Running head: IMPROVING ORAL HEALTH IN PREGNANCY

Improving Oral Health in Pregnancy
Philsy Jaison BSN, RN
Arizona State University

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Abstract
Maintaining good oral health during pregnancy is a significant contributor to healthy
pregnancy outcomes. The physiological changes that happen during pregnancy can adversely
affect women’s oral health and place her at risk for pregnancy outcomes such as miscarriage and
preeclampsia. The unborn child’s health can also be affected by premature birth and low birth
weight. Although professional organizations have evidence-based practice guidelines for both
prenatal and dental providers, the evidence shows a gap between recommendations and practice.
An oral health promotion project for pregnant women was implemented in a federally qualified
community health center where there was a lack of adherence to the guidelines. The purpose of
this project was to implement established oral health screening guidelines for pregnant women
and to increase dental visits among pregnant women. For this project, a two-item maternal oral
health-screening tool (MOS) for the prenatal providers was added into the electronic health
record to standardize and document oral health screening for pregnant women at their first
prenatal visit. After three months of implementation, there was a significant increase in maternal
oral health screening and referral. This project may be replicated at any prenatal setting to
improve oral health during pregnancy.
Keywords: Oral health assessment, pregnancy, and dental visits

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Improving Oral Health in Pregnancy
Oral health is a pivotal element of general health and wellbeing. According to the World
Health Organization (WHO), oral health is a “state of being free from chronic mouth and facial
pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal
disease, tooth decay and tooth loss, and other diseases and disorders that affect the oral cavity”
(WHO, 2016). In the United States, 27.4% of adults aged 20-44 years have dental carries
(National Center for Health Statistics, 2015). The 7th oral health objective of Healthy People
2020 is to increase the proportion of children, adolescents, and adults who used the oral health
care system in the past year. The baseline for this objective in the year 2007 was 44.5% and the
target is 49% by the year 2020. Unfortunately, from 2007 to 2011 this rate decreased to 41.8%
(U.S Department of Health and Human Services, 2014). Thus, promoting oral health is a
significant unmet need across the lifespan.
Pregnancy is an opportune time for health promotion and maintenance and may be the
only time low income women with poor oral health seek medical care. It has been demonstrated
that mothers who obtain dental care are more likely to take children to the oral health provider.
Besides these advantages, oral health care in pregnancy is indispensible for many reasons.
Therefore, a proactive approach is necessary to eliminate the barriers and include this type of
care during pregnancy. This project focused on the importance of oral health in pregnancy and
effective oral health promotion interventions during pregnancy.
Background and Significance
Undetected and untreated infections and inflammatory conditions in the oral cavity of the
mother can have serious consequences for both the mother and fetus. The presence of

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periodontal pathogens in the feto-placental compartment can produce IgM antibodies that in turn
may result in premature birth or miscarriage. This can occur through direct dissemination or
indirectly as a result of cytokine and mediator production. In addition, the placental structural
changes from infection or inflammation can lead to preeclampsia in the mother and nutritional
deficiency in the fetus (Madianos, Bobetsis, & Offenbacher, 2013). Hyperemesis gravidarum and
increased estrogen levels are the other significant contributing factors for oral problems during
pregnancy. Although pregnancy itself does not cause periodontal disease or gingivitis, the
normal physiologic changes that occur with pregnancy may exacerbate any pre-existing oral
conditions (Hemelatha, Manigandan, Sarumathi, Aarthi, & Amudhan, 2013).
Between the years of 1999-2004, only 58.3% of pregnant women had a dental visit;
61.4% of those encounters were for preventive care (Azofeifa, Yeung, Alverson, & BeltranAguila, 2014). Although there is no data available for Arizona, it is helpful to look at information
from other comparable states. The Pregnancy Risk Assessment Monitoring System (PRAMS)
2011 survey results from ten States estimates that only 49% women visited a dentist during the
last pregnancy (Centers for Disease Control and Prevention, 2011). According to Washington
State PRAMS, 58% of the surveyed women reported no dental care (Lydon-Rochelle,
Krakowiak, Hujoel, & Peters, 2004). Recently the Cigna Corporation did a small national study
on this topic that discloses some interesting facts. Among 801 participants, 76% reported having
oral health problems whereas only 47% had dental checkups (Cigna Corporation, 2015).
Anecdotal evidence collected from local women’s health providers show that oral health
screening is not routinely included in the prenatal care bundle of services. Although there is a
dental grant to provide dental care funding for pregnant women without dental insurance
available in this health center, eligible women are usually unaware of the program. This

