Running head: ORAL HEALTH CARE

Oral Health Care in Pregnancy
Stephanie A. Rideaux
Arizona State University

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Abstract

Pregnancy is a specific time in a woman’s life filled with complex changes in health, including
the oral cavity. During this time, dental and perinatal care teams can be influential in helping
women initiate and maintain essential habits to improve health and prevent adverse outcomes.
There is research evidence that dental providers are reluctant to treat dental problems during
pregnancy. Barriers to practice identified by dentists include lack of education, time, financial
constraints, and concern for the safety treating pregnant women. Factors that facilitate dental
care for pregnant women include purposeful assessment, referrals from prenatal providers, and
continuing education for dental team members. Multiple organizations recommend the treatment
of oral health conditions during pregnancy to promote health and prevent pregnancy
complications. In order to promote community-based partnerships in a healthcare system,
dentists are encouraged to develop an intentional plan to increase collaboration with other
members of the women’s healthcare team. Prior to developing a system wide intervention to
improve access to dental care during pregnancy, dental team members were surveyed to identify
barriers and facilitators which promote or hinder care in their practice. The data acquired will be
used to inform the design and implementation of an intervention to specifically meet the needs of
patients and providers in that system.
Keywords: dental health, pregnancy, health outcomes, interprofessional collaboration

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Oral Health Care in Pregnancy

Prenatal care is an important part of pregnancy that includes direct care and patient
education to promote healthy behaviors which benefit both mother and child. It is also a time in
which providers can prevent potential health problems and treat existing conditions. The oral
cavity is a potential site of disease and portal of entry for bacteria that may affect one’s general
health status. Thus, assessing oral health care encompasses both primary and secondary
prevention and should be an integral piece of prenatal care (U.S. Department of Health and
Human Services [DHHS], 2000).
Problem Statement
Oral health is an important part of general health and should be maintained during
pregnancy and throughout the lifespan. Pregnancy is a time in a women’s life which is filled with
complex physiologic changes in her health. These physiologic changes can exacerbate oral
health conditions that may complicate pregnancy. Gingivitis, benign oral gingival lesions, tooth
mobility, tooth erosion, dental caries, and periodontitis may impact pregnancy outcomes
(American College of Obstetricians and Gynecologists [ACOG], 2013). Unfortunately, oral
health is often not provided to pregnant women and pregnant women often do not seek oral
health care during this time.
Poor oral health in pregnancy has been linked to unfavorable birth outcomes in women
who are from low socioeconomic groups or minorities (Erchick et al., 2019; Lopez, DaSilva,
Ipinza, & Gutierrez, 2005). These outcomes have a potential result of lifelong complications,
family stress, and increased expenditure. Despite awareness, little improvement has been
achieved in birth outcomes among vulnerable populations (March of Dimes, 2019). Such data

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have led organizations to seek effective interventions that could improve the health and
wellbeing of pregnant women and their infants.
Purpose and Rationale
Investigators in the United States have demonstrated that dentists diverged from scientific
literature on several recommendations related to dental care (Alves et al., 2012). Dentists in the
United States report barriers such as a knowledge, time, economics, financial constraints, skills,
dental staff resistance, and peer pressure (Lee et al., 2010). Furthermore, researchers in Brazil
revealed that dentists not exposed to professional education regarding oral health during
pregnancy presented with less favorable attitudes towards providing dental care to pregnant
women (Alves et al., 2012). Administration and staff in Federally Qualified Health Centers
(FQHCs) are seeking strategies to improve the uptake of quality, evidence-based care.
The purpose of this project was to examine the effects of oral health on pregnancy and
identify barriers that may be hindering pregnant women from receiving oral health treatment
during pregnancy in a system of federally qualified health centers.
Background/Significance
During pregnancy, hormones such as estrogen and progesterone are produced in large
amounts causing changes in the gingiva (Karimi, Hamissi, Naeini, & Karimi, 2016). Poor oral
health is associated with infections, gingivitis, and periodontal disease. Periodontal disease is
characterized by a group of inflammatory conditions, typically caused by oral bacteria that can
progress from reversible accumulation of plaque and inflammation of gingival tissue to
irreversible breakdown of the supportive tissues of the teeth (Erchick et al., 2019).
Pregnant women who have pre-existing poor dental hygiene are at an increased risk for
gingivitis and periodontitis due to inflammatory changes, hormone influence, and increased

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acidity in the mouth. Oral bacteria and periodontitis have been linked to intrauterine infections,
preterm birth, and small for gestational age neonates among poor and minority women (Ide &
Papapanou, 2013; Karimi et al., 2016; Vamos et al., 2015). Oral inflammation and infection
stimulate a physiologic response in the immune system that activates the release of cytokines and
other inflammatory mediators. These biochemicals produce a response in the maternal system
that, among other effects, stimulates the mechanisms that may induce contractions of sufficient
strength and frequency to result in premature birth. This phenomenon can result in preterm
rupture of membranes (PROM) that puts the mother at risk for an intrauterine infection.
Intrauterine infections, caused by bacteria, may initiate an inflammatory response that can trigger
the initiation of preterm labor and subsequently a preterm delivery (Kemp, 2014).
Babies who are born prematurely may not achieve their full potential birth weight, and
are subject to other neonatal complications because of their shortened gestation. These infants
are subject to respiratory dysfunction, feeding difficulties, developmental delays, vision and
hearing problems, and cerebral palsy. In 2016, the rate of preterm birth rose for the second
straight year among minority women (Centers for Disease Control and Prevention [CDC], 2018).
The CDC and other organizations have undertaken research to understand why preterm births
disproportionately occur in minority women and what can be done to help prevent them (CDC,
2018). In addition to compromising neonates, periodontal disease during pregnancy has also
been associated with adverse maternal outcomes such as systemic inflammation, preeclampsia,
and spontaneous abortion (Lopez et al., 2005; Marchi, Fisher-Owen, Weintraub, Yu, &
Braveman, 2010).
Perinatal and neonatal morbidity and mortality remain a concern. Thousands of babies,
approximately one in ten, are born each year preterm and/or with low birth weight. These births

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result in prolonged hospital stays and increased healthcare costs and are directly related to racial
and ethnic disparities (March of Dimes, 2019). Although the exact rate is not known, it is
believed that some of these preterm births could be avoided by early identification and treatment
of existing dental disorders during pregnancy.
Oral Health in Community Health Centers
Although periodontal health is recognized as an important component of general
wellbeing, oral health remains neglected in low income communities (Erchick et al, 2019).
Dental care is directly related to income level and dental insurance coverage, making it unlikely
that low socioeconomic status (SES) individuals, the underinsured, or uninsured have access to a
dental provider (ACOG, 2013; Thompson, Cheng, & Strobino, 2013). The Surgeon General
warns that oral health disorders are associated with many disease processes which are affecting
our most vulnerable citizens (DHHS, 2000).
Oral Health Screening and Treatment
Dental and perinatal teams can be instrumental in helping women establish dental care
and improve pregnancy and lifelong oral health habits. Adequate oral health care is characterized
by brushing twice a day, flossing daily, avoiding sugary snacks, and seeing a dental professional
twice a year (American Dental Association [ADA], 2018). Assessing oral health status at a
prenatal visit, providing reassurance regarding the safety of examination, diagnosis, and
treatment of oral conditions, and referral for dental care are essential components of
comprehensive interdisciplinary prenatal care (ACOG, 2013). Treatment of oral health
conditions during pregnancy is recommended and should not be delayed until the completion of
pregnancy (ACOG, 2013; ADA, 2018).

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Current Practice
Approximately 40% of pregnant women have some form of periodontal disease (Erchick
et al., 2019; Vamos et al., 2015). According to a report from the Surgeon General, this is most
commonly encountered in ethnic minority women and those using public health services (DHHS,
2000). Most obstetricians acknowledge a need for oral health care in pregnancy, but
approximately 80% do not ask oral health screening questions during prenatal visits and over
90% do not routinely refer patients to a dentist (Strafford, Shellhaas, & Hade, 2008). There is
anecdotal evidence that dental clinics are not treating patients with oral health conditions at
specific trimesters in pregnancy and others will not schedule an appointment without a written
referral from the prenatal provider.
Despite the known risks to mother and fetus, women across the nation are not
consistently receiving oral health care during pregnancy. Barriers for not receiving oral health
care and treatment during pregnancy include high cost, unavailability of services, and the
misconception that women should not receive dental treatment when pregnant (George et al.,
2017). To address this concern, national organizations have established guidelines
recommending that all expectant women receive oral health education, assessment, and referrals
for dental care from their perinatal care provider (George et al., 2017). Once perinatal providers
and pregnant women have increased awareness, it is equally important that a consensus is
reached among dentists. If not, barriers that prevent pregnant women from receiving necessary
dental care will continue to exist.
Understanding the importance of oral health during pregnancy requires a comprehensive,
interdisciplinary approach. The opinions and knowledge of nurse practitioners, certified nurse

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midwives, physicians, and dentists can be barriers or facilitators to women receiving oral health
care during pregnancy (Alves et al., 2012).
Screening, Referral, and Treatment
One of the quality indicators in Healthy People 2020 is to increase the proportion of
children, adolescents, and adults who have used the oral health care system in the past year
(DHHS, 2000, p. 33-59). Additionally, several national organizations, including the American
Academy of Pediatrics (AAP), ACOG, and the ADA, have undertaken efforts to improve the
overall oral health of women during pregnancy. Researchers suggest that oral health is important
during pregnancy and is crucial to overall health and wellbeing for mom and baby. Preventive,
diagnostic, and restorative dental treatment is safe during pregnancy and should not be withheld
or delayed until delivery (ACOG, 2013; National Maternal and Child Oral Health Resource
Center, 2012).
In order to achieve the Health People 2020 goal, all stakeholders should be encouraged to
initiate an action-oriented plan to involve dental professionals and staff using every encounter
with pregnant women to provide counseling and services to alleviate possible health risks. To
form such a plan, system and personnel barriers and facilitators to dental care within systems
must be identified.
Internal Evidence
Each state has a primary care association that works to promote and facilitate the
development and delivery of affordable and accessible community-oriented care. Community
health centers (CHC) employ primary care practitioners, dentists, women’s health providers,
registered nurses, behavioral health specialists, social workers, and pediatricians. There are
several times the number of providers in the form of staff in clinical and administration roles.

