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Oral Health in Pregnancy

Open AccessPublished:June 06, 2016DOI:https://doi.org/10.1016/j.jogn.2016.04.005

      Abstract

      Oral health is crucial to overall health. Because of normal physiologic changes, pregnancy is a time of particular vulnerability in terms of oral health. Pregnant women and their providers need more knowledge about the many changes that occur in the oral cavity during pregnancy. In this article we describe the importance of the recognition, prevention, and treatment of oral health problems in pregnant women. We offer educational strategies that integrate interprofessional oral health competencies.

      Keywords

      In the last decade, the importance of oral health during pregnancy has garnered the attention of policymakers, foundations, agencies, and health care providers who serve pregnant women and young children. The U.S. Surgeon General (
      U.S. Department of Health and Human Services
      Oral health in America: A report of the Surgeon General.
      ), World Health Organization (
      • Petersen P.E.
      World Health Organization global policy for improvement of oral health—World Health Assembly 2007.
      ), and American College of Obstetricians and Gynecologists (
      American College of Obstetricians and Gynecologists Women's Health Care PhysiciansCommittee on Health Care for Underserved Women
      Committee opinion no. 569: Oral health care during pregnancy and through the lifespan.
      ) have all recognized that oral health is an integral part of preventive health care for pregnant women and their newborns. Three Institute of Medicine reports (
      Institute of Medicine
      Advancing oral health in America.
      ,
      Institute of Medicine
      Oral health literacy: Workshop summary.
      ,
      Institute of Medicine & National Research Council
      Improving access to oral health care for vulnerable and underserved populations.
      ) highlighted the significance of addressing oral health as a population health issue for pregnant women. In 2012, the Oral Health Care During Pregnancy Expert Workgroup highlighted the importance of the provision of oral health care to pregnant women in their landmark document, Oral Health During Pregnancy: A National Consensus Statement. The U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) released Integration of Oral Health and Primary Care Practice (2014), which outlines interprofessional oral health core clinical competencies appropriate for primary care providers including nurse practitioners (NPs), nurse-midwives (NMs), medical doctors (MDs), doctors of osteopathic medicine (DOs), and physician assistants (PAs).
      During pregnancy, many changes occur in the oral cavity that can be linked to periodontal disease, which includes gingivitis and periodontitis. Studies have indicated that there is a connection between “increased plasma levels of pregnancy hormones and a decline in periodontal health status” (
      • Wu M.
      • Chen S.-W.
      • Jiang S.-Y.
      Relationship between gingival inflammation and pregnancy.
      , p. 8). Approximately 60% to 75% of pregnant women have gingivitis (
      American Dental Association Council on Access, Prevention, and Interprofessional Relations
      Women's oral health issues.
      ). Although various numbers have been reported for the prevalence of periodontitis in pregnancy, almost half of adults in the United States have this condition (
      • Eke P.I.
      • Dye B.A.
      • Wei L.
      • Thornton-Evans G.O.
      • Genco R.J.
      Prevalence of periodontitis in adults in the United States: 2009 and 2010.
      ).
      During pregnancy, a woman's oral health can affect her health and the health of her unborn child. The purpose of this article is to present information on the importance of women's health care providers in the recognition, prevention, and management of oral health problems during pregnancy. Strategies that integrate interprofessional oral health competencies into women's health care provider education and practice are provided.

      Periodontal Disease in Pregnancy

      Periodontal disease, including gingivitis and periodontitis, has been associated with pregnancy (
      • Wu M.
      • Chen S.-W.
      • Jiang S.-Y.
      Relationship between gingival inflammation and pregnancy.
      ). According to the American Academy of Periodontology, periodontal disease is “an inflammatory disease that affects the soft and hard structures that support the teeth” (n.d., “The Causes and Symptoms,” para. 2). Gingivitis, the early stage of periodontal disease, occurs when “the gums become swollen and red due to inflammation,” and periodontitis, the most serious form of periodontal disease, occurs when the “gums pull away from the tooth and supporting gum tissues are destroyed” (

      American Academy of Periodontology. (n.d.). Periodontal disease fact sheet. Retrieved from https://www.perio.org/newsroom/periodontal-disease-fact-sheet

      , “The Causes and Symptoms,” para. 2).
      Lack of oral health care during pregnancy can negatively affect mother and newborn.

       Gingivitis

      • Figuero E.
      • Carrillo-de-Albornoz A.
      • Martín C.
      • Tobías A.
      • Herrera D.
      Effect of pregnancy on gingival inflammation in systemically healthy women: A systematic review.
      reported in their systematic review that the relationship between pregnancy and gingivitis confirmed “the existence of a significant increase in gingivitis throughout pregnancy and between pregnant versus post-partum or non pregnant women” (p. 457).
      • Ehlers V.
      • Callaway A.
      • Hortig W.
      • Kasaj A.
      • Willershausen B.
      Clinical parameters and aMMP-8-concentrations in gingival crevicular fluid in pregnancy gingivitis.
      compared the dental evaluation and gingival crevicular fluid from 40 pregnant women and 40 age-matched nonpregnant control subjects. They found that 80% of pregnant women had gingival inflammation compared with 40% of control subjects.
      • Gogeneni H.
      • Buduneli N.
      • Ceyhan-Öztürk B.
      • Gümüş P.
      • Akcali A.
      • Zeller I.
      • Özçaka Ö.
      Increased infection with key periodontal pathogens during gestational diabetes mellitus.
      reported that pregnant women with gingivitis and pregnant women with gingivitis and gestational diabetes mellitus (GDM) had high levels of systemic C-reactive protein. These findings indicate that gingivitis is a problem in pregnant women.