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knowledge deficit contributes to low utilization of the funds. Despite the understanding of the
relationship between periodontal disease and adverse pregnancy outcome, most women’s health
providers are not familiar with any guidelines on oral health in pregnancy. In addition, more than
one third of obstetricians never advised women to get prophylactic dental care and 80% have
never even thought about it (George et al., 2012). Similarly, in a survey done among Australian
dentists, 95.7% of dentists requested more information on oral care in pregnancy regardless of
their knowledge (George et al., 2017). In an Oregon study, more than 50% of dental providers
were reluctant to provide even routine dental care during pregnancy (Rainchuso, 2013). The
Association of State and Territorial Dental Directors (ASTDD) (2012) found insufficient
knowledge, lack of experience, and outdated guideline usage as the reasons dentists offer for
being uncomfortable in treating pregnant women. The financial constraints and lack of insurance
for low-income women also may reduce access to dental care. The Patient Protection and
Affordable Care Act does not require states to provide dental coverage during pregnancy
(Affordable Care Act, 2010). The Arizona Health Care Cost Containment System (AHCCCS)
will cover up to $1000 in emergency dental services per year for enrollees over 21 years of age
(Arizona Public Health Association, 2017).
Government agencies, policy makers, and professional organizations have begun to
recognize the importance and value of perinatal oral health care (Hartnett et al., 2016). There is
national consensus statement guidance available for the professionals who provide prenatal care,
dentistry, and other healthcare on how to improve oral health during pregnancy (National
Maternal and Child Oral Health Resource Center, 2012). ASTDD recommends many strategies
for improving perinatal oral health (ASTDD, 2012). California Dental Association Foundation
(CDA) in association with American College of Obstetrics and Gynecology (ACOG), District IX

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provides evidence-based guidelines (CDA, 2010). In addition, ACOG Committee Opinion
number 569 emphasizes the significance of oral health during pregnancy and recommends
maternal oral health screening at the first prenatal visit (ACOG, 2013).
The most updated best evidence based practice approach for the organizations is from the
National Maternal and Child Bureau (2016). It recommends the partnership with state programs,
professional organizations, and the state agency implementing perinatal and infant oral health
quality improvement grant. Organizations should promote the updated oral health guidelines. In
addition, assure that all pregnant women get oral health screening, referral if needed, identify the
dentist (dental home), and cleaning before giving birth. Moreover, education and training the
prenatal healthcare professionals about the importance of oral health during pregnancy and how
to incorporate it into practice also should be incorporated. Furthermore, it proposes to offer
incentives for having at least one dental visit during pregnancy (National Maternal and Child
Oral Health Resource Center, 2016).
Problem Statement and PICOT Question
Despite women’s increased receptiveness during pregnancy and the benefits of oral care,
evidence shows that pregnant women seldom seek dental care and confirms the need to promote
oral care in prenatal programs. This analysis has lead to a clinically relevant PICOT question: In
women’s health providers, how does implementing oral health promotion compared to standard
of care, affect the rates of dental visits among pregnant women over a three month time period?
Search Strategy
Identification and creation of a list of key words with the consideration of synonyms as
the first step in this search technique. Studies were abstracted from three databases: PubMed,
Cumulative Index of Nursing and Allied Health Literature (CINAHL), and The Cochrane

