthetic injections (for example, lidocaine) or providing nitrous oxide, 23.5 percent of respondents said they administered local anesthetic injections often, 71.4 percent said they administered the injections sometimes or rarely, and 2.7 percent said they never administered local anesthetic injections to pregnant patients. A total of 80.8 percent believed it was never appropriate to provide nitrous oxide to a pregnant patient, 90.1 percent said they never did so, and 5.4 percent said they rarely did so.


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  		TABLE 3 Oregon general dentists’ knowledge and appropriate use of procedures with pregnant patients (N = 829).

 
When asked if their practices differed from what they did in the past—in the years 1999 through 2002—few dentists reported any changes. Of those who provided comments, most described doing more at the time of the survey than previously. For example, one dentist wrote that in the past, "I would only do routine treatment during second trimester, now we do it as long as (the) pregnancy is healthy."

Knowledge and practice of providing emergency treatment to pregnant patients. In response to the questions the survey asked about providing dental emergency procedures—extracting a tooth, opening and broaching, incising and draining, placing a temporary restoration, and administering a long-acting local anesthetic injection—most respondents reported that they believed it was appropriate to provide these if needed in an emergency. The second trimester was most frequently reported as the most appropriate time for each. Greatest caution was reported for a long-acting anesthetic such as bupivacaine hydrochloride, an FDA category C drug (one for which animal studies have shown an adverse effect, and there are no adequate and well-controlled studies in pregnant women, or no animal studies have been conducted, and there are no adequate and well-controlled studies in pregnant women35). When asked about its use in emergency cases, 42.7 percent of respondents replied it was never appropriate.

Knowledge and practice of prescribing pharmaceuticals to pregnant patients. The survey asked six questions about prescribing or recommending pharmaceuticals—acetaminophen, ibuprofen, aspirin, narcotic pain medication, antiseptic agents such as PerioChip (an FDA category C drug) and Periostat. A total of 13.1 percent of respondents reported that they never prescribe or recommend acetaminophen to pregnant patients (Table 4Go31–33,35). Fifty-one percent reported they never prescribe or recommend NSAIDs such as ibuprofen to pregnant patients. A total of 28.3 percent of respondents reported they do or would recommend aspirin to pregnant patients; an additional 4.8 percent of respondents did not answer this question. With regard to methods to control infection, 59.2 percent of respondents said they rarely or never treat pregnant patients with PerioChip. A total of 6.7 percent of respondents said they use Periostat, an FDA category D drug, often or sometimes with pregnant patients, and 18.2 percent said they used it rarely.


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  		TABLE 4 Oregon general dentists’ report of prescription and recommendation of pharmaceuticals for pregnant patients (N = 829).

 
Six respondents described making greater efforts at the time of the survey to consult with the pregnant patient’s physician regarding medications and prescriptions.

Twenty-one of 829 respondents commented on changes since 2002 in their use of pharmaceuticals. They described prescribing or recommending pharmaceuticals more often at the time of the survey than in the past. Ten of 15 dentists mentioned pharmaceuticals by name: four said they used Perio-Chip more often at the time of the survey than previously, four reported they had recommended Tylenol (acetaminophen, McNeil-PPC, Fort Washington, Pa.) only rarely in the past, and two reported prescribing Vicodin (hydrocodone, Abbott Laboratories, Abbott Park, Ill.) more often at the time of the survey than previously. In addition, six respondents described making greater efforts at the time of the survey to consult with the pregnant patient’s physician regarding medications and prescriptions.

Multivariate analyses of associations between respondents’ characteristics and preferred practices. We used logistic regression to test if dental education was associated with respondents’ knowledge regarding provision of services to pregnant patients. Each analytic model included three categorical variables: years since receiving dental degree (in the preceding 10 years versus 11 or more years previous), receiving CDE on a pregnancy-related topic (yes versus no) and dentist’s sex (male versus female).

We examined nine responses: two attitudes for which there was a diversity of opinion within the sample ("My practice is too busy to add counseling for pregnant women" and "It is worth my time to counsel pregnant patients about how tooth decay can affect their baby"), two beliefs about routine procedures for which practice recommendations are clear (performing scaling and root planing and performing a single tooth extraction, both of which are appropriate during pregnancy), three beliefs about procedures for which there is confusion or controversy in the literature (obtaining full-mouth radiographs, providing nitrous oxide and prescribing or recommending acetaminophen; each are appropriate during pregnancy) and two safety concerns (knowing to avoid recommending aspirin and to avoid administering bupivacaine hydrochloride even in an emergency situation). Table 5Go (page 219), a statistical contingency table, shows the independent variables and responses for each outcome as coded for the regression analyses.


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  		TABLE 5 Responses for variables used in the logistic regression models.