       Periodontitis

      Recent studies have shown an association between periodontitis during pregnancy and low birth weight (LBW), very low birth weight (VLBW), preeclampsia, and GDM (
      • Corbella S.
      • Taschieri S.
      • Del Fabbro M.
      • Francetti L.
      • Weinstein R.
      • Ferrazzi E.
      Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association.
      ,
      • Guimarães A.N.
      • Silva-Mato A.
      • Siqueira F.M.
      • Cyrino R.M.
      • Cota L.O.M.
      • Costa F.O.
      Very low and low birth weight associated with maternal periodontitis.
      ,
      • Ha J.E.
      • Jun J.K.
      • Ko H.J.
      • Paik D.I.
      • Bae K.H.
      Association between periodontitis and preeclampsia in never-smokers: A prospective study.
      ,
      • Xiong X.
      • Elkind-Hirsch K.E.
      • Vastardis S.
      • Delarosa R.L.
      • Pridjian G.
      • Buekens P.
      Periodontal disease is associated with gestational diabetes mellitus: A case-control study.
      ).
      • Guimarães A.N.
      • Silva-Mato A.
      • Siqueira F.M.
      • Cyrino R.M.
      • Cota L.O.M.
      • Costa F.O.
      Very low and low birth weight associated with maternal periodontitis.
      showed in their cross-sectional study of 1,206 postpartum women that “maternal periodontitis was associated with a decrease in mean birth weight, as well as LBW and VLBW” (p. 1024).
      • Corbella S.
      • Taschieri S.
      • Del Fabbro M.
      • Francetti L.
      • Weinstein R.
      • Ferrazzi E.
      Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association.
      conducted a meta-analysis of studies in which researchers controlled for periodontitis as a risk factor associated with negative pregnancy outcomes. They chose 22 out of 422 studies, which included 17,053 subjects. They found that there was an association between periodontitis and negative consequences in pregnancy; however, this association was weak (
      • Corbella S.
      • Taschieri S.
      • Del Fabbro M.
      • Francetti L.
      • Weinstein R.
      • Ferrazzi E.
      Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association.
      ).
      • Xiong X.
      • Elkind-Hirsch K.E.
      • Vastardis S.
      • Delarosa R.L.
      • Pridjian G.
      • Buekens P.
      Periodontal disease is associated with gestational diabetes mellitus: A case-control study.
      found that periodontitis was associated with GDM (77.4% of pregnant women with GDM had periodontis) with an adjusted odds ratio of 2.6 and a confidence interval of 95% in their case-control study of 53 pregnant women with GDM and 106 without GDM.
      • Ha J.E.
      • Jun J.K.
      • Ko H.J.
      • Paik D.I.
      • Bae K.H.
      Association between periodontitis and preeclampsia in never-smokers: A prospective study.
      found “a significant relationship between periodontitis and preeclampsia in never smokers” (p. 869) in their prospective cohort study of 283 pregnant women who had never smoked, 67 with periodontitis and 216 without periodontitis.
      Although these studies did not show conclusive evidence of the link between periodontal disease and negative pregnancy outcomes, periodontal treatment is safe for pregnant women, avoids the adverse consequences of periodontitis (e.g., pain, tooth loss) for the mother, and is not associated with any negative infant or maternal outcomes (
      • Wrzosek T.
      • Einarson A.
      Dental care during pregnancy.
      ).

