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JOURNAL OF WOMEN’S HEALTHVolume 14, Number 10, 2005© Mary Ann Liebert, Inc.

Oral Health during Pregnancy: Current Research

JESSAMYN RESSLER-MAERLENDER, M.P.H., RANJITHA KRISHNA, B.D.S., M.P.H., and VALERIE ROBISON, Ph.D., D.D.S., M.P.H.

ABSTRACT

This report describes recent efforts by the Centers for Disease Control and Prevention (CDC),Division of Oral Health, to understand more fully women’s knowledge and attitudes regard-ing oral health and dental visits during pregnancy. Using data from the CDC Pregnancy RiskAssessment Monitoring System (PRAMS), investigators are conducting both quantitative andqualitative research on these issues. PRAMS is an ongoing state-based and population-basedsurveillance survey of women’s attitudes, experiences, and behaviors before, during, and af-ter pregnancy. Findings have shown that most mothers did not make a dental visit duringpregnancy, and of those who reported having oral problems, one-half did not seek care. Pre-liminary analysis of qualitative results shows that some women may believe that poor oralhealth status during pregnancy is normal; also, they may fear certain aspects of dental careduring pregnancy. For example, some women may believe that they or their fetus could beharmed by treatment. If pregnancy modifies perceptions of oral health and dental care in wo-men, it may contribute to women’s avoidance of dental treatment while pregnant. Therefore,researchers and health program planners should give increased attention to the oral healthneeds and behaviors of pregnant women.

Report from the CDC

Division of Oral Health, Centers for Disease Control and Prevention, Chamblee, Georgia.Disclaimer: The use of trade names is for identification only and does not imply endorsement by the U.S. Depart-

ment of Health and Human Services.

INTRODUCTION

PREVENTIVE DENTAL CARE (e.g., examination, ed-ucation, oral prophylaxis) is important before

and during pregnancy for several reasons. Stud-ies suggest an association between severe peri-odontal (gum) disease and adverse birth out-comes, such as preterm delivery and infant lowbirth weight.1,2 Hormonal changes during preg-nancy increase the risk of gingivitis, a milder formof and precursor to more severe periodontal dis-

ease. The American Academy of Periodontology(AAP) reports that half of all women experiencegingivitis during pregnancy. The AAP recom-mends that women visit the dentist for a peri-odontal evaluation before pregnancy and thatthey maintain oral hygiene during pregnancy.3

Barriers to dental care may be greater for preg-nant women because the window of treatmenttime has traditionally been restricted to the sec-ond trimester. The American Dental Association(ADA) suggests that elective dental care should

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be avoided, if possible, during the first trimesterand the last half of the third trimester.4 That rec-ommendation leaves fewer than 4 months forpregnant women to receive oral health education,preventive care, and treatment of any disease.

Although pregnant women represent a popu-lation with distinct oral health needs, there arefew reports about self-perceived oral health sta-tus or factors influencing dental care use duringpregnancy. The Centers for Disease Control andPrevention’s (CDC’s) Division of Oral Health andDivision of Reproductive Health have collabo-rated to fill this knowledge gap by including oralhealth questions on state Pregnancy Risk Assess-ment Monitoring System (PRAMS) surveys.

MATERIALS AND METHODS

Quantitative research

Thirty-one states and New York City currentlyconduct the PRAMS survey. Each state uses thesame standardized mail and telephone method tosurvey mothers who recently gave birth. Samplesizes among states range from 1300 to 3400 wo-men annually. Responses are then weighted to berepresentative of all women who gave birth ineach state that year.5 Currently, 12 states ask theoptional oral health questions on their PRAMSsurvey; by 2006, responses from 19 states andNew York City will be available. The survey con-tains the following oral health questions:

This question is about the care of your teeth dur-ing your most recent pregnancy. For each item,circle Y (Yes) if it is true and N (No) if it is nottrue.

A. I needed to see a dentist for a problemB. I went to a dentist or dental clinic.C. A dental or other healthcare worker talked

with me about how to care for my teeth andgums.

In the first report from CDC, which analyzed1998 PRAMS data from Arkansas, Illinois,Louisiana, and New Mexico, a range of 23%–35%of respondents reported dental care use duringpregnancy (Yes to question B).1 This range is wellbelow the national Healthy People 2010 target that56% of the adult population should have an an-nual dental visit.6 However, some of the womenwho participated in PRAMS could have visited

the dentist immediately before or after preg-nancy. For New Mexico, Illinois, and Louisiana,12%–25% of respondents reported having a den-tal problem, and of these, only 45