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They include medical assistants, dental assistants, receptionists, and those in positions to manage
the day to day operations and sustainability of the clinic. In addition, CHCs provide care to
thousands of patients each year, many of whom are under or uninsured. Within a system of
Federally Qualified Health Centers located in one county in the southwest United States, oral
health in pregnancy has been identified as an unmet need in care despite the existence of dental
units within the system. Interviews with stakeholders in the clinics and with the state community
health association led to the identification of a goal to increase dental screenings, establish a
formal dental care referral process, and increase interprofessional collaboration among prenatal
providers and dentists. Currently, they have no tracking system in place that could provide
empirical data to support their assumptions. A gap analysis to provide information about
assessment and follow up related to oral health during pregnancy has been completed among the
prenatal providers. A companion gap analysis to assess the processes within the dental health
team related to oral health care in pregnancy has been completed and is the subject of this report.
PICO Question
This inquiry has led to the clinically relevant PICO question, among dental professionals
and staff at a federally qualified community health center (P), what factors facilitate (I) or inhibit
(C) oral health care for women during pregnancy (O)?
Search Strategy
Databases searched for the literature review included PubMed, Cumulative Index of
Nursing and Allied Health Literature (CINAHL), and PsycInfo. Keywords included; pregnancy,
pregnant women, oral health, dental health, outcomes, birth outcomes, childbirth outcomes,
neonatal outcomes, and maternal outcomes.

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Exclusion criteria included articles in the non-English language and articles published
prior to 2010 to establish the most current knowledge about the topic. Reviewing the titles and
abstracts of the articles yielded 30 relevant studies. Additionally, the reference lists of these
articles were scanned to identify additional sources of relevant data. Full text copies of the most
relevant and high-quality studies were obtained and reviewed. Rapid critical appraisal checklists
were used to reduce the number of articles down to the ten most relevant and highest quality
studies. Studies selected to inform the project design and implementation demonstrate the
relationship between the chosen PICOT components; pregnant women, dental care, barriers,
facilitators, and overall pregnancy health status or outcomes (Appendix A).
Critical Appraisal & Synthesis of Evidence
The articles chosen for review include one cohort study, two cross sectional studies, five
randomized controlled trials, one non-randomized pilot study, and one Cochrane review. Quality
and strength of the evidence was determined by the Fineout-Overholt and Melnyk’s (2009) rapid
critical appraisal. All studies included pregnant or postpartum women with varying degrees of
satisfactory oral health status. There was limited bias throughout the articles. Demographics
included mean age less than 30 with the majority having a high school education. Socioeconomic
status (SES) ranged from below poverty to high income as determined by federal SES
guidelines. Studies selected for inclusion were conducted in various areas of the world.
Measurement tools included pre and post intervention surveys, health record review, and
oral health assessments. Outcome areas of interest included barriers, facilitators, preterm birth
rate, low birth weight, and overall oral health status in pregnant women (Appendix A).
Barriers inhibiting dental care during pregnancy include cost, availability,
misconceptions, lack of education among dentists, and decreased awareness of procedure safety

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among pregnant women (Suri, Singla, & Suri, 2017). Additional barriers include concern for
safety of dental procedures during a specific trimester of pregnancy, the safety of medications,
and the fear of dental team responsibility if harm were to occur to a pregnant woman (Umoh &
Azodo, 2013).
In order to examine knowledge and attitudes of dental providers within a system of
federally qualified health centers in the southern United States, data collection is essential.
Topics of interest should include knowledge, education, perceived barriers, and current practice
(George et al., 2017). Implementation of oral health initiatives based on guidelines is often a
slow process in which barriers must be acknowledged before intervention can be adopted
(Jackson et al., 2015).
Interventions associated with an increased uptake of women seeking dental care during
pregnancy include screening during prenatal visits, oral health education among dental and
prenatal providers, oral examinations, and referrals (Suri, Singla, & Suri, 2017). In their survey
of general dentists conducted within the United States, researchers found that completion of
continuing education on oral health care in pregnancy for dental team members was associated
with a stronger belief in counseling and treatment (Kloetzel et al., 2012). Furthermore, dentists
were more likely to provide treatment if the patient presented with a written referral from the
prenatal care provider (Jackson et al., 2015).
Community based partnerships have demonstrated improved access to and receipt of
dental care in pregnant women. Increasing the number of pregnant women receiving care is
likely to improve with coordinated interdisciplinary approaches to education and referrals.
Providing a referral informs the dentist of prenatal provider support and reassures the patient of
the safety and importance of the recommendation (Kloetzel, Huebner, & Milgrom, 2011).

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There is rigorous evidence that oral health care in pregnancy and treatment of periodontal
disease may aid in reducing the number of preterm births or low birth weight infants among low
SES pregnant women and women with high risk pregnancies. In multiple studies, periodontal
treatment during pregnancy was associated with a decrease of gingival bleeding on probing, a
decrease of oral inflammation, reduction of supragingival calculus, improved clinical attachment
level, and a decrease of gingival plaque. Additionally, oral health care in pregnancy was not
associated with any adverse outcomes leading to the assumption that care should be provided to
pregnant women and not delayed until the conclusion of pregnancy (Appendix B).
Barriers and facilitators have been acknowledged among dentists in previously conducted
surveys throughout the world. In order to address an identified unmet need in the screening,
referral, and treatment process in the federally qualified health centers in southern United States,
a gap analysis was needed to identify barriers and facilitators for that care. Once that knowledge
was acquired, tested interventions that were successful in environments with similar agency,
staff, and patient characteristics can be compared to the environment where this gap analysis was
conducted to aid in designing and implementing an intervention that is the right fit.
Theory Application/Conceptual Framework
The Quality Health Outcomes Model (QHOM) was selected as the conceptual framework
for this project due to its goodness and fit to the design and implementation of an oral health
intervention in pregnancy (Appendix C). The QHOM was indirectly used to synthesize nine
articles in this review. The QHOM is sufficiently broad and is used to suggest key variables in
clinical intervention (Mitchell et al., 1998). The structure of this model references a linear
process of knowledge collection and intervention, which in turn affects outcomes. Additionally,

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it provides a framework that aids the design, implementation, and evaluation of organizational
and system level interventions.
When applying this framework to oral health in pregnancy at the project site, a gap in
care was identified. A gap analysis among dentists and dental team members, when added to the
data already obtained from the perinatal team, can inform system and unit level policy and
procedural changes specific to the FQHC participants and lead to the development and
implementation of one or more interventions that will improve assessment, referral, and
treatment of oral health care needs during pregnancy.
EBP Model or Quality Improvement Model
The quality improvement model for this project was the Knowledge to Action (KTA)
Framework (Appendix D). This dynamic, team model was applied in the initial stages of this
project because the goal of the project was to answer a question (knowledge inquiry). Once that
inquiry was articulated, a problem was identified, and it was decided that a gap analysis was
needed to identify the conditions that were contributing to the problem. Because the identified
problem had to do with dental care during pregnancy, it was decided that stakeholders in the
perinatal care and dental care units should be queried to complete a gap analysis to understand
barriers and facilitators to inform the design and implementation of an intervention. Once an
intervention is in place, the health centers can evaluate outcomes and sustain knowledge
acquisition and application in a dynamic fashion.
The KTA framework is intended to help individuals gain insight that will improve
outcomes and strengthen the health care system. Each dynamic phase of this model was used
sequentially to guide such knowledge into practice change. Oral health care during pregnancy
requires a collaboration of efforts between perinatal and dental providers. Once data from the

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survey completed by dental service providers and staff is analyzed and combined with the data
from the perinatal teams, system level interventions will be designed and applied to initiate
evidence-based dental care for pregnant women. This model was an appropriate choice to guide
the project because it uses knowledge creation to inform the action phase of system level change.
Methods
Project Summary
A gap analysis in a system of Federally Qualified Health Centers in Maricopa County,
Arizona was completed in partnership with the Arizona Alliance for Community Health Centers
(AACHC). A survey was administered to dental clinicians and staff at a group of community
clinics to identify facilitators and barriers related to oral health care for pregnant women. The
data obtained will be used to design and implement an intervention to increase screening,
referral, and treatment of oral health conditions during pregnancy. There are no financial
conflicts of interests. In kind support for the project was provided by the state Primary Care
Association (PCA) and Arizona State University (ASU). A budget that detailed the anticipated
costs for the project is provided in Appendix E.
Process
All current employees in the dental service units at a group of FQHCs were invited to
participate in an online, 77 item survey distributed via Survey Monkey. Participant recruitment
occurred in the fall of 2019 through project emails, site visits, and live presentations to
encourage participation in the project. The survey was available for four weeks. The survey
instrument was determined to be reliable and valid via psychometric testing. The survey
instrument evaluates multiple domains related to oral health in pregnancy. Those domains
include counseling pregnant patients, efficacy of counseling and treatment, pressures on the

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dental profession, periods of pregnancy appropriate to perform routine services, the prescribing
of pharmaceuticals, identifying pregnancy status, authorizing procedures on pregnant women,
emergency services during pregnancy, and education related to oral health in pregnancy
(Appendix F). A total of 128 dental health clinicians and staff were invited to participate in the
survey. From that participant pool, 53 individuals elected to participate. Fifty-two (52)
individuals completed the survey accounting for a 40.6% response rate. One survey was
discarded as less than 50% of the questions were answered. The intent-to-treat standard was
applied for the analysis to reconcile the occurrence of missing data in seven survey responses.
Results
Demographics
Participants included dentists (n=12; 23.1%), specialty dentists (n=1; 1.9%), dental
hygienists (n=9; 17.3%), dental assistants (n=21; 40.9%), patient services representatives (n=5;
9.6%), office managers (n=3; 5.8%), and appointment center specialists (n=1; 1.9%).
Outcomes
Oral health and pregnancy. Questions were administered to obtain knowledge
regarding perceptions related to pregnant women and oral health care. The majority (n=51;
98.1%) strongly agree that oral health is connected to systemic health and a large portion (n=41;
78.9%) strongly agree that bacteria causing tooth decay in moms can be passed on to babies. A
large majority (n=47; 90.4%) strongly agree that hormonal changes in pregnant women increase
their risk of gum disease but only 30 participants (57.7%) strongly agree that periodontal disease
is associated with miscarriage, preterm birth, and low birth weight infants.
Counseling pregnant patients. Questions regarding counseling pregnant women were
addressed. All participants (n=52; 100%) strongly agree that counseling pregnant women about