      Access to Care

      Access to dental care is reported to be related to multiple factors and situations that may be concurrent. Examples of these factors and situations include the following: (a) race/ethnicity (
      • Azofeifa A.
      • Yeung L.F.
      • Alverson C.J.
      • Beltrán-Aguilar E.
      Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004.
      ,
      • Hwang S.S.
      • Smith V.C.
      • McCormick M.C.
      • Barfield W.D.
      Racial/ethnic disparities in maternal oral health experiences in 10 states, pregnancy risk assessment monitoring system, 2004-2006.
      ), (b) age and income level (
      • Azofeifa A.
      • Yeung L.F.
      • Alverson C.J.
      • Beltrán-Aguilar E.
      Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004.
      ), (c) personal stressors (
      • Le M.
      • Riedy C.
      • Weinstein P.
      • Milgrom P.
      An intergenerational approach to oral health promotion: Pregnancy and utilization of dental services.
      ), (d) lack of education (
      • Azofeifa A.
      • Yeung L.F.
      • Alverson C.J.
      • Beltrán-Aguilar E.
      Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004.
      ), (e) lack of perceived need (
      • Marchi K.S.
      • Fisher-Owen S.A.
      • Weintraub J.A.
      • Yu Z.
      • Braveman P.A.
      Most pregnant women in California do not receive dental care: Findings from a population-based study.
      ), (f) insurance coverage (), and (g) sociodemographic differences (
      • Azofeifa A.
      • Yeung L.F.
      • Alverson C.J.
      • Beltrán-Aguilar E.
      Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004.
      ,
      • Hwang S.S.
      • Smith V.C.
      • McCormick M.C.
      • Barfield W.D.
      Racial/ethnic disparities in maternal oral health experiences in 10 states, pregnancy risk assessment monitoring system, 2004-2006.
      ).
      • Hwang S.S.
      • Smith V.C.
      • McCormick M.C.
      • Barfield W.D.
      Racial/ethnic disparities in maternal oral health experiences in 10 states, pregnancy risk assessment monitoring system, 2004-2006.
      analyzed Pregnancy Risk Assessment Monitoring System data from 2004 through 2006 and found significant disparities in race and ethnicity in the oral health experiences of pregnant women. Black non-Hispanic and Hispanic women were significantly less likely to receive dental care during pregnancy than White non-Hispanic women. Through their use of data from the 1999 through 2004 National Health and Nutrition Examination Survey,
      • Azofeifa A.
      • Yeung L.F.
      • Alverson C.J.
      • Beltrán-Aguilar E.
      Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004.
      showed significant sociodemographic disparities in dental service use and self-reported oral health among U.S. women in general and between pregnant and nonpregnant women. The probability of having a dental visit within the year significantly increased as the pregnant woman's age, education, and income increased.
      Health care providers lack information on the oral health care needs of pregnant women.
      There is evidence that a high percentage of pregnant women do not visit a dentist. For example, the recently conducted a national survey of 801 pregnant women, only half of whom had dental insurance. They found that although 76% of pregnant women reported that they had a dental problem, only 57% reported a dental visit during pregnancy. Those with dental insurance were twice as likely to visit the dentist.
      • Le M.
      • Riedy C.
      • Weinstein P.
      • Milgrom P.
      An intergenerational approach to oral health promotion: Pregnancy and utilization of dental services.
      and
      • Marchi K.S.
      • Fisher-Owen S.A.
      • Weintraub J.A.
      • Yu Z.
      • Braveman P.A.
      Most pregnant women in California do not receive dental care: Findings from a population-based study.
      studied why women did not access dental care during pregnancy. Le et al. conducted a telephone interview with 51 randomly selected pregnant women who participated in an Oregon oral health pilot study. They reported that both personal stressors (e.g., financial, employment, and domestic) and dental care issues (e.g., time, cost, attitudes of dental providers, and comprehension of importance of oral health) were some of the barriers that prevented pregnant women from accessing dental care during pregnancy.
      • Marchi K.S.
      • Fisher-Owen S.A.
      • Weintraub J.A.
      • Yu Z.
      • Braveman P.A.
      Most pregnant women in California do not receive dental care: Findings from a population-based study.
      used a population-based survey of over 21,000 pregnant patients and found that the primary reason the women did not access dental care was because of lack of perceived need and that the second most common reason was financial barriers. In a study conducted by
      • Morgan M.A.
      • Crall J.
      • Goldenberg R.L.
      • Schulkin J.
      Oral health during pregnancy.
      , 77% of obstetrician-gynecologists reported that their patients had been refused dental services because of pregnancy.
      Unfortunately, dental care is not a mandated essential for adults in the ). Many women do not have a dental benefit with their public or private health plans. Although many states provide a Medicaid dental benefit during pregnancy (), these benefits may end when the woman gives birth or shortly thereafter, so timely oral assessment by health professionals and the facilitation of access to appropriate dental care is a priority. Furthermore, access to dental care during pregnancy remains limited because only 32% of the 193,300 U.S. dentists in 2011 reported that they accepted Medicaid (

      Medicaid-CHIP State Dental Association. (n.d.). National profile of state Medicaid and CHIP oral health programs. Retrieved from http://www.msdanationalprofile.com

      ). These findings on access to care highlight the need to improve education in oral health and access for U.S. women of childbearing age.

      Oral Health Practice Behavior of Women's Health Care Providers

      Many health professionals are aware of the importance of oral health, but often they do not address it as part of their provision of preconception, prenatal, or well woman care (
      • Hashim R.
      • Akbar M.
      Gynecologists' knowledge and attitudes regarding oral health and PD leading to adverse pregnancy outcomes.
      ,
      • Morgan M.A.
      • Crall J.
      • Goldenberg R.L.
      • Schulkin J.
      Oral health during pregnancy.
      ). Hashim and Akbar found that 95.4% of gynecologists surveyed had knowledge about the association between oral health and pregnancy and that 85.2% recommended dental visits for their patients. However, they also found that many gynecologists mistakenly believed that dental x-ray imaging (73%) and local dental anesthesia (59.3%) were unsafe. Similarly, Morgan et al. found that 84% of obstetrician-gynecologists were aware of the importance of oral health in pregnancy but that 54% did not ask about oral health issues and 69% did not provide information on oral health. Furthermore, only 62% recommended dental visits for their patients. In a summary of its survey of pregnant patients, reported that “only 44% of women surveyed say their doctor talked to them about oral health during their pregnancy visits” (p. 2). Many dentists are unwilling to see pregnant patients because of liability concerns, yet they may face more liability from not treating pregnant patients than from treating them (
      National Maternal and Child Oral Health Policy Center
      Improving the oral health of pregnant women and young children: Opportunities for policymakers.
      ). This suggests that dentists may still lack knowledge about the oral–systemic connection.