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Library. In addition, Google Scholar search was done to extract articles about barriers to dental
care and insurance coverage for dental care during pregnancy with the key words oral health
care, pregnancy, insurance coverage, and barriers with 5-year time limit. Further, the Centers of
Disease Control and Prevention website was explored to find national and local data related to
the problem. Ancestor search was done for the articles from year 2016 and 2017 with the criteria
of 5-year limit. The final yield retained for review from the database search was 41 articles. The
exclusion criteria applied for the final search was non-pregnant population, articles before 2007,
and non-English language. The inclusion criteria were the outcomes oral health behavior, dental
visits during pregnancy, oral health knowledge and attitude, and studies delivered in prenatal
settings. Finally, 10 studies were selected for the critical evaluation based on the inclusion and
exclusion criteria. All these studies were targeted to oral health promotion in pregnancy.
Evidence Synthesis
Selected studies were conducted in different countries: ten in North America, two in
Asia, and three in Europe. All were found to be free of significant bias. Eight out of ten articles
are written within last three years. Only one study chosen is a systematic review with level I
evidence. However, there are four randomized controlled trials with level II evidence, two
experimental studies with level III evidence, and one cross sectional study and two cohort studies
with level IV evidence. All of them used appropriate methods to analyze the data with programs
like SPSS and Microsoft excel. A questionnaire is the most common tool used and all
instruments were tested and confirmed with pilot studies for reliability and validity. Cibulka,
Forney, Goodwin, Lazaroff, & Sarabia, (2011) used Cronbach’s alpha to measure the reliability
and expert panel critique to establish content validity of a KAP questionnaire. Seven out of ten

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studies had more than one intervention and all ten studies included education, either to the
providers or to pregnant women, as one of the interventions.
Because all the studies were done in prenatal settings, most studies had small samples
and the samples were either pregnant women or providers in homogenous characteristics.
Interestingly, two of the studies’ populations were medical students; of those two studies one
included dental providers because the researchers were investigating the need for collaboration
between the dental and prenatal clinics. Half of the studies focused on the improvement of
knowledge, attitude, and behavioral changes as their dependent variables where as one study
only looked at the influence of good oral health in pregnancy outcomes in terms of preterm birth
and low birth weight. The evidence concerning oral health in pregnancy confirms the need to
promote oral care in prenatal programs. Although not all the studies measured the improvement
in number of dental visits, all of them indirectly included that goal.
Purpose Statement
Purpose of this project is to increase adherence to the ACOG practice guidelines for oral
health care in pregnancy at a federally qualified health center and thereby increase the number of
dental visits among pregnant women.
Conceptual/Theoretical Model and Evidence Based Practice Model
The Theory of Reasoned Action proposes that a behavioral action is an outcome of
behavioral intentions, which are based on the subjective norms and the attitude toward a
particular action (Fishbein & Azjen, 1975). A person’s attitude to the behavior develops from the
belief about the outcome of the behavior and the evaluation of the outcome (Appendix A). The
subjective norms are the perception of the society’s belief on this particular action and the
commitment to do the social standards (Fishbein & Azjen). For example, if the provider has a

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commitment to practice according to the guidelines and realizes that the guidelines recommend
oral health promotion in pregnancy, that realization can transform oral health promotion into a
behavior norm for that provider. Similarly, when the provider believes that the oral health
promotion increases the dental visits among pregnant women and that dental care in pregnancy
can reduce the risk for preterm labor and low birth weight, a positive attitude towards oral health
promotion may develop. This positive attitude towards the norm of oral health promotion leads
to the practice change decision and includes oral health promotion during the prenatal care.
OTTAWA Model of Research offers a comprehensive and interdisciplinary framework
for evidence-based practice. Each element of the model influences the other elements (Appendix
B). According to this model there is a process of assessing, monitoring, and evaluating each
component before, during, and after the implementation of any innovative intervention.
Assessment of barriers, potential adopters, and the practice environment must be completed to
identify the factors that can affect the intervention uptake. Through the application of the model,
the intervention can be modified as needed to get the maximum benefit. The monitoring is
ongoing and the outcome is evaluated to determine intended or unintended effects (RycroftMalone & Bucknall, 2010). For example, the current practice guidelines, evidence, possible
barriers, and current practice behavior regarding oral health care during pregnancy are assessed
and documented as the first steps to the development of the potential project. At the
implementation stage, utilization of the federal grant provided for dental care in pregnant women
can be the financial barrier management. Close monitoring of the practice environment and the
outcome will help the innovator to make necessary changes in the project to improve the
possibility of achieving the expected outcome.