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oral health is important and 47 participants (90.4%) strongly agree that counseling a pregnant
woman about oral health can improve the oral health of her baby. When asked if they have the
skills to counsel pregnant women, only 40 participants (76.9%) strongly agree they are prepared.
Thirty participants (57.9%) strongly disagree that their dental practice is too busy to provide
counseling about oral care for pregnant patients and 20 participants (38.5%) neither agree nor
disagree that insurance plans compensate the dental practice adequately for time spent on
counseling pregnant women. The majority of participants (n=38; 73.1%) strongly agree it is the
responsibility of the dental provider to counsel a pregnant woman on the dangers of smoking and
49 participants (94.2%) strongly agree that a pregnant woman should be counseled to have a
dental provider look at her baby’s teeth when they first erupt. Over half (n=29; 55.8%) strongly
disagree that explaining the possible link between periodontal disease and preterm birth takes too
much time out of the schedule and 35 participants (67.3%) strongly disagree that explaining the
link between dental caries in mothers and dental caries in babies takes too much time out of the
schedule.
Efficacy of counseling and treatment. When asked about the efficacy of counseling and
treatment, 39 participants (75%) strongly agree that it is worth their time to counsel pregnant
patients about their diet and 22 participants (42.3%) strongly disagree that physicians are better
able than dentists to counsel pregnant patients about oral health. Furthermore, the majority of
participants (n=48; 92.3%) strongly agree that dental treatment should be a part of a women’s
prenatal care. The majority of participants (n=41; 78.9%) strongly agree that pregnant patients
are more likely to seek dental care if their physician recommends it. Thirty-six participants
(69.2%) strongly disagree that there is little they can do to affect a pregnant women’s oral
hygiene and 41 participants (78.9%) believe it is important for a pregnant woman to have her

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blood pressure taken during a dental appointment. Approximately one-fourth of participants
(n=14; 26.9%) neither agree nor disagree that a dental provider has the ability to identify possible
complications of a pregnancy and more than half (n=27; 51.9%) strongly agree it is safe to
provide dental treatment to a pregnant woman. Furthermore, 21 participants (40.4%) neither
agree nor disagree that they are concerned about being sued if something goes wrong in a
pregnancy after dental treatment.
Pressure on the dental profession. Twenty participants (38.5%) strongly disagree that
clinicians in the community will be critical of the agency staff if they provide necessary oral
health care to pregnant patients and the majority of participants (n=38; 73.1%) strongly agree
that patients would feel positively about their clinic if staff members provide comprehensive care
to pregnant patients.
Routine Services. Participants were asked during which period of pregnancy they
believe it is appropriate to provide each of the following routine services. Forty-seven
participants (90.4%) believe oral health instructions can be performed anytime during pregnancy.
Fifty participants (96.2%) believe prophy (routine surface cleaning procedures performed by
dental clinicians), and 38 participants (73.1%) believe scaling and root planing (deep cleaning
below the gum line) are safe throughout anytime during pregnancy. Twenty-five participants
(48.1%) believe site specific antibiotics (medicine inserted subgingivally into a pocket) should
be prescribed for emergency procedures only and 41 participants (78.9%) agree that fluoride
varnish treatment can be performed anytime during pregnancy. More than half (n=29; 55.8%)
agree that a single periapical x-ray can be performed at any time during pregnancy but 22
participants (42.3%) believe full mouth x-rays should never be performed during pregnancy.
Twenty-six participants (50%) believe an injection of local anesthetic such as lidocaine, a single

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tooth extraction (n=38; 73.1%), and an amalgam (mercury, silver, copper, and tin) restoration
(n=23; 44.2%) should only be performed as an emergency only procedure. Thirty-one
participants (59.6%) agree that composite (tooth colored) restoration can be performed anytime
during pregnancy and 36 participants (69.2%) believe root canal therapy should be performed as
an emergency only procedure. For the final two questions of this section, participants were asked
at what point in pregnancy crown and bridge could be performed and half (n=26; 50%) believe
this should be performed as an emergency procedure only while the majority (n=47; 90.4%)
believe a pregnant woman should never be given nitrous oxide or oxygen sedation.
Pharmaceuticals. Participants were asked how often they recommend or prescribe the
following pharmaceuticals. Thirty-seven participants (71.2%) state they never recommend nonsteroidal or anti-inflammatory agents such as ibuprofen, 22 participants (42.3%) sometimes
recommend acetaminophen, 42 (80.8%) never recommend aspirin, 40 (76.9%) never recommend
pain medicine containing codeine or other narcotics, 21 (40.4%) never recommend
chlorhexidine, 18 (34.6%) sometimes recommend oral antibiotics, and 43 (82.7%) never
recommend periostat (doxycycline).
Pregnancy status. Participants were asked how they learn the pregnancy status of their
patients. Forty (76.9%) state the receptionist does not ask for pregnancy status when scheduling
an appointment. Forty-nine participants (94.2%) state there is a question about pregnancy in the
routine health update that the patient fills out. Thirty-eight participants (73.1%) agree their
patients reveal in casual conversation and 40 participants (76.9%) ask if they suspect a patient
might be pregnant. Forty-four participants (84.6%) state a staff member will note it on the
patient’s chart if someone determines a patient is pregnant but 31 participants (59.6%) state a
staff member will not note it on the daily schedule.

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Performing/authorizing procedures. Participants were asked how often they perform or
authorize the following procedures on pregnant women. Thirty-nine participants (75%) state they
often provide oral hygiene instructions, 37 (71.2%) often provide prophy, 17 (32.7%) often
provide scaling and root planing, 30 (57.7%) don’t perform or authorize site specific antibiotics,
15 (28.9%) sometimes provide fluoride varnish treatment, 19 (36.5%) sometimes perform single
periapical x-ray, 22 (42.3%) never perform full mouth x-rays, and 19 (36.5%) don’t perform or
authorize an injection of local anesthetic. Twenty-three participants (44.2%) don’t perform or
authorize single tooth extractions, amalgam restoration (n=27; 51.9%), composite restoration
(n=25; 48.1%), root canal therapy (n=27; 51.9%), or a crown and bridge (n=25; 48.1%). Twentysix participants (50%) never authorize nitrous oxide and oxygen sedation to pregnant women.
Emergency Services. When asked which periods of pregnancy they believe it is
appropriate for patients to have each of the following emergency services performed, 19
participants (36.5%) believe tooth extraction should only be performed during the second
trimester. Twenty-five participants (48.1%) believe never or don’t know when an open and
broach could be performed. Fifteen participants (28.9%) believe incision and draining of an
abscess can be performed at any point in pregnancy and 15 participants (28.9%) admit to either
not knowing or believing this should never be performed. Thirty-two participants (61%) either
don’t know or believe injection of local anesthetic should never be performed at any point in
pregnancy. When asked if they believe a temporary filling can be performed during pregnancy,
22 participants (42.2%) believe it can be performed at any time during pregnancy.
Education. Participants were asked about their beliefs on continuing education. Thirtyfive participants (67.3%) strongly agree that a continuing ed program about care for pregnant
patients would be of interest. Twenty-eight participants (53.9%) strongly agree that receiving

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examples of a checklist to initiate conversations with their patients about oral health care during
pregnancy would interest them and 35 participants (67.3%) strongly agree that receiving
education materials to provide to their patients interests them. When asked about incorporating
new procedures into their practice or the dental office, 21 (40.4%) strongly agree that it is easy.
Of those surveyed, 33 (63.5%) of participants enjoy experimenting with new procedures or ways
of doing things.
Correlations. Kendall correlations were performed using Intellectus Software.
Correlations were examined based on an alpha value of 0.05. A significant positive correlation
was observed between providers believing it is worth their time to counsel pregnant patients and
team members desiring information about a continuing education program on care for pregnant
patients (rs = 0.30, p = .031). The correlation coefficient between providers believing it is worth
their time to counsel pregnant patients and team members desiring information about a
continuing education program on care for pregnant patients was 0.30, indicating a small effect
size.
Discussion
Demographics
The response rate included a representative mix of dental team members including
dentists, dental hygienists, dental assistants, office managers, appointment center specialists, and
patient service representatives. All surveyed team members have been identified as participants
linked to scheduling, treating, or interacting with pregnant women.
Oral Health in Pregnancy
Knowledge scores are high overall. However, the majority of participants do not strongly
agree that periodontal disease is associated with miscarriage, preterm birth, or low birth weight

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infants. Knowledge of the relationship between periodontal disease and adverse pregnancy
outcomes has been demonstrated to be strongly correlated with pregnant women receiving access
to oral health care. Additionally, the majority of participants do not strongly agree that bacteria
that cause tooth decay in moms can be passed onto babies. Effective management strategies for
early childhood caries is encouraged by multiple organizations. Organizations associated with
dental health encourage dental team members to acknowledge the fact that maternal oral bacteria
level is associated with oral infections among children and predicts increased early childhood
caries (Chaffee et al., 2014).
Counseling Pregnant Patients
All participants surveyed acknowledge the value in counseling pregnant women about
oral health during pregnancy. Participants believe they have time counsel patients and that
education fits into their daily schedule. The majority the participants believe they have the skills
to educate pregnant women, but further study results reveal continuing education may be a
benefit to increasing knowledge.
Efficacy of Counseling and Treatment
The majority of participants believe dental treatment should be a part of a women’s
prenatal care and that women would be more likely to seek care if recommended by their
perinatal provider. Survey participants do not consistently agree that dental care is safe during
pregnancy and many are unsure if a dental health professional would have the ability to prevent
pregnancy complications. Although the rate of oral health disease affecting pregnancy is
unknown, it is believed some preterm births among low SES women could be avoided by early
identification and treatment of existing dental conditions during pregnancy and that dental health
professionals have the ability to make a positive impact on the health and wellbeing of pregnant

ORAL HEALTH CARE

22

women. In addition to potentially preventing pregnancy complications, oral health treatment
during pregnancy is associated with improved oral and overall health (ACOG, 2013).
Pressure on the Dental Profession
The majority of survey participants are not concerned about receiving criticism from the
community if they provide dental care to pregnant women and they agree that patients will feel
positive about their clinic if they provide comprehensive dental care to pregnant women.
Routine Services
In this section of the survey, participants were asked which during which period of
pregnancy they believed it was safe to perform routine dental procedures. The responses to
questions in this section demonstrate the uncertainty of safe dental care treatment for pregnant
women. In a committee opinion issued from ACOG, the safety of dental procedures and the
recommendation to treat pregnant women is outlined. Patients and providers should be reassured
that prevention, diagnosis, and treatment of oral health conditions included x-rays and local
anesthesia are safe during pregnancy (ACOG, 2013). Additionally, conditions such as
extractions, root canals, and restoration of untreated caries may be managed at any point in
pregnancy and delaying treatment may result in further complications.
Pharmaceuticals
Survey participants were asked how often they prescribe particular medications to
pregnant women. Acetaminophen is the drug of choice for analgesic during pregnancy and can
be used at any point during pregnancy. If utilized, medications such as aspirin, ibuprofen, and
narcotics should be closely monitored. Antibiotic use in pregnancy may be appropriate but
antibiotics such as doxycycline are contraindicated after the 18th week in pregnancy.