      Essential Oral Health Competencies

      Women and their health care providers, including dentists, need more knowledge and clarification about the safety of dental treatments during pregnancy. Dental care during pregnancy is safe, and there are appropriate guidelines for the treatment of pregnant patients (
      Oral Health Care During Pregnancy Expert Workgroup
      Oral health care during pregnancy: A national consensus statement—Summary of an expert workgroup meeting.
      ). Dental visits can take place during any trimester and, if urgent, should never be delayed (
      • Silk H.
      • Douglass A.
      • Douglass J.
      • Silk L.
      Oral health during pregnancy.
      ). The risk of radiation exposure is extremely low when lead aprons are used during dental x-ray imaging (
      • Kurien S.
      • Kattimani V.S.
      • Sriram R.R.
      • Sriram S.K.
      • Prabhakara Rao V.K.
      • Bhupathi A.
      • Patil N.
      Management of pregnant patient in dentistry.
      ). The most common medications and anesthetics prescribed by dentists are in U.S. Food and Drug Administration Category B, and these drugs have not been found to be a risk to the fetus (
      Oral Health Care During Pregnancy Expert Workgroup
      Oral health care during pregnancy: A national consensus statement—Summary of an expert workgroup meeting.
      , ).
      The perinatal period offers a teachable moment for oral health care and can potentially have an effect on maternal and infant health (
      American College of Obstetricians and Gynecologists Women's Health Care PhysiciansCommittee on Health Care for Underserved Women
      Committee opinion no. 569: Oral health care during pregnancy and through the lifespan.
      ,
      California Dental Association FoundationAmerican College of Obstetricians and Gynecologists, District IX
      Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals.
      ). The 2013 Committee Opinion from the American College of Obstetricians and Gynecologists recommends that all health care providers assess oral health at the first prenatal visit (
      American College of Obstetricians and Gynecologists Women's Health Care PhysiciansCommittee on Health Care for Underserved Women
      Committee opinion no. 569: Oral health care during pregnancy and through the lifespan.
      ). Subsequent prenatal visits provide numerous opportunities to implement oral health promotion interventions, including anticipatory guidance and referrals for dental care. Women's health care providers can incorporate oral–systemic health into all patient encounters from preconception counseling through prenatal and postpartum anticipatory guidance by transitioning the traditional HEENT (i.e., head, eyes, ears, nose, and throat) examination to the HEENOT (i.e., head, eyes, ears, nose, oral cavity, and throat) examination (
      • Haber J.
      • Hartnett E.
      • Allen K.
      • Hallas D.
      • Dorsen C.
      • Lange-Kessler J.
      • Wholihan D.
      Putting the mouth back in the head: HEENT to HEENOT.
      ). The four essential questions to include in an oral history are presented in Table 1.
      • Hummel J.
      • Phillips K.E.
      • Holt B.
      • Hayes C.
      Oral health: An essential component of primary care.
      introduced the Oral Health Delivery Framework (see Figure 1) that guides the integration of the HEENOT (
      • Haber J.
      • Hartnett E.
      • Allen K.
      • Hallas D.
      • Dorsen C.
      • Lange-Kessler J.
      • Wholihan D.
      Putting the mouth back in the head: HEENT to HEENOT.
      ) approach into the history, physical examination, and treatment plan.
      Table 1Oral Health History From Smiles for Life Prenatal Oral Health Pocket Card
      Note. Adapted from “Prenatal Oral Health Pocket Card,” by , Smiles for Life: A National Oral Health Curriculum. Copyright 2012 by Smiles for Life. Adapted with permission.
      Questions
      1. Do you brush twice a day and floss daily?
      2. Do you have a dentist, dental insurance?
      3. Have you seen the dentist in the past 6 months for a regular check-up and cleaning?
      4. Do you need any dental treatment completed?
      Figure thumbnail gr1
      Figure 1Oral Health Delivery Framework.
      Reprinted from “Oral Health: An Essential Component of Primary Care,” by
      • Hummel J.
      • Phillips K.E.
      • Holt B.
      • Hayes C.
      Oral health: An essential component of primary care.
      , Seattle, WA: Qualis Health. Copyright 2015 by Qualis Health. Reprinted with permission.
      Although many health care providers may voice concern over the amount of time involved, an oral examination typically takes 1 minute to perform. During the physical examination, the provider examines the lips, mucous membranes, teeth, gums, and tongue. A plan of care, which includes education for prevention of oral health problems, maintenance of good oral health, and referral for any oral health problems is integral to the provision of whole-person care. Prevention includes information about oral hygiene, such as regular brushing twice a day and flossing daily. Women who experience vomiting should be instructed to rinse afterward with a solution of baking soda to prevent erosion of tooth enamel (
      • Silk H.
      • Douglass A.
      • Douglass J.
      • Silk L.
      Oral health during pregnancy.
      ). Mothers need to know that Streptococcus mutans, the bacteria associated with dental caries, can be transmitted to the child, infect the child’s teeth, and increase the risk for early childhood caries (
      • Berkowitz R.J.
      Mutans streptococci: Acquisition and transmission.
      ,
      California Dental Association FoundationAmerican College of Obstetricians and Gynecologists, District IX
      Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals.
      ). In a population-based study,
      • Weintraub J.A.
      • Prakash P.
      • Shain S.G.
      • Laccabue M.
      • Gansky S.A.
      Mothers’ caries increases odds of children's caries.
      showed that the odds of children having untreated caries almost doubled when the mother had untreated caries. To reduce the transmission of bacteria from mother to child, it is important for women's health care providers to educate mothers about good oral hygiene practices and minimal “saliva-sharing activities” (
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies.
      , p. 51). Good maternal oral health practices have the potential to influence the child’s lifelong oral health. Documentation of all oral health assessment findings and interventions is essential. The development of a network of community dentists for collaboration and referral is invaluable to offer patients for oral health maintenance.