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Project Methods
Internal evidence disclosed a gap between professional guidelines and current practice in
a federally qualified community health center with 20 women’s health providers. An evidence
based maternal oral health screening tool (George et al., 2015) was identified with 2 questions as
follows: 1) Do you have bleeding gums, swelling, sensitive teeth, loose teeth, holes in your teeth,
broken teeth, toothache or any other problems in your mouth? 2) Have you seen a dentist in the
last 12 months?
After obtaining permission from the author to use the Maternal Oral Health Screening
tool (MOS), the management of the health center welcomed the proposed innovative project. The
Arizona State University Institutional Review Board approved the project with an expedited
review. In collaboration with the health center informative technology staff the 2-point MOS was
embeded into the electronic health reord (EHR) as a part of the assessment at first prenatal visit
(new OB visit). Women’s health providers were informed about the project and the new EHR
fields that were added to the system. Based on the patients‘ responses to the MOS questions,
providers were asked to document dental referral using the same process as the current
workflow. Moreover, dental providers at the same health center collaborated in the project by
scheduling the appointments for pregnant women who were referred for dental care. In addition,
a dental grant available at this facility covers the cost of dental care for144 non-insured pregnant
women per year. At the end of three months intervention period, post intervention data was
collected and compared to data from the same three-month period one year prior to the initiation
of the practice change intervention.
Chart audits are commonly used technique in primary health care research (Hogg et al.,
2010). The Agency for Healthcare Research and Quality (AHRQ) recommends using chart

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audits as a tool to collect data in the primary care setting (AHRQ, n.d). A chart audit form was
used to record the patient’s age, ethnicity, type of provider that completed the visit, and dental
insurance status. In addition, the outcome variables of responses to the oral health screening
questions, referral generation and kept dental clinic visit were also recorded in the audit. Each
data point was assigned a number that was not connected to any participant, patient, or other
personal identifying information. SPSS®23 was used to store, manage, and analyze the data.
Results
A chart audit was performed on all new OB patients of 20 women’s health providers: 545
charts from pre-intervention period and 350 charts from post-intervention period were included.
The average age of the patients audited during pre-intervention period was 27 years (SD=6.5)
and the ages ranged from 15 to 47 years. Most of the women (n=409; 75%) were Hispanic
(Appendix C), 17(3%) of the women had no dental insurance, 28(5%) had dental insurance. For
500 women (92%) dental insurance status was not documented; that information is not recorded
because no dental care is provided at this facility. Nurse practitioners performed the new OB
visit for 416 (76%) patients and physicians completed the new OB visit for 129 (24%) patients
included in the pre-intervention chart review.
The average age of the patients whose records were audited during post-intervention
period was also 27 (SD=6.88) and the ages ranged from 15 to 44 years. Most of the women
(n=266; 76%) were Hispanic (Appendix C), 20 (6%) of the women had no dental insurance, 12
(3%) had dental insurance. For 318 women (91%), their dental insurance status was not available
because dental care was not available at this facility. Nurse practitioners cared for 300 of the
women (86%) and physicians cared for 50 (14%) of the new OB patients in the post-intervention
chart audit period.

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Chi-Square test of independence was calculated comparing the frequency of outcome
variables in pre and post interventional groups. Phi Coefficient was used to assess the impact of
MOS tool on outcome variables. A significant improvement was noted on maternal oral health
screening and dental referral in the post-intervention group. There was a notable increase in the
number of scheduled visits. However, because quite a few of the scheduled visits were not kept,
there was no statistically significant change in the number of actual visits.
Screening: A significant interaction was found between frequency of maternal oral health
screening in pre and post intervention group (χ2 (2)=296.48, p < .001). Post-intervention group
was more likely to screen (n=157) than pre-intervention group (n=0) (Appendix D). A weak
positive association was found (φ=0.58) between MOS tool and maternal oral health screening.
Referral: A significant interaction was found between dental referral in pre and post
intervention group (χ2 (2)=62.69, p < .001). Post-intervention group is more likely to refer
(n=90) than pre-intervention group (n=37) (Appendix D). A weak positive association was found
(φ= .3) between MOS tool and the number of pregnant women who were provided with a dental
referral.
In addition to the 277 women who had complete oral health screening, 59 (10.6%)
women had a partial oral health screening at their first prenatal visit. Although only 32 out of 277
screened women visited the dentist, considering the number of women who scheduled for a
dental visit (n=24) who did not need to see a dentist, and appointment cancellation number
suggests a clinical significance of the efficacy of the MOS tool for increasing dental visit among
pregnant women. Moreover, the fact that 75% of the women who visited the dentist were
screened by the women’s health provider is also indicates the positive influence of screening in
pregnant women. Among the post-intervention group, 132 out of 277 screened women were