ORAL HEALTH CARE

23

Pregnancy Status
Survey respondents reported various ways that pregnancy status is obtained in their
clinic. A standardized approach to obtaining pregnancy status may aid in documentation
improvement and pregnancy awareness among all dental team members.
Performing/Authorizing Procedures
Participants were asked how often they authorize or perform procedures on pregnant
women. Survey responses varied based on position held on the dental unit. Pregnancy is defined
as a teachable moment and a time where assessment and treatment of oral health conditions may
be possible. Perinatal and dental professionals are encouraged to establish a collaborative,
standardized approach to meeting oral health needs during pregnancy and ensuring treatment is
being performed (ACOG, 2013).
Emergency Services
Survey respondents were asked which point in pregnancy they believe routine and
emergency dental services are appropriate. The Health Resources and Services Administration’s
Maternal and Child Health Bureau, in collaboration with ACOG and the ADA, stress the safety
of performing all dental procedures during any point in pregnancy. Dental and perinatal team
members are encouraged to inform women that conditions which require immediate treatment,
such as extractions, root canals, and restoration (amalgam or composite) of untreated caries, may
be managed at any time during pregnancy. Oral bacteria may result in additional health concerns
and treatment should not be delayed until the conclusion of pregnancy (ACOG, 2013).
Education
Dental team members agree that continuing education related to oral health in pregnancy
would be of benefit to their practice. Additionally, they agree a safety checklist would be useful

ORAL HEALTH CARE

24

when educating pregnant women. Dental team members believe it’s easy to incorporate new
procedures into their practice and they enjoy practicing new ways of doing things. If dental team
members are provided with education as it relates to oral health care in pregnancy, the uptake of
dental services for pregnant women has the potential to increase.
Strengths and Limitations
Strengths of this project include a robust response rate, high survey completion rate, and
diverse representation of dental health team members. The survey tool utilized in testing was
evaluated for content validity through psychometric assessment. Survey length provided a
diverse pool of questions for review of current processes, beliefs, and desires among
respondents.
Limitations to the project include self-reported behaviors from participants as this may
impact the accuracy of information. Self-reporting of dental team members may increase the
response of how one believes they should be practicing instead of how they are actually
practicing. The survey tool utilized consisted of 77 questions. Most respondents answered all
questions. One respondent discontinued the survey prior to completion and 7 survey participants
excluded one question each. The length of the survey may have contributed to missed data.
Recommendations
Dental and perinatal providers are encouraged to review survey results from participating
FQHCs. After obtaining results, providers are encouraged to identify facilitators and barriers as
they relate to pregnant women receiving oral health care treatment. Once identified, a system
wide intervention should be implemented to standardize screening, referral, and treatment of oral
health conditions during pregnancy.

ORAL HEALTH CARE

25

Evidence suggests that dental treatment during pregnancy is safe and recommended
(ACOG, 2013). Preliminary recommendations to overcome barriers include continuing education
for staff members, interdisciplinary collaboration among specialties, and referrals from the
perinatal department.
Continuing education for staff members. Various team members participate in the
scheduling and performance of dental treatment for pregnant women. Dental health team
members including front desk staff, dental hygienists, dental assistants, referral coordinators,
practice managers, and dentists can be influential in promoting positive oral health habits during
pregnancy. Formal education programs for all dental team members may impact specific
behaviors related to promoting dental care to pregnant women and may positively impact
treatment rates. Oral health education regarding pregnant women has been shown to improve
confidence and attitudes toward providing oral health care during pregnancy and is strongly
linked to increasing treatment rates (George et al., 2016). Team members strongly agree that oral
health is connected to systemic health and they indicate a desire to receive formal continuing
education training.
Interdisciplinary collaboration among specialties. CHCs offer various comprehensive
health services which include prenatal and dental care. Health centers reduce disparities by
providing care management to patients with multiple healthcare needs. CHCs employ numerous
employees who operate in various roles. Interdisciplinary collaboration between dental and
perinatal team members may provide positive, consistent messages to pregnant women who are
subject to health disparities. Team members should receive consistent education and be
encouraged to collaborate with other specialties to overcome barriers to care.

ORAL HEALTH CARE

26

Referrals from the perinatal department. Written referrals from prenatal providers to
the dental department have been strongly linked to the completion of oral health treatment for
pregnant women (George et al., 2016). Written referrals provide recommendation to the need and
safety of dental treatment during pregnancy. Referrals can be hand delivered to the dental office,
provided to the patient, or sent electronically.
Conclusion
Preterm births and low birth weight infants remain a public health burden and costs can
be lowered when intervention is tailored to specific populations. Although not all pregnancy
complications can be prevented, all healthcare providers can take positive measures towards
promoting healthy habits and safe care. A gap analysis previously conducted among perinatal
providers in the metropolitan southwest United States will complement this gap analysis among
the dental team to aid in developing a system wide intervention to standardize screening, referral,
and treatment of oral health conditions in pregnant women. The intervention will be data driven,
and designed in the context of research evidence for best practices in oral health care during
pregnancy.

ORAL HEALTH CARE

27
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Appendix A

Table A1
Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/Method/
Purpose

Sample/Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

Gesase et al.
(2018).

Inferred to the
Quality Health
Outcomes model

Design: CSS

N=1117
Demographics:
Edu: 38.9%
post-secondary.
Mean age: 28.5.
Marital status:
90% married.
Parity 1-3:
86.6%.

IV- PD

Structured
questionnaire
including
sociodemographi
c characteristics,
previous
obstetric history,
and index
pregnancy
information

Prevalence of
PD: 14.2%.

File review

SPSS version
20. Descriptive
statistics
summarized
using mean and
SD for
continuous
variables while
frequency and
proportions used
for categorical
variables.

Clinical
periodontal
exam: CPI
scoring

OR with 95% CI
estimated using
multivariable
logistic model.

0 = no PD
1= gingivitis
(BOP, probing
depth ≤ 3mm)
2= gingivitis
(calculus with
plaque seen or
felt on probing)

p-value less than
0.05 (2 tailed)
considered
statistically
significant.

The association
between
periodontal
disease and
adverse
pregnancy
outcomes in
Northern
Tanzania: A
cross sectional
study
Country:
Northern
Tanzania, Africa
Funding: Selffunded
by authors
Bias: None
recognized

Purpose: To
determine the
prevalence of
periodontal
disease and
associated
adverse
pregnancy
outcomes among
women
delivering at the
KCMC

Setting: Tertiary
teaching hospital
with an average
of 3,300
deliveries per
year.
Inclusion: All
pregnant women
delivering at the
KCMC labor
ward, ages 1846, GA 28wks42wks.

DV1: PTB (<37
wks. gestation)
DV2: PE
DV3: LBW
(<2,500 grams)
DV4: premature
rupture of
membranes

DV1(aOR=2.32;95%
CI:1.33-4.27)
DV2:
(aOR=4.12;
95%CI:2.207.90)
DV3:
(aOR=2.41;95%
CI:1.34-4.33)
DV4:
(aOR=1.83;
95%CI:0.754.21)

Level/Quality
of Evidence;
Decision for
practice
LOE: II
Strengths: large
sample size
Weaknesses:
Study carried out
at tertiary
hospital where
most of
community lives
in urban setting.
Education level
of participants
may have not
represented
entire
population.
Attrition rate not
discussed.
Conclusion:
Maternal
periodontal
disease is a
potential
independent risk

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

34
Exclusion: MG,
any systemic
infection apart
from
periodontitis,
and those who
lacked the
number of teeth
necessary to
register the CPI.

3= periodontitis
(pathological
pocket >3mm &
<6mm)
4=periodontitis
(pathological
pocket ≥ 6mm)

indicator for PE,
LBW, and PTB.
Feasibility/appli
cation to pt.
population:
Periodontal
assessment and
therapy should
form part of the
preventive
antenatal care as
exam as
treatment can
reduce
reoccurrence or
deterioration.

Attrition: Not
discussed

Citation

Theory/
Conceptual
Framework

Design/Method
Purpose

Sample/Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

Weidlich et al.,
2013.

Inferred to be
Protection
Motivation
Theory

Design: RCT

N – 303
IG – 145
CG-154

IVComprehensive
NSPT

Chart Review

PTB (CG 9.09%
vs IG 11.72%,
p=0.57)

Demographics:
Edu: Elementary
(CG 46.75%, IG
51.73%); Age:
20-30(CG
64.28%, IG
66.9%); SEC:
ML (CG
50.65%, IG
51.04%); non-

DV1- PTB (<37
weeks gestation)

Categorical data
were
summarized by
absolute and
relative
frequencies.

Effect of
nonsurgical
periodontal
therapy and
strict plaque
control on
preterm/low
birth weight: A
randomized
controlled
clinical trial.

Purpose: Assess
the effect of
comprehensive
nonsurgical
periodontal
treatment and
strict plaque
control
performed
during
pregnancy on the

DV2- LBW
(<2500 grams)
Comprehensive
NSPT Completed
before the 24th
week of

PTB (birth
occurring before
37 weeks
gestation)
LBW (birth
weight less than
2500grams)
Randomly
allocated to EG
using blockstratified

Comparisons
between groups
performed using
Chi-square and
Fisher’s exact
test.

LBW (CG 2.6%
vs IG 4.1%,
p=0.59)
Reduction of
plaque (IG
48.5% vs CG
10.32%,
p<0.001)

Level/Quality
of Evidence;
Decision for
practice
Level of
Evidence: II
Strengths:
Study design
employed; very
low attrition rate
achieved; well
balanced;
meticulous PT
and strict plaque
control
implemented

Gingival

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

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reduction of
PTLBW

Country: Brazil
Funding:
Partially
supported by the
National Council
of ResearchBrazil and the
Department of
Periodontology,
University of
Oslo, Norway.

Caucasian (CG
31.17%, IG
32.41%)
Setting:
Pregnant women
seeking PNC at
PVMH.
Inclusion: 18-35
y.o., <20 wks.
gestation
Exclusion:
MG, receiving
OT, needing abx
prophylaxis for
DT

Bias: None
recognized

pregnancy
including
excavation and
sealing of
cavities, removal
of overhanging
restorations,
extraction of
hopeless teeth,
supragingival
calculus
removal, and
subgingival
sealing, root
planning under
local anesthesia,
and oral hygiene
instruction.

strategy
according to
smoking extent
(<5 of >5
cigarettes per
day)
Structured
questionnaire
comprising
demographics,
socioeconomic
status, medical
and dental
history used to
collect maternal
data.