      Preparing the Next Generation of Women's Health Care Providers

      Women's health care providers may lack adequate knowledge to distinguish between normal changes in oral health during pregnancy because they did not have this information in their curriculum. According to
      • Ferullo A.
      • Silk H.
      • Savageau J.A.
      Teaching oral health in U.S. medical schools: Results of a national survey.
      , about 70% of MD degree–granting (n = 72) and DO degree–granting (n = 13) schools surveyed had fewer than 5 hours of oral health education. Authors of the most recent review indicate that PA and NM programs have not required oral health content or competencies in their curricula (,
      National Commission on Certification of Physician, AssistantsAccreditation Review Commission on Education for the Physician AssistantAmerican Academy of Physician AssistantsPhysician Assistant Education Association
      Competencies for the physician assistant profession.
      ).
      The National Interprofessional Initiative on Oral Health has played a leadership role in raising awareness among NP, NM, and PA faculty members; oral health is beginning to be integrated into these curricula. The
      National Organization of Nurse Practitioner Faculties
      Nurse practitioner core competencies with suggested curriculum content.
      has recently included oral health in the latest Nurse Practitioner Core Competencies With Suggested Curriculum Content (2014). The New York University College of Nursing Oral Health Nursing Education and Practice (OHNEP) program, the nursing arm of the National Interprofessional Initiative on Oral Health, has sponsored oral health workshops at the American College of Nurse-Midwives Annual Meeting and Exhibition in 2013, 2014, and 2015. In 2016, the OHNEP program administered a survey to all 39 Directors of Midwifery Education in the United States. The survey showed that 27 of the 30 programs (90%) that responded indicated they include oral health in the curriculum. In 2014, the PA arm of the National Interprofessional Initiative on Oral Health surveyed 182 PA Directors of accredited programs in the United States. According to
      • Langelier M.H.
      • Glicken A.D.
      • Surdu S.
      Adoption of oral health curriculum by physician assistant education programs in 2014.
      , the survey showed that 98 of the 125 respondents (78.4%) indicated that their “programs had integrated oral health content into their curriculum,” which represented an increase from 2008 (p. 62).

      Strategies for Integrating Oral Health

      In 2014, HRSA released Integration of Oral Health and Primary Care Practice, which outlines interprofessional oral health core clinical competencies appropriate for primary care providers, including but not limited to NPs, NMs, MDs, DOs, and PAs (
      U.S. Department of Health and Human ServicesHealth Resources and Services Administration
      Integration of oral health and primary care practice.
      ). Smiles for Life: A National Oral Health Curriculum is an interprofessional oral health curriculum designed to provide the same women's health care providers with education in oral health promotion across the lifespan (
      • Clark M.
      • Douglass A.
      • Maier R.
      • Deutchman M.
      • Douglass J.
      • Gonsalves W.
      • Quinonez R.
      Smiles for life: A national oral health curriculum.
      ). Three specific Smiles for Life courses, “Relationship of Oral Health to Systemic Health,” “Oral Health and the Pregnant Patient,” and “The Oral Examination,” are found on the Web site (www.smilesforlifeoralhealth.org) and are recommended for qualified women’s health professionals to earn continuing education credits. These and other essential resources that contain important knowledge about oral health and related interprofessional competencies for women's health care providers and students can be found in Table 2.
      Clinicians who care for women during pregnancy should incorporate oral health competencies into their education and practice.
      Table 2Oral Health Resources
      OrganizationResourceWeb Site
      American Academy of PediatricsBright Futures Oral Health Supervision Guidelines (3rd ed.)