 
Table 6Go (pages 220–221) summarizes the results of the regression analyses.36 We found that six of 27 tests of associations between respondents’ characteristics and dental practices were statistically significant. The odds of agreeing it was worth their time to counsel pregnant patients about the transmission of caries-causing bacteria were higher among respondents who had graduated in the preceding 10 years than it was among those who had graduated 11 or more years before (odds ratio [OR] = 2.54; 95 percent confidence interval [CI] = 1.54–4.19), and it was higher among those who had received CDE regarding a pregnancy-related topic compared with those who had not (OR = 2.09; 95 percent CI = 1.33–3.28). Respondents who had graduated in the preceding 10 years were less likely to give the preferred response regarding scaling and root planing (that is, to provide these procedures) (OR = .36; 95 percent CI = .15–.86) but were more likely to agree that a full-mouth radiograph is appropriate (OR = 1.51; 95 percent CI = 1.09–2.09). Also, recent graduates were more likely to give the preferred response concerning recommending aspirin (avoiding recommending it) (OR = 3.94; 95 percent CI = 2.53–6.13), as were female dentists (OR = 2.47; 95 percent CI = 1.40–4.38).


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  		TABLE 6 Associations between characteristics of Oregon general dentists and odds of giving the preferred response regarding procedures and practices for pregnant patients.*

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 References
 
Each year more than six million women in the United States become pregnant.37 Preventive, routine and emergency dental procedures can and should be provided to pregnant patients. Beyond treatment, there is a need for pregnancy-specific preventive care and oral health education. To provide this care, knowledgeable dentists should become key members of the prenatal health care team. The results of our study indicate that dentists are willing to help make this happen. There was nearly universal agreement among the respondents that dental treatment should be part of prenatal care, and most respondents reported having favorable attitudes toward pregnancy-specific counseling. One-third of respondents reported receiving CDE, and two-thirds reported an interest in receiving CDE about a pregnancy-related topic.

We identified several areas that could be addressed by CDE. A total of 21.3 percent of respondents reported they felt neutral or were not confident about their counseling skills; 81.1 percent endorsed this as a topic of personal interest.

Our data indicate some misinformation regarding routine procedures. The procedures of obtaining full-mouth radiographs and providing nitrous oxide were the most misunderstood, but gaps in knowledge also were evident regarding obtaining a single periapical radiograph, performing scaling and root planing, opening and broaching, or extracting a single tooth as emergency services.

Safety concerns were revealed by dentists’ responses to questions about their knowledge regarding administration of a long-acting anesthetic injection even in an emergency situation and that lidocaine is safe for use,34 as well as in their recommendations regarding aspirin and ibuprofen. The extent of misinformation about aspirin in particular is a solid argument for addressing this problem with general dentists, because they are the practitioners most likely to treat pregnant patients experiencing dental pain.

We found relatively few associations between years since graduation or CDE and preferred dental practices; however, those associations that did emerge are encouraging. Receiving CDE was associated with significantly greater odds of reporting "it is worth my time to counsel pregnant patients about how decay can affect the baby," which suggests CDE could be a useful strategy in increasing this practice even more widely. In addition, recent graduates were more likely to be up-to-date on three of the nine preferred practices we examined by means of multivariate analyses. These results suggest both CDE and dental school curricula could be strengthened further, and that CDE might be marketed specifically to dentists who received their degrees more than 10 years previous to update their knowledge about the provision of care to pregnant patients.

One approach to professional education would be to train both dentists and obstetricians in the oral health needs and care of pregnant patients. A recent survey of Ohio dentists and obstetricians suggests each type of practitioner would gain, as would their patients.38 The results of the survey showed that obstetricians were more comfortable than dentists with dental procedures and medication use during pregnancy, but they were less likely to agree that oral health screening should be part of prenatal care. In contrast, 97 percent of dentists endorsed oral health screening, but were less likely to endorse specific treatments and medications as safe.

Educating health care professionals and their patients about the safety and advantages of dental treatment during pregnancy can benefit all women—especially low-income women—who are at greater risk of experiencing adverse pregnancy outcomes, including preterm delivery,39 and untreated dental caries.40 For low-income women, pregnancy can be the only time they have access to comprehensive health services. The primary public funding source of dental services, Medicaid, requires coverage of services for people younger than 21 years; for adults older than 21 years, dental services are an optional benefit not included in most state plans.41 In Oregon, dental services for pregnant patients who are eligible for Medicaid are covered, but the benefits extend to only 60 days postpartum.42 Thus, pregnancy is a fleeting opportunity to provide dental care to low-income women and for dentists to encourage health-promoting behaviors that can have longer-term benefits for mothers and children.


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
References
 
Focused CDE, better coordination between dental and medical delivery systems, and changes in public and private health insurance benefits may be effective strategies to improve the provision of oral health care to pregnant patients.


   FOOTNOTES
 

Dr. Huebner is an associate professor, Department of Health Services, University of Washington, Seattle, and the director, graduate program in Maternal and Child Health Public Health Leadership, University of Washington, Seattle, Box 357230, Seattle, Wash. 98195–7230, e-mail "colleenh{at}u.washington.edu". Address reprint requests to Dr. Huebner.


Dr. Milgrom is a professor, Department of Dental Public Health Sciences, and the director, Northwest/Alaska Center to Reduce Oral Health Disparities, University of Washington, Seattle.


Dr. Conrad is a professor in the Department of Health Services, University of Washington, Seattle. Ms. Lee is a graduate student, Department of Sociology, University of Washington, Seattle.


Disclosures. None of the authors reported any disclosures.


This study was supported by grant R40MC03622 to Dr. Milgrom from the Maternal and Child Health Bureau, Health Resources and Services Administration, and grant 1 U54 DE14254 from the National Institute of Dental and Craniofacial Research, National Institutes of Health.


   References
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 SUBJECTS, MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 References
 

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