Continuous data
summarized by
means, SD, CI,
and groups were
compared by
independent
sample t tests.
p-value <0.05
considered
statistically
significant

bleeding (IG
23.31% vs CG
2.5%, p<0.001)
Supragingival
calculus (IG
21.33% vs CG
4.13%, p<0.001)
BOP (IG
38.05% vs. CG
2.56%, p<0.001)

Conclusion: PT
and strict plaque
control
significantly
improved
periodontal
health. However,
no reduction of
PTLBW rates
were observed.
Feasibility/appli
cation to pt.
population:
Successful PT
performed up to
the second
trimester of
gestation may
significantly
improve
periodontal
inflammation.

Attrition: CG:2
lost to follow up
(1.2%). IG:1 lost
to follow up & 1
lost to
undetermined
GA (1.4%)

Citation

Theory/
Conceptual
Framework

Design/Method/
Purpose

Sample/Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Finding/Results

George et al.,
2018

Inferred to the
Quality Health
Outcomes model

Design:
MCRCT

N=639

IV-MIOH-DS
program

10 item
questionnaire pre

SPSS 21,
descriptive
statistics

Uptake of dental
servicesp<0.001 (20.2%

n=215 (CG)

Weaknesses:
Sample size
smaller than
recent studies

Level/Quality
of Evidence;
Decision for
practice
Level of
Evidence: II

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE
Evaluation of a
midwifery
initiated oral
health-dental
service program
to improve oral
health and birth
outcomes for
pregnant
women: A multicentre
randomized
controlled trial.
Country:
Australia
Funding:
National Health
and Medical
Research
Counsel (project
grant
App1022007)
Bias: None
recognized

36
Purpose: To
assess the
effectiveness of
a MIOH-DS
program in
improving
uptake of dental
services, oral
health
knowledge,
quality of oral
health, oral
health status,
and birth
outcomes of
pregnant women

n= 212 (IG1)
n= 212 (IG2)

DV1-Uptake of
dental services

and post
intervention

Demographics:
Age (CG 29.0,
IG1 29.1, IG2
29.0), private
insurance (CG
16.4%, IG1
14.4%, IG2
21.2%), tertiary
education (CG
52.6%, IG1
54.6%, IG2
52.1%)

DV2-Oral health
knowledge

Final dental
evaluation

Setting: Three
large
metropolitan
public hospitals
in Sidney,
Australia
Inclusion:
>18 y.o., single
LRP between
12-20 wks.
gestation
Exclusion:
Known FA,
HRP, unable to
attend dental
treatment
regularly

DV3-Quality of
oral health
DV4-Oral health
status
DV5-Birth
outcomes
MIOH-DS
program- IG1
received a
midwifery
intervention
from midwives
involving OH
education,
screening, and
referrals to
existing dental
pathways.
IG2- received
midwifery
intervention and
a dental
intervention
involving
assessment/treat
ment cost free

Pearson’s chisquared analysis;
Logistic
regression;
ANOVA; t-test;
Kruskal-Wallis
p-value <0.05
considered
statistically
significant

CG, 28.3% IG1,
87.2% IG2)
Women’s OH
knowledgep=0.03
Quality of OH –
p<0.001
OH status –
p<0.001
Birth outcomes no significant
differences
between groups
for prematurity
or LBW

Strengths:
Successful
implementation
and evaluation
of OH model of
care for
midwifery
practice.
Feasible to
implement.
Weaknesses:
Only included
women visiting a
public hospital
during
pregnancy
Conclusion: No
effect in
improving birth
outcomes among
pregnant women
Feasibility/appli
cation to pt.
population:
MIOH-DS
program is
effective in
improving DSU,
oral hygiene, OH
knowledge, and
quality of oral
health among

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

37

Citation

Theory/
Conceptual
Framework

Design/Method/
Purpose

Albert et al.,
2011.

Inferred to the
Quality Health
Outcomes model

Design:
Retrospective
Cohort study

An examination
of periodontal
treatment, dental
care, and
pregnancy
outcomes in an
insured
population in the
United States.
Country: USA
Funding:
Supported by the
New York State
Foundation for
Science,
Technology, and
Innovation;
Aetna; and
Clinical and
Translational

Purpose:
Examine
whether
periodontal
treatment or
other dental care
is associated
with adverse
birth outcomes
within a medical
and dental
insurance
database.

Attrition: IG1:
29% PQ, 59%
FE; IG2: 39%
dental
intervention,
27% PQ, 52%
FE)
Sample/Setting

N=23441
n=464 (group1)
n=622 (group2)
n=8010 (group3)
n=2024 (group4)
n=12,321
(group5)
Demographics:
Mean age: 30.9
years, 63%
reside where
population is 110% African
American,
56.4% reside
where income
exceeds the 80th
percent
nationally
Setting: Aetna
Data Warehouse
representing

pregnant
women.

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

IV: PT, dental
prophylaxis, and
other dental
treatment

Claims data
review of ICD-9
and CDT-3
coding

SPSS version
15.0

Observed
probability of
LBW: (group1:
3.7%, group2
1.8%, group3
3.3%, group4
4.6%, group5
5%)

DV1: PTB

Descriptive
statistics to
characterize the
study cohort.

DV2: LBW
Group 1: first
instance of
periodontal
treatment
occurred before
delivery
Group 2: First
instance of
periodontal
treatment
occurred
postdelivery
Group 3: Only
prophylactic

Pearson x2, one
way analysis of
variance,
Kruskal-Wallis
test, logistic
regression
analysis

Observed
probability of
PTD: (group1
9.9%, group2
6.3%, group3
7.6%, group4
9.4%, group5
10.1%)
Those who did
not receive any
dental care
during the study
period had the
highest rates of

Level/Quality
of Evidence;
Decision for
practice
Level of
Evidence: IV
Strengths:
Large cohort
study
Weaknesses:
May not be
representative of
insured women
nationwide.
Conclusion:
Receiving
preventive dental
treatment is
associated with a
lower incidence
of adverse birth
outcomes
compared with
instances when
no dental

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

38

Science aware
from the
National
Institute of
Health

pregnant women
in 47 US states
Inclusion: Fully
insured women
participating in
medical and
dental insurance
plans who
delivered
between
1/1/2003 and
9/30/2006.

Bias: None
recognized

Exclusion: 5627
women had
ICD-9 codes
with presence of
medical
exclusion factors

treatment at least
once during
observation

LBW and PTB
outcomes

services are
delivered
Feasibility/Appl
ication to
patient
practice:
Pregnant women
should be
screened and
referred for oral
care in order to
prevent
undesired
outcomes.

Group 4:
Received other
dental treatment
but no PT or
prophylaxis
during
observation
Group 5: No
dental treatment
of any kind
during period of
observation

Attrition: Not
discussed
Citation

Theory/
Conceptual
Framework

Design/Method/
Purpose

Sample/Setting

Major
Variables &
Definitions

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

Moreira et al.,
2015

Inferred to the
Quality Health
Outcomes
Model

Design: RCT

N= 90

IV- PT

SPSS

Purpose: To
compare
periodontal
therapy
outcomes during

n=49 (IG)
n=41 (CG)

DV1: PI
DV2: GI
DV3: PPD
DV4: CAL
DV5: BOP
DV6: GCF

Periodontal
examination to
include: Plaque
index, gingival
index,
periodontal
probing depth,
clinical

DV1: PI (CG
1.27 to 0.28, IG
1.42 to 0.42)

Periodontal
treatment
outcomes during
pregnancy and
postpartum.

Demographics:
Age between 2025 y.o.

Chi-square,
Fisher’s exact
test, t test,
Shapiro-Wilk
test

DV2: GI (CG
1.32 to 1.0, IG
1.28 to 0.98)

Level/Quality
of Evidence;
Decision for
practice
Level of
Evidence: II
Strengths:
Limited previous
comparison of
PT in pregnancy
vs. postpartum

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE
Country: Brazil
Funding:
Supported by the
National Council
of ResearchBrazil &
scholarship from
CAPES
Bias: None
recognized

39
pregnancy and
after delivery.

(CG:42.3%,
IG:35.1%),
Caucasian (CG:
63.5%,
IG:68.4%), high
school education
(CG: 40.4%, IG:
36.8%)
Setting: dental
unit of Maternal
Hospital
Presidente
Vargas.
Inclusion: 18-35
y.o., <20 wks.
gestation
Exclusion: MG,
receiving OT,
needing abx
prophylaxis for
DT
Attrition: 21%
CG, 14% IG

PT: Excavation
of sealing of
cavities, removal
of overhanging
restorations,
extractions of
hopeless teeth,
and
supra/subgingiva
l sealing and
root planning
under local
anesthesia.

attachment level,
bleeding on
probing, and
gingival
crevicular fluid
volume

DV3: PPD (CG
2.42 to 2.05, IG
2.43 to 2.1)
DV4: CAL (CG
0.18 to 0.17, IG
0.13 to 0.13)
DV5: BOP (CG
45.71% to
8.07%, IG
49.14% to
11.10%) p=0.95
DV6: GCF (CG
0.44 to 0.29, IG
0.5 to 0.34)
No statistically
significant
differences were
observed
between groups
concerning
plaque index,
gingival index,
periodontal
probing depth,
clinical
attachment level,
and gingival
crevicular fluid
Periodontal
therapy
significantly
reduced

Weaknesses:
Lack of
blindness among
researchers as
sample was
taken from
previously
conducted RCT.
Conclusion:
Hormonal
changes during
pregnancy do
not interfere in
treatment
outcomes in
women with
widespread
gingival
inflammation
and limited
periodontal
destruction.
Feasibility/Appl
ication to
patient
practice:
Periodontal
health can be
reestablished
irrespective of
the hormonal
challenge that
takes place

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

40
periodontal
inflammation in
both groups.

during
pregnancy. PT
therapy is safe
can be
performed
during
pregnancy
without serious
adverse events.
Level/Quality
of Evidence;
Decision for
practice
LOE: III

Citation

Theory/
Conceptual
Framework

Design/Purpose
/Method

Sample/Setting

Major
Variables &
Definitions

Measurement/I
nstrumentation

Data Analysis
(stats used)

Findings/
Results

Geisinger et al.,
2014

Inferred to the
Quality Health
Outcomes
Model

Design: Pilot
Study, nonrandomized

N= 96

IV: OH
education and
therapy

Examination
performed by
single examiner
trained in study
protocol and
examination
procedures at
baseline, 4
weeks, and 8
weeks after
prophylaxis and
intensive oral
hygiene
measures

ANOVA

DV1: PI (1.35
baseline to 0.61
at 8 week follow
up) p<0.001

Oral health
education and
therapy reduces
gingivitis during
pregnancy.
Country: USA
Funding:
Supported in
part by funding
and materials
from Procter &
Gamble
Corporation
Bias: None
recognized

Purpose: To
evaluate an
intensive
protocol aimed
at reducing
gingivitis in
pregnant women
and pilot data for
large-scale
randomized
controlled trials
investigating
oral hygiene
measures to
reduce
pregnancy
gingivitis and