      Bright Futures in Practice: Oral Health—Pocket Guide (2nd ed.)
      http://www.brightfutures.org

      http://mchoralhealth.org/pocket/index.html
      American Academy of Pediatric DentistryPediatric Oral Health Policies and Clinical Practice Guidelineshttp://www.aapd.org/policies
      Association of American Medical CollegesOral Health in Medicine Model Curriculum

      Oral Health Management of Pregnant Patients
      https://www.mededportal.org/about/initiatives/oralhealth

      https://www.mededportal.org/publication/4056
      Association for Prevention Teaching and ResearchOral Health Across the Lifespan learning moduleshttp://www.aptrweb.org/?PHLM_15
      California Dental AssociationPerinatal Oral Health Guidelines and Policyhttp://www.cdafoundation.org/education/perinatal-oral-health
      Health Resources and Services AdministrationInterprofessional oral health core clinical domains and competencieshttp://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhealth.pdf
      National Maternal and Child Oral Health Resource CenterOral health educational resources for patients and providers

      Oral Health Care During Pregnancy: A National Consensus Statement
      http://www.mchoralhealth.org

      http://www.mchoralhealth.org/materials/consensus_statement.php
      Oral Health Nursing Education and PracticeOral health nursing education resourceshttp://www.ohnep.org
      Qualis HealthOral health delivery framework for primary care providershttp://www.safetynetmedicalhome.org/sites/default/files/White-Paper-Oral-Health-Primary-Care.pdf
      Smiles for Life: A National Oral Health CurriculumOral health education for primary care providershttp://www.smilesforlifeoralhealth.org
      Teaching Oral Systemic HealthInterprofessional oral health resourceshttp://www.toshteam.org
      Primary prevention requires more workforce capacity than the dental community alone can provide. The development of an interprofessional oral health primary care workforce capacity is integral to increasing access to oral health care for pregnant women. Heightened awareness of oral–systemic health must be included in women's health care provider education for clinicians to translate the information into practice. The OHNEP program has developed an Interprofessional Oral Health Faculty Toolkit (www.ohnep.org/faculty-toolkit). This Toolkit uses the HEENOT approach that was previously described. It includes a wealth of oral–systemic health resources for health assessment, health promotion, and clinical practice for faculty, students, and practicing clinicians to teach both the theory and practice of the integration of oral health into the history and physical examination. Examples of the Toolkit's overall strategies include (a) visual aids to supplement class discussions of normal versus abnormal oral findings, (b) oral–systemic case studies, and (c) projects to develop educational resources for pregnant women, such as the development of a community resource of dental providers willing to see pregnant women. It also provides specific strategies to teach future providers how to promote effective self-management of oral and overall health in their patients through interprofessional collaborative practice, health literacy, and community service. The Toolkit provides a firm foundation for future collaborative practice, highlighting that dental referrals for pregnant women are essential to safe practice.
      Women's health care providers, to provide quality and safe care, must engage their patients in an oral health discussion and offer consistent prevention messages.

      Conclusion

      There is sufficient evidence that the lack of oral health care during pregnancy can have negative outcomes for both mothers and their newborns. To improve the oral–systemic health outcomes for mothers and their newborns, it is essential to increase the current and future interprofessional oral health workforce capacity. Current women's health care providers and NP, NM, MD, DO, and PA students, as future women's health care providers, can increase their knowledge of the oral health care needs of pregnant women through the use of oral health educational resources. Essential resources include the OHNEP Interprofessional Oral Health Faculty Toolkit and the Smiles for Life modules. These resources provide a firm foundation for the integration of oral health into clinical practices. By integrating the HRSA Interprofessional Oral Health Core Clinical Competencies, the HEENOT approach, and the Oral Health Delivery Framework in clinical practice models, women's health care providers can use a “best practice” approach. Meeting the oral health needs of pregnant women and their newborns will be accomplished only through collaboration among all health care professional educators and providers to promote the incorporation of oral health needs as a gold standard for educational programs and clinical practice.

      Acknowledgment

      The authors thank Donna Hallas, PhD, RN, PNP-BC, CPNP, PMHS, FAANP; Jeanne Conroy, MD, PhD; Melinda Clark, MD; and Jill Fernandez, MPH, for their contributions to this article.

      References

        • American Academy of Pediatric Dentistry
        Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies.
        Pediatric Dentistry. 2015; 37 (Retrieved from): 50-52
      1. American Academy of Periodontology. (n.d.). Periodontal disease fact sheet. Retrieved from https://www.perio.org/newsroom/periodontal-disease-fact-sheet