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categorized as “visit not applicable” to see a dentist either because of early miscarriage, intrauterine fetal death, history of dental visit in last year, or the first prenatal visit was at full term
pregnancy stage (Appendix D).
Discussion
As pre-intervention period screening data shows, maternal oral health screening during
pregnancy was a missing component at this facility. Any health screening provides a platform for
both the provider and the patient to discuss and offer a recommended preventive care service
(Center for Substance Abuse Treatment, 2009).
All the insured women in this project were enrolled in AHCCCS, the Arizona version of
Medicaid, which currently covers only emergency dental care for 21 years of age and above.
This means that during the pre-intervention period, 62% of women (n=26) who saw the dentist
had dental symptoms. Less utilization of dental grant money through this period also illustrated
adherence to the minimum standard for preventive care. On the other hand, even though the
grant money was not available for the first month of this project, maternal oral health screening
was associated with an increase in referral for and completion of preventive dental care. Of the
women in post-intervention group who had a dental visit 63% (n=20) were uninsured and their
care was paid by grant funds. Among those who had oral health screening with MOS tool
(n=277), 25% of women (n=70) had oral health symptoms, only 12 women (17%) had dental
insurance including AHCCCS. However, the beneficiaries of AHCCCS are now looking forward
to a current Arizona Senate Bill (SB1445) that addresses this issue and proposes dental coverage
for all pregnant women regardless of their symptoms (Arizona Legislative Information System,
2018). If this bill becomes the law, financial hurdle of dental care during pregnancy will resolve
in the future in Arizona for women on publicly funded insurance plans.

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Collaboration between dentistry and the women’s clinic also plays an important role in
facilitating adherence to the preventive care standards. A successful implementation of dental
care element into prenatal service requires a multidisciplinary approach and a collaborative
relationship between women’s health and dental providers (Jackson et al., 2015). In the
beginning of this project, dental providers’ chief concern in this facility was the lack of timely
dental referrals from the women’s health providers. Implementation of a standardized maternal
oral health screening tool into the new obstetrical patient registration process increased the
referral rate among the women who visited the dentist from 76% to 88%. In addition to all the
above impact and benefits, the organization adapted the MOS tool and decided to continue
maternal oral health screening at NOB visit.
The length of the project limited the accuracy of the findings. Most of the patients who
are in post-intervention group are just started their pregnancy and have months to visit a dentist.
Unexpected closure of one of the dental office in the organization also affected the outcome of
the project. In addition, the dental grant was not available for the first month of the project and
the women’s health providers misunderstood that no dental referral can be provided at that
month. Hence, a 9-month long project is recommended for the future.
Conclusion
Increased use of dental service is a national goal. Pregnancy is the perfect time to
encourage preventive care and pregnant women are more receptive to health messages. The
literature concerning oral health in pregnancy stresses the need to focus oral care in prenatal
programs for healthy pregnancy outcomes. According to the professional and national
organizational, maternal oral health screening and dental care are standard of care. Two-point
MOS tool increase screening rate, referral rate, and dental visits among pregnant women.

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Appendix A
Theory of Reasoned Action

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Appendix B
OTTAWA Model of Research Use

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Appendix C
Table 1 Ethnicity: Pre-intervention group
Ethnicity
Caucasian
Hispanic
Asian
African American
Other

N
37
409
9
75
15

Percent
6.8
75.0
1.7
13.8
2.8

N
25
266
3
44
12

Percent
7.1
76.0
0.9
12.6
3.4

Table 2 Ethnicity: Post-intervention group
Ethnicity
Caucasian
Hispanic
Asian
African American
Other

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22

Appendix D
Table 1 Screening

Screening done
Screening not done

Pre-intervention
0
545

Post-intervention
157
193

Pre-intervention
37
508

Post-intervention
90
260

Table 2 Referral

Referred
Not referred

Table 3 Dental visit: Post-intervention

No
Yes
Scheduled
Cancelled
Not applicable

N
339
32
24
30
132

Percent
60.9
5.7
4.3
5.4
23.7