Demographics:
Race (black
82.5%),
Education (high
school diploma
70%),
Unmarried
(88.3%)
Setting: Center
for Reproductive
Health at the
University of
Alabama at
Birmingham.
Inclusion: GA
between 16 and
24 weeks with
GI scores ≥2 at

DV1: PI
DV2: Gingival
inflammation
DV3: PPD
DV4: CAL
OH education
and therapy:
Educational
DVD at baseline
and copy for
home, clinical
evaluation of
intra and extra
oral structures at
baseline and all
subsequent study
visits, one on

Statistical
significance set
at p<0.01

DV2: Gingival
inflammation
(1.45 at baseline
to 0.75 at 8 week
follow up)
p<0.001
DV3: PPD (3.41
mm at baseline
to 2.97 mm at 8
week follow up)
p<0.001
DV4: CAL
(2.26mm at
baseline to
2.02mm at 8

Strengths: Well
suited study for
widespread
public health
intervention
Weaknesses:
Lack of control
subjects who
were observed
did not receive
prophylaxis and
intensive oral
hygiene
instructions
during
pregnancy
Conclusion:
Intensive oral

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

41
alter maternity
outcomes

≥50% of tooth
sites, free from
periodontitis, at
least 16 y.o., 20
natural teeth
minimally

one intervention,
reinforcement of
home care with
periodic cell
phone messages

week follow up)
p<0.001

Feasibility/Appl
ication to
patient
practice: Low
cost
interventions
may result in
overall
improvement of
maternal and
fetal oral and
systemic health.
Repeated and
systematic oral
hygiene
instruction may
aid in reducing
gingivitis noted
in pregnant
women and
should be
implemented in
prenatal
education

Exclusion:
plural gestation,
previous
spontaneous PT,
body mass index
<19.88, or
bacterial
vaginosis
Attrition:
19%

Citation

Theory/
Conceptual
Framework

Design/Purpose
/Method

Sample/Setting

hygiene regimen
decreased
gingivitis in
pregnant
patients.

Major
Variables &
Definitions

Measurement/I
nstrumentation

Data Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE
Ramesh Reddy
et al., 2014
The effect of
phase-1
periodontal
therapy on
pregnancy
outcome in
chronic
periodontitis
patients.
Bias: None
recognized
Country: India
Funding: None
recognized

Inferred to the
Quality Health
Outcomes
Model

42
Design: RCT
Purpose:
Determine the
effect of nonsurgical
periodontal
therapy on
pregnancy
outcomes in
women with
periodontitis and
to detect IgM
and IgG status in
cord blood
during delivery.

N=20
n=10 (CG)
n=10 (IG)

IV – Phase-I
periodontal
therapy

Demographics:
Age: (CG 27.04,
IG 26.23), GA:
(CG 18.15 wks.,
IG 16.35 wks.)

DV1: Oral
health index
DV2: bleeding
index
DV3: PPD
DV4: CAL
DV5: PTB
DV6: LBW

Setting:
Department of
Periodontology,
Narayana Dental
College and
Hospital and
Jubilee Govt.
Mother and
Child Hospital
Inclusion: 18-35
y.o., 12-24
weeks GA,
diagnosed
periodontitis, no
treatment within
the previous 6
months
Exclusion:
Current smokers,
history of
alcohol
consumption,
taking systemic
medications,

Phase I
periodontal
therapy –
therapy before
28 weeks
gestation and
maintenance
until delivery

Precise case
history, clinical
examination, and
complete
periodontal
examination.
Chart Review
LBW defined as
<2,500 gms.
PTD defined as
<37 weeks
gestation

ANOVA, χ2
analysis

DV1: Oral
health index (CG
5.0 to 4.8, IG 4.2
to 1.0) p<0.001
DV2: bleeding
index (CG 3.8 to
3.3, IG 3.3 to
1.2) p<0.001
DV3: PPD (4.9
to 4.4, IG 4.5 to
1.9) p<0.001
DV4: CAL (CG
5.0 to 4.7, IG 4.9
to 2.2) p = 0.001
DV5: PTB
(CG10%, IG
0%)
DV6: LBW
(CG20%, IG0%)

LOA: II
Strengths: Zero
percent attrition
rate.
Weaknesses:
Small sample
size
Conclusion:
Women with
periodontitis are
two to three
times more
likely to deliver
a preterm, low
birth weight
infant than
periodontally
healthy women.
Feasibility/Appl
ication to
patient
practice:
Periodontal
therapy may be
useful in
reducing the
occurrence of
LBW and PTB

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

43
have systemic
diseases
Attrition: None
(0%)

Citation

Theory/
Conceptual
Framework

Design/Purpose
/Method

Sample/Setting

Major
Variables and
Definition

Measurement/I
nstrumentation

Data Analysis
(stats used)

Findings/
Results

Pirie et al., 2013

Inferred to the
Quality Health
Outcomes
Model

Design: RCT

N=99

DV1: PTB (CG,
2% IG,8%)

n= 50 (CG)
n=49 (IG)

Periodontal
examination by
one examiner
who had been
calibrated to a
gold standard
examiner

Independent
sample T test

Purpose:
Investigate the
potential link
between
maternal
periodontitis and
pregnancy
outcomes,
specifically
LBW and PTB

IV –
Intrapregnancy
non-surgical PT

Level of
significance set
at p<0.05

DV2: LBW (CG
2%, IG 6%)

Intrapregnancy
non-surgical
periodontal
treatment and
pregnancy
outcome: A
randomized
controlled trial
Bias: None
recognized
Funding: None
recognized
Country:
Ireland

Demographics:
Mean age: (CG
20.5 years, IG
30.5 years),
Number of years
in full time
education (CG
15.8, IG 15.8),
high social class
(CG 38%, IG
61%), Null
parity (CG46%,
IG 41%)
Setting:
Antenatal clinic
in the Royal
Jubilee
Maternity
Service, Belfast,
Northern Ireland

DV1: PTB <37
weeks gestation)
DV2: LBW
(<2500 grams)
Intrapregnancy
non-surgical PT
– completed by
the end of
gestational week
24. Consisted of
oral hygiene
instructions,
supragingival
and subgingival
scaling and root
planning (SRP)
of sites with PDs
greater than or
equal to 4mm,

Chart review of
medical notes

ANCOVA,
Mann-Whitney
U, Wilcoxon
signed-ranks test

No improvement
noted in PTB or
LBW seen in
control group vs.
investigation
group
Plaque present:
% of sites (pre
treatment 79,
post treatment
37) p<0.001
BOP present: %
of sites (pre
treatment 76,
post treatment
50) p<0.001

Level/Quality
of Evidence;
Decision for
practice
LOA: II
Strengths:
Independent
finding that
periodontal
treatment during
pregnancy
improved
clinical
periodontal
parameters
Weaknesses:
Periodontal
disease in
participants may
not have been
severe enough,
majority
Caucasian
population, and
relatively small
sample size

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

44
Inclusion:
>18y.o.,
singleton
pregnancy, and
≥20 teeth

and polishing of
all teeth

PD greater than
or equal to 4
mm: % of sites
(pretreatment
19.9, post
treatment 6.1)
p<0.001

Exclusion: MG,
diabetes, known
pregnancy
complications,
requiring abx
prophylaxis,
aggressive
periodontitis, or
PT in the past 12
months

Conclusions:
Non-surgical
periodontal
treatment,
performed
during weeks 20
to 24 of
pregnancy, does
not influence
pregnancy
outcomes in the
Caucasian
population.
Feasibility/Appl
ication to
patient
practice: Study
showed
improvement in
oral health when
PT was initiated
during
pregnancy even
though it didn’t
show changes in
birth outcomes.

Attrition: None
(0%)

Citation

Theory/
Conceptual
Framework

Design/Purpose
/Method

Sample/Setting

Major
Variables &
Definition

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

Zhang et al.,
2019

Inferred to the
Quality Health
Outcomes
Model

Design: CSS

N=9234
Demographics:
All white, non-

Massachusetts
Pregnancy Risk
Assessment

SAS 9.4,
SUDAAN 11.0,
Chi square

DV: PTB rate

Purpose: To
examine the

IV1: Dental
cleaning during
pregnancy

Level/Quality
of Evidence;
Decision for
practice
LOA: II

Neither dental
cleaning during

Strengths:
Population based

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE
Dental cleaning,
community
water
fluoridation, and
preterm birth,
Massachusetts:
2009-2016
Bias: None
recognized
Funding:
Centers for
Disease Control
and Prevention
grant
Country: United
States

45
association of
maternal dental
cleaning during
pregnancy and
exposure to
CWF on preterm
birth using a
population-based
survey of
women who
recently gave
birth

Hispanic
(66.2%), 30-39
years old
(53.6%), college
degree (50.6%),
household
income above
200% FPL
(58.6%), born in
US (72.9%),
normal BMI
prior to
becoming
pregnancy
(54.9%)
Setting: Women
delivering in
Massachusetts
from 2009-2016
Inclusion: All
women
delivering
singleton, live
births
Exclusion:
adoption,
surrogates, MB
Attrition: None
(0%)

IV2: CWF
DV: PTB rate
(<37 weeks
gestation)
Confounders:
Maternal
race/ethnicity,
age, education,
FPL, insurance
status, prepregnancy
diabetes, prior
preterm birth,
nativity, and prepregnancy BMI

Monitoring
System survey

pregnancy or
CWF (11.5%)

Massachusetts
Department of
Public Health,
Office of Oral
Health, CWF
town lists

Dental cleaning
only (7.7%)
CWF only (9%)
Dental cleaning
and CWF (7.4%)
After adjusting
for confounders,
women who
received dental
cleaning and
CWF were 26%
less likely to
have a preterm
birth than
women who
received neither.
[aRR 0.74, 95%
CI (0.55-0.98),
aRR 0.74, 95%
CI (0.57-0.95)].
Women who
received dental
cleaning alone
and dental
cleaning with
CWF have
significantly
lower prevalence
of PTB
compared with

survey
strengthening
generalizability,
able to account
for relevant
confounders
strengthening
internal validity,
study provides a
replicable
framework for
other PRAMS
states
Weaknesses:
Unknown if
additional dental
services were
provided,
women’s length
of residency in
CWF
unavailable
Conclusion:
Women who had
dental cleaning
during
pregnancy and
lived in a
community with
water
fluoridation had
lower prevalence
of PTB.