        • American College of Nurse Midwives
        ACNM core competencies for basic midwifery practice.
        2012 (Retrieved from)
        • American College of Obstetricians and Gynecologists Women's Health Care Physicians
        • Committee on Health Care for Underserved Women
        Committee opinion no. 569: Oral health care during pregnancy and through the lifespan.
        Obstetrics and Gynecology. 2013; 122: 417-422https://doi.org/10.1097/01.AOG.0000433007.16843.10
        • American Dental Association Council on Access, Prevention, and Interprofessional Relations
        Women's oral health issues.
        ([white paper])2006 (Retrieved from)
        • Azofeifa A.
        • Yeung L.F.
        • Alverson C.J.
        • Beltrán-Aguilar E.
        Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999–2004.
        Preventing Chronic Disease. 2014; 11: E163https://doi.org/10.5888/pcd11.140212
        • Berkowitz R.J.
        Mutans streptococci: Acquisition and transmission.
        Pediatric Dentistry. 2006; 28: 106-109
        • California Dental Association Foundation
        • American College of Obstetricians and Gynecologists, District IX
        Oral health during pregnancy and early childhood: Evidence-based guidelines for health professionals.
        2010 (Retrieved from)
        • Cigna Corporation
        Healthy smiles for mom and baby: Insights into expecting and new mothers' oral health habits.
        2015 (Retrieved from)
        • Clark M.
        • Douglass A.
        • Maier R.
        • Deutchman M.
        • Douglass J.
        • Gonsalves W.
        • Quinonez R.
        Smiles for life: A national oral health curriculum.
        3rd ed. Society of Teachers of Family Medicine, Washington, DC2010 (Retrieved from)
        • Corbella S.
        • Taschieri S.
        • Del Fabbro M.
        • Francetti L.
        • Weinstein R.
        • Ferrazzi E.
        Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association.
        Quintessence International. 2016; 47: 193-204https://doi.org/10.3290/j.qi.a34980
        • Ehlers V.
        • Callaway A.
        • Hortig W.
        • Kasaj A.
        • Willershausen B.
        Clinical parameters and aMMP-8-concentrations in gingival crevicular fluid in pregnancy gingivitis.
        Clinical Laboratory. 2013; 59: 605-611https://doi.org/10.7754/Clin.Lab.2012.120619
        • Eke P.I.
        • Dye B.A.
        • Wei L.
        • Thornton-Evans G.O.
        • Genco R.J.
        Prevalence of periodontitis in adults in the United States: 2009 and 2010.
        Journal of Dental Research. 2012; 91: 914-920https://doi.org/10.1177/0022034512457373
        • Ferullo A.
        • Silk H.
        • Savageau J.A.
        Teaching oral health in U.S. medical schools: Results of a national survey.
        Journal of the Association of American Medical Colleges. 2011; 86: 226-230https://doi.org/10.1097/ACM.0b013e3182045a51
        • Figuero E.
        • Carrillo-de-Albornoz A.
        • Martín C.
        • Tobías A.
        • Herrera D.
        Effect of pregnancy on gingival inflammation in systemically healthy women: A systematic review.
        Journal of Clinical Periodontology. 2013; 40: 457-473https://doi.org/10.1111/jcpe.12053
        • Gogeneni H.
        • Buduneli N.
        • Ceyhan-Öztürk B.
        • Gümüş P.
        • Akcali A.
        • Zeller I.
        • Özçaka Ö.
        Increased infection with key periodontal pathogens during gestational diabetes mellitus.
        Journal of Clinical Periodontology. 2015; 42: 506-512https://doi.org/10.1111/jcpe.12418
        • Guimarães A.N.
        • Silva-Mato A.
        • Siqueira F.M.
        • Cyrino R.M.
        • Cota L.O.M.
        • Costa F.O.
        Very low and low birth weight associated with maternal periodontitis.
        Journal of Clinical Periodontology. 2012; 39: 1024-1031https://doi.org/10.1111/jcpe.12000
        • Ha J.E.
        • Jun J.K.
        • Ko H.J.
        • Paik D.I.
        • Bae K.H.
        Association between periodontitis and preeclampsia in never-smokers: A prospective study.
        Journal of Clinical Periodontology. 2014; 41: 869-874https://doi.org/10.1111/jcpe.12281
        • Haber J.
        • Hartnett E.
        • Allen K.
        • Hallas D.
        • Dorsen C.
        • Lange-Kessler J.
        • Wholihan D.
        Putting the mouth back in the head: HEENT to HEENOT.
        American Journal of Public Health. 2015; 105: 437-441https://doi.org/10.2105/AJPH.2014.302495
        • Hashim R.
        • Akbar M.
        Gynecologists' knowledge and attitudes regarding oral health and PD leading to adverse pregnancy outcomes.
        Journal of International Society of Preventive & Community Dentistry. 2014; 4: S166-S172https://doi.org/10.4103/2231-0762.149028
        • Hummel J.
        • Phillips K.E.
        • Holt B.
        • Hayes C.
        Oral health: An essential component of primary care.
        ([white paper]) Qualis Health, Seattle, WA2015 (Retrieved from)
        • Hwang S.S.
        • Smith V.C.
        • McCormick M.C.
        • Barfield W.D.
        Racial/ethnic disparities in maternal oral health experiences in 10 states, pregnancy risk assessment monitoring system, 2004-2006.
        Maternal and Child Health Journal. 2011; 15: 722-729https://doi.org/10.1007/s10995-010-0643-2
        • Institute of Medicine
        Advancing oral health in America.
        The National Academies Press, Washington, DC2011https://doi.org/10.17226/13086
        • Institute of Medicine
        Oral health literacy: Workshop summary.
        The National Academies Press, Washington, DC2013 (Retrieved from)
        • Institute of Medicine & National Research Council
        Improving access to oral health care for vulnerable and underserved populations.
        The National Academies Press, Washington, DC2011https://doi.org/10.17226/13116
        • Kurien S.
        • Kattimani V.S.
        • Sriram R.R.
        • Sriram S.K.
        • Prabhakara Rao V.K.
        • Bhupathi A.
        • Patil N.
        Management of pregnant patient in dentistry.
        Journal of International Oral Health. 2013; 5: 88-97
        • Langelier M.H.
        • Glicken A.D.
        • Surdu S.
        Adoption of oral health curriculum by physician assistant education programs in 2014.
        The Journal of Physician Assistant Education. 2015; 26: 60-69https://doi.org/10.1097/JPA.0000000000000024
        • Le M.
        • Riedy C.
        • Weinstein P.
        • Milgrom P.
        An intergenerational approach to oral health promotion: Pregnancy and utilization of dental services.
        Journal of Dentistry for Children. 2009; 76: 46-52
        • Marchi K.S.
        • Fisher-Owen S.A.
        • Weintraub J.A.
        • Yu Z.
        • Braveman P.A.
        Most pregnant women in California do not receive dental care: Findings from a population-based study.
        Public Health Reports. 2010; 125: 831-842https://doi.org/10.2307/41434849
      2. Medicaid-CHIP State Dental Association. (n.d.). National profile of state Medicaid and CHIP oral health programs. Retrieved from http://www.msdanationalprofile.com