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

46
women who had
neither after
controlling for
confounders

Citation

Theory/
Conceptual
Framework

Design/Purpose
/Method

Sample/Setting

Major
Variables and
Definition

Measurement/
Instrumentatio
n

Data Analysis
(stats used)

Findings/
Results

Iheozor-Ejiofor
et al., 2017

Inferred to the
Quality Health
Outcomes
Model

Design: MetaAnalysis,
Cochrane
Review

N=7161
15 studies

IV – Periodontal
treatment

Demographics:
Mean GA (14.0
to 39.6 weeks),
age (22.2-30.5
years)

DV1: PTB (<37
weeks gestation)

Setting: RCTs
conducted in
either university
hospitals, public
hospitals, public
health clinics,
antenatal clinics,
maternity

DV3: small for
gestational age

Electronic search
review including
Cochrane Oral
Health’s Trials
Register,
Cochrane
Pregnancy and
Childbirth’s
Trials Register,
Cochrane
Central Register
of Controlled
Trials,
MEDLINE
Ovid, Embase
Ovid, LILACS
BIREME Virtual

Effect measures
include the odds
ratio (OR), risk
ratio (RR), or
risk difference
(RD) for
dichotomous
data, mean
difference (MD)
or standardized
mean difference
(SMD) for
continuous data

DV1: PTB: 11
studies. 5671
participants.
There is no clear
difference in
preterm birth <
37 weeks (RR
0.87, 95% CI
0.70 to 1.10; I2
= 66%)

Treating
periodontal
disease for
preventing
adverse birth
outcomes in
pregnant women
Bias: 10 studies
unclear risk and
5 studies low
risk

Purpose: To
assess the effects
of treating
periodontal
disease in
pregnant women
in order to
prevent or
reduce perinatal
and maternal
morbidity and
mortality

DV2: LBW
(<2500 grams)

DV4: Perinatal
Mortality
DV5: Maternal
Mortality

DV2: LBW: 7
studies.
Periodontal
treatment may
reduce the
incidence of low

Feasibility/Appl
ication to
patient
practice:
Promotion of
dental cleanings
during
pregnancy and
CWF improve
birth outcomes
and women’s
health which
suggest they
should be
recommended
Level/Quality
of Evidence;
Decision for
practice
LOA: I
Strengths:
Diverse group
ranging from
mild to severe
PD.
Weaknesses:
Variation in
definition of
periodontitis
across studies,
high risk of bias
due to lack of
blinding of

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE
Funding:
Research
institutes, the
government,
scientific
research fund, a
university,
“institutional
support”, and a
manufacturer of
oral healthcare
products
Country: North
America, South
America, Asia,
Europe, and
Australia

47
hospitals or a
combination of
university and
antenatal clinics
Inclusion: all
RCTs
investigating the
effects of
periodontal
treatment in
preventing or
reducing
perinatal and
maternal
morbidity and
mortality,
diagnosed PD or
gingivitis
Exclusion:
studies where
obstetric
outcomes were
not reported,
nonrandomization,
inclusion of
pregnant women
regardless of
periodontal
status
Attrition: varies
per study

DV6: PreEclampsia
DV7: Adverse
effects of
therapy

Health Library,
ClinicalTrials.go
v, & World
Health
Organization
International
Clinical Trials
Registry
Platform

birth weight <
2500 g (9.7%
with PT versus
12.6% with no
treatment. RR
0.67, 95% CI
0.48 to 0.95; I2
= 59%)
DV3: Small for
gestational age:
7 studies.
Periodontal
treatment may
lead to no clear
difference in
births of babies
which are small
for gestational
age when
compared with
no treatment
(RR 0.97, 95%
CI 0.81 to 1.1)
DV4: Perinatal
Mortality, 3
studies. It is
uncertain
whether
periodontal
treatment
increases or
decreases
perinatal
mortality (RR
0.85, 95% CI

participants in
13 studies
Conclusion: It is
not clear if
periodontal
treatment during
pregnancy has
an impact on
preterm birth
(low-quality
evidence). There
is low-quality
evidence that
periodontal
treatment may
reduce low birth
weight (< 2500
grams)
Feasibility/Appl
ication to
patient
practice: There
may be
insufficient
evidence to
determine
if/which PD
treatment during
pregnancy is
better but
treatment did not
inflict harm or
poor outcomes
and therefore

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

48
0.51 to 1.43; I2
= 21%)

may be
beneficial.

DV5: Maternal
mortality: 4
studies. 0%
mortality rate.
DV6: PreEclampsia: 3
studies. It is
uncertain
whether
periodontal
treatment results
in a difference in
pre-eclampsia
when compared
to no treatment
(RR 1.10, 95%
CI 0.74 to 1.62)
DV7: Adverse
effects of
therapy: 4
studies. 0%
adverse effects

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

49
Appendix B

Table B1
Synthesis Table

Year
CSS
RCT
Cohort
Pilot
Cochrane
Demographics
Mean age (yrs.)
% Non-Caucasian
Findings
Preterm birth rate
Low birth weight
Oral health status
Independent Variables
Non-surgical therapy
MIOH-DS
Periodontal treatment
Dental prophylaxis
Dental Treatment
Oral health education
and therapy
Dental cleaning

Gesase

Weidlich

George

Albert

Moreira

Geisinger

2018
X

2012

2018

2011

2015

2014

X

X

X

RameshReddy
2013

Pirie

Zhang

2013

2019
X

X

X

IheozorEjiofor
2017

X
X
X
28.5

20-30
32.41

29

30.9

20-25
31.6

not stated
82.5

↓
↓

↑

↑

↑

↑

26.23

30.5

↓
↓
↑

↑

X

X

30-39
33.8
↓
↓

22.2-30.5

↓

X
X
X
X
X

X

X

X
X

Abbreviation Key: abx- antibiotics; aOR- adjusted odds ratio; BOP- bleeding on probing; CAL – clinical attachment level; CG- control group; CI- confidence interval; CPI- community
periodontal index; CSS- cross-sectional study; CWF- community water fluoridation; DSU- dental services utilization; DT- dental treatment; DV- dependent variable; FA- fetal anomalies; FE- final
evaluation; GA- gestational age; GCF- gingival crevicular fluid; GI- gingival index; HRP- high risk pregnancy; IG- intervention group; IV- independent variable; KCMC- Kilimanjaro Christian
Medical Centre; LBW- low birth weight; LRP- low risk pregnancy; MCRCT- Multi-centre randomized controlled trial; MG- multiple gestation; MIOH-DS– Midwifery initiated oral health-dental
service; ML- medium low; mm- millimeters; N- number; NSPT- non surgical periodontal treatment; NSW- New South Wales; OH- oral health; OR- odds ratio; OT-orthodontic treatment; PDperiodontal disease; PE- pre-eclampsia; PI-plaque index; PNC- prenatal care; PPD- periodontal probing depth; PQ- post questionnaire; PT- periodontal treatment; PTB- preterm birth; PTLBWpreterm low birth weight; PVMC – Presidente Vargas Maternal Hospital; RR- risk ratio; SD- standard deviation; SEC- socioeconomic status; wks- weeks; y.o.- year old

ORAL HEALTH CARE

50
Appendix C

Figure C1
Quality Health Outcomes Model

ORAL HEALTH CARE

51
Appendix D

Figure D1
Knowledge to Action Framework

ORAL HEALTH CARE

52
Appendix E

Figure E1
Budget
Category
Personnel

Tools

Facility/Project
Implementation

Activity

Projected Cost

Out of Pocket
Expenses

In Kind Support

Project Director- DNP
$40/hr ~5
student (project plan/IRB
hours week for
submission/implementation/ 10 months
data analysis) June 2019April 2020

$8,000

Project Mentor- Dr. Denise
Link

$65/hr ~2
hours/wk for 10
months

$5,200

Dental Providers (reading
emails/completing survey)

$80/hr ~30
minutes each
x~25 providers

$1,000

Project Champion and Oral
Health Coordinator at
AACHC

$45/hr ~5
hours/month
for 10 months

$2,250

Survey Monkey utilization
for 1 year

$75/month x12
months

$900

SPSS software

Available for a
discounted rate
through ASU

$125

Project introduction and
promotion at ~5 facilities
(room utilization)

$250

Refreshments & snacks
provided during
introduction/completion
report
Project completion report at
~5 facilities (room
utilization)
Total Projected Costs:

$500

$250

$1,525

$16,950

ORAL HEALTH CARE

53
Appendix F

Table F1
Oral Health in Pregnancy Survey Results
Variable
What is your position held on dental unit
Appointment Center Specialist
Dental Assistant
Dental Hygienist
Dentist
Office Manager
Patient Services Representative
Specialty Dentist
Oral health is connected to systemic health
Strongly agree
Strongly disagree
Bacteria that cause tooth decay in moms can be passed on to babies
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Hormonal changes in pregnant women increase their risk of gum disease
Somewhat agree
Somewhat disagree
Strongly agree
Periodontal disease is associated with miscarriage, preterm birth, and low birth
weight
Neither agree/disagree
Somewhat agree
Strongly agree
Strongly disagree
Counseling pregnant women about oral health is important
Strongly agree
Counseling a pregnant woman about oral health can improve the oral health of her
baby
Neither agree/disagree

n

%

1 1.92
21 40.38
9 17.31
12 23.08
3 5.77
5 9.62
1 1.92
51 98.08
1 1.92
2 3.85
6 11.54
2 3.85
41 78.85
1 1.92
4 7.69
1 1.92
47 90.38

14 26.92
6 11.54
30 57.69
2 3.85
52

100

2

3.85

ORAL HEALTH CARE
Somewhat agree
Strongly agree
I have the skills to counsel pregnant patients
Neither agree/disagree
Somewhat agree
Strongly agree
Our dental practice is too busy to provide counseling about oral care for pregnant
women
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Insurance plans compensate our dental company adequately for time spent on
counseling pregnant women
Neither agree/disagree
Somewhat disagree
Strongly agree
It is the responsibility of the dental provider to counsel a pregnant woman on the
dangers of smoking
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
A pregnant woman should be counseled to have a dental provider look at their
baby’s teeth when they first erupt
Somewhat agree
Strongly agree
Explaining the possible link between periodontal disease and preterm birth takes
too much time out of the schedule
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Explaining the link between dental caries in mothers and dental caries in babies
takes too much time out of the schedule
Neither agree/disagree
Somewhat agree

54
3 5.77
47 90.38
7 13.46
5 9.62
40 76.92

8
6
7
1
30

15.38
11.54
13.46
1.92
57.69

20 38.46
10 19.23
4 7.69

6 11.54
7 13.46
1 1.92
38 73.08

3 5.77
49 94.23

5 9.62
5 9.62
11 21.15
2 3.85
29 55.77

3
4

5.77
7.69

ORAL HEALTH CARE
Somewhat disagree
Strongly agree
Strongly disagree
It is worth our time to counsel pregnant patients about their diet
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Dental treatment should be a part of woman’s prenatal care
Neither agree/disagree
Somewhat agree
Strongly agree
Physicians are better able than dentists to counsel pregnant patients about oral
health
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Patients more likely to seek dental care if their physician recommends it
Neither agree/disagree
Somewhat agree
Strongly agree
There is little I can do to affect a woman’s oral hygiene
Neither agree/disagree
Somewhat disagree
Strongly disagree
It is important for a pregnant woman to have her blood pressure taken during a
dental appointment
Neither agree/disagree
Somewhat agree
Strongly agree
A dental provider has the ability to identify possible complications of a pregnancy
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree

55
9 17.31
1 1.92
35 67.31
2 3.85
8 15.38
2 3.85
39
75
1 1.92
1 1.92
3 5.77
48 92.31

11 21.15
3 5.77
11 21.15
5 9.62
22 42.31
1 1.92
10 19.23
41 78.85
8 15.38
8 15.38
36 69.23

1 1.92
7 13.46
41 78.85
14
11
8
6

26.92
21.15
15.38
11.54

ORAL HEALTH CARE
Strongly disagree
It is safe to provide dental treatment to pregnant women
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
I am concerned about being sued if something goes wrong in a pregnancy after
dental treatment
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Clinicians in the community will be critical of us if we provide necessary oral
health care to pregnant patients
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Patients would feel positively about our clinic if we provide comprehensive care
to pregnant patients
Neither agree/disagree
Somewhat agree
Strongly agree
During which period of pregnancy do we believe routine services are
appropriate?
Oral hygiene instructions
Anytime during pregnancy
Anytime during pregnancy, Emergency only
Emergency only
Prophy
Anytime during pregnancy
Anytime during pregnancy, Emergency only
Emergency only
Scaling and root planning
Anytime during pregnancy
Emergency only
Never

56
13

25

6 11.54
14 26.92
5 9.62
27 51.92

21
9
8
5
9

40.38
17.31
15.38
9.62
17.31

13
25
7 13.46
2 3.85
10 19.23
20 38.46

5 9.62
9 17.31
38 73.08

47 90.38
1 1.92
4 7.69
50 96.15
1 1.92
1 1.92
38 73.08
13
25
1 1.92

ORAL HEALTH CARE
Site specific antibiotic (e.g. Perio Chip, Arestin)
Anytime during pregnancy
Emergency only
Never
Fluoride varnish treatment
Anytime during pregnancy
Anytime during pregnancy, Emergency only
Emergency only
Never
Single periapical x-ray
Anytime during pregnancy
Anytime during pregnancy, Emergency only
Emergency only
Full mouth x-rays
Anytime during pregnancy
Anytime during pregnancy, Emergency only
Emergency only
Never
Injection of local anesthetic (e.g., lidocaine)
Anytime during pregnancy
Anytime during pregnancy, Emergency only
Emergency only
Never
Single tooth extraction
Anytime during pregnancy
Emergency only
Amalgam restoration
Anytime during pregnancy
Emergency only
Never
Composite restoration
Anytime during pregnancy
Emergency only
Never
Root canal therapy
Anytime during pregnancy
Emergency only
Never

57

11 21.15
25 48.08
16 30.77
41 78.85
1 1.92
6 11.54
4 7.69
29 55.77
1 1.92
22 42.31
13
25
1 1.92
16 30.77
22 42.31
23 44.23
1 1.92
26
50
2 3.85
14 26.92
38 73.08
22 42.31
23 44.23
7 13.46
31 59.62
18 34.62
3 5.77
14 26.92
36 69.23
2 3.85

ORAL HEALTH CARE
Crown and bridge
Anytime during pregnancy
Emergency only
Never
Nitrous oxide and oxygen sedation
Anytime during pregnancy
Emergency only
Never
How often do you recommend or prescribe the following pharmaceuticals?
Non-steroidal, anti-inflammatory agents, NSAIDS (e.g., Ibuprofen)
Never
Rarely
Sometimes
Acetaminophen (e.g. Tylenol)
Never
Often
Rarely
Sometimes
Aspirin
Never
Rarely
Sometimes
Pain medicines containing codeine or other narcotics (e.g., Vicodin or
Oxycodone)
Never
Rarely
Sometimes
Chlorhexidine
Never
Often
Rarely
Sometimes
Oral antibiotics
Never
Often
Rarely
Sometimes
Periostat (doxycycline)

58

18 34.62
26
50
8 15.38
1 1.92
4 7.69
47 90.38

37 71.15
10 19.23
5 9.62
9
10
11
22

17.31
19.23
21.15
42.31

42 80.77
7 13.46
3 5.77

40 76.92
7 13.46
5 9.62
21 40.38
4 7.69
9 17.31
18 34.62
16 30.77
3 5.77
15 28.85
18 34.62

ORAL HEALTH CARE
Never
Rarely
Sometimes
How do you learn the pregnancy status of your patients?
The receptionists asks for pregnancy status when scheduling an appointment
No
Yes
There is a question about pregnancy in the routine health update that the patient
fills out
No
Yes
Our patients tell us in casual conversation
No
Yes
We ask if we suspect a patient might be pregnant
No
Yes
If a staff member determines a patient is pregnant, she/he noted it on the patient’s
chart
No
Yes
If a staff member determines a patient is pregnant/she/he notes it on the daily
scheduled
No
Yes
How often to you perform/authorize the following procedures on pregnant
women?
Oral hygiene instruction
I don't perform or authorize this service
Often
Rarely
Sometimes
Prophy
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Scaling and root planing

59
43 82.69
6 11.54
3 5.77

40 76.92
12 23.08

3 5.77
49 94.23
14 26.92
38 73.08
12 23.08
40 76.92

8 15.38
44 84.62

31 59.62
21 40.38

8 15.38
39
75
1 1.92
4 7.69
10 19.23
1 1.92
37 71.15
2 3.85
2 3.85

ORAL HEALTH CARE
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Site specific antibiotic (e.g., Perio Chip, Arestin)
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Fluoride varnish treatment
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Single periapical x-ray
I don't perform or authorize this service
Often
Rarely
Sometimes
Full mouth x-rays
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Injection of local anesthetic (e.g., lidocaine)
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Single tooth extraction
I don't perform or authorize this service
Never
Often

60
15 28.85
3 5.77
17 32.69
5 9.62
12 23.08
30 57.69
16 30.77
1 1.92
1 1.92
4 7.69
11
6
14
6
15

21.15
11.54
26.92
11.54
28.85

9
17
7
19

17.31
32.69
13.46
36.54

9
22
6
8
7

17.31
42.31
11.54
15.38
13.46

19
3
10
6
14

36.54
5.77
19.23
11.54
26.92

23 44.23
1 1.92
6 11.54

ORAL HEALTH CARE
Rarely
Sometimes
Amalgam restoration
I don't authorize or perform this service
Never
Often
Rarely
Sometimes
Composite restoration
I don't authorize or perform this service
Never
Often
Rarely
Sometimes
Root canal therapy
I don't perform or authorize this service
Never
Often
Rarely
Sometimes
Crown & bridge
I don't authorize or perform this service
Never
Often
Rarely
Sometimes
Nitrous oxide and oxygen sedation
I don't perform or authorize this service
Never
Rarely
Sometimes
During which periods of pregnancy do you believe it is appropriate for patients to
have each of the following emergency services, even if you do not provide this
service
Tooth extraction
1st trimester
1st trimester, 2nd trimester, 3rd trimester
1st trimester, 3rd trimester
2nd trimester

61
8 15.38
14 26.92
27 51.92
4 7.69
4 7.69
9 17.31
8 15.38
25
1
9
7
10

48.08
1.92
17.31
13.46
19.23

27
6
3
6
10

51.92
11.54
5.77
11.54
19.23

25
11
2
6
8

48.08
21.15
3.85
11.54
15.38

24 46.15
26
50
1 1.92
1 1.92

2 3.85
11 21.15
1 1.92
19 36.54

ORAL HEALTH CARE
2nd trimester, 3rd trimester
3rd trimester
Never/Don't know
Open and broach
1st trimester
1st trimester, 2nd trimester, 3rd trimester
1st trimester, 3rd trimester
2nd trimester
2nd trimester, 3rd trimester
3rd trimester
Never/Don't know
Incision and draining an abscess
1st trimester
1st trimester, 2nd trimester
1st trimester, 2nd trimester, 3rd trimester
1st trimester, 3rd trimester
2nd trimester
2nd trimester, 3rd trimester
3rd trimester
Never/Don't know
Injection of local anesthetic (e.g., Marcaine)
1st trimester
1st trimester, 2nd trimester
1st trimester, 2nd trimester, 3rd trimester
2nd trimester
2nd trimester, 3rd trimester
3rd trimester
Never/Don't know
Temporary filling
1st trimester
1st trimester, 2nd trimester, 3rd trimester
2nd trimester
3rd trimester
Never/Don't know
Information about a Continuing Ed program on care for pregnant patients interests
me
Neither agree/disagree
Somewhat agree

62
4 7.69
7 13.46
8 15.38
1 1.92
7 13.46
1 1.92
13
25
3 5.77
2 3.85
25 48.08
2 3.85
1 1.92
15 28.85
1 1.92
12 23.08
3 5.77
3 5.77
15 28.85
2 3.85
1 1.92
1 1.92
11 21.15
2 3.85
3 5.77
32 61.54
5 9.62
22 42.31
11 21.15
5 9.62
9 17.31

5 9.62
12 23.08

ORAL HEALTH CARE
Strongly agree
Receiving examples of a checklist to initiate conversations with our patients about
oral health care during pregnancy interests me
Neither agree/disagree
Somewhat agree
Strongly agree
Strongly disagree
Receiving education materials to provide to our pregnant patients interests me
Neither agree/disagree
Somewhat agree
Strongly agree
Strongly disagree
Do you agree or disagree that it is easy to incorporate new procedures in your
practice of dentistry or in the dental office
Neither agree/disagree
Somewhat agree
Somewhat disagree
Strongly agree
Strongly disagree
Which best describes your feelings about trying new ways of doing things, or
adding changes, to your job responsibilities
I enjoy experimenting with new procedures or ways of doing things.
I only try new procedures or ways of doing things when regulations require
them.
I only try new procedures when the ADA and/or FDA approve them.
I prefer to wait until new procedures have been established for awhile.
I prefer to wait until others have tried new procedures or ways of doing things.

63
35 67.31

7 13.46
16 30.77
28 53.85
1 1.92
5 9.62
11 21.15
35 67.31
1 1.92

5 9.62
17 32.69
3 5.77
21 40.38
6 11.54

33 63.46
3

5.77

7 13.46
6 11.54
3 5.77