        • Morgan M.A.
        • Crall J.
        • Goldenberg R.L.
        • Schulkin J.
        Oral health during pregnancy.
        The Journal of Maternal-Fetal & Neonatal Medicine. 2009; 22: 733-739https://doi.org/10.3109/14767050902926954
        • National Commission on Certification of Physician, Assistants
        • Accreditation Review Commission on Education for the Physician Assistant
        • American Academy of Physician Assistants
        • Physician Assistant Education Association
        Competencies for the physician assistant profession.
        2012 (Retrieved from American Academy of Physician Assistants Web site:)
        • National Health Law Program
        Dental coverage for low-income pregnant women.
        2012 (Retrieved from)
        • National Maternal and Child Oral Health Policy Center
        Improving the oral health of pregnant women and young children: Opportunities for policymakers.
        2012 (Retrieved from)
        • National Organization of Nurse Practitioner Faculties
        Nurse practitioner core competencies with suggested curriculum content.
        2014 (Retrieved from)
        • Oral Health Care During Pregnancy Expert Workgroup
        Oral health care during pregnancy: A national consensus statement—Summary of an expert workgroup meeting.
        2012 (Retrieved from)
        • Patient Protection and Affordable Care Act
        • 42 U.S.C. § 18001
        (Retrieved from)
        • Petersen P.E.
        World Health Organization global policy for improvement of oral health—World Health Assembly 2007.
        International Dental Journal. 2008; 58: 115-121https://doi.org/10.1111/j.1875-595X.2008.tb00185.x
        • Silk H.
        • Douglass A.
        • Douglass J.
        Prenatal oral health pocket card.
        2012 (Retrieved from)
        • Silk H.
        • Douglass A.
        • Douglass J.
        • Silk L.
        Oral health during pregnancy.
        American Family Physician. 2008; 77: 1139-1144
        • U.S. Department of Health and Human Services
        Oral health in America: A report of the Surgeon General.
        2000 (Retrieved from)
        • U.S. Department of Health and Human Services
        • Health Resources and Services Administration
        Integration of oral health and primary care practice.
        2014 (Retrieved from)
        • Weintraub J.A.
        • Prakash P.
        • Shain S.G.
        • Laccabue M.
        • Gansky S.A.
        Mothers’ caries increases odds of children's caries.
        Journal of Dental Research. 2010; 89: 954-958https://doi.org/10.1177/0022034510372891
        • Wrzosek T.
        • Einarson A.
        Dental care during pregnancy.
        Canadian Family Physician. 2009; 55: 598-599
        • Wu M.
        • Chen S.-W.
        • Jiang S.-Y.
        Relationship between gingival inflammation and pregnancy.
        Mediators of Inflammation. 2015; 2015: 623427https://doi.org/10.1155/2015/623427
        • Xiong X.
        • Elkind-Hirsch K.E.
        • Vastardis S.
        • Delarosa R.L.
        • Pridjian G.
        • Buekens P.
        Periodontal disease is associated with gestational diabetes mellitus: A case-control study.
        Journal of Periodontology. 2009; 80: 1742-1749https://doi.org/10.1902/jop.2009.090250

      Biography

      Erin Hartnett, DNP, APRN-BC, CPNP, is the Program Director of the Oral Health Nursing Education and Practice & Teaching Oral-Systemic Health programs, New York University Rory Meyers College of Nursing, New York, NY.
      Judith Haber, PhD, APRN, BC, FAAN, is the Ursula Springer Leadership Professor in Nursing and the Executive Director of Oral Health Nursing Education and Practice & Teaching Oral-Systemic Health programs, New York University Rory Meyers College of Nursing, New York, NY.
      Barbara Krainovich-Miller, EdD, RN, PMHCNS-BC, ANEF, FAAN, is a clinical professor, New York University Rory Meyers College of Nursing, New York, NY.
      Abigail Bella, MPH, is the Program Coordinator of the Teaching Oral-Systemic Health program, New York University Rory Meyers College of Nursing, New York, NY.
      Anna Vasilyeva, MPH, is the Program Coordinator of the Oral Health Nursing Education and Practice program, New York University Rory Meyers College of Nursing, New York, NY.
      Julia Lange Kessler, CM, DNP, FACNM, is the Program Director of the Nurse Midwifery/WHNP Program and an assistant professor, Georgetown University, School of Nursing & Health Studies, Washington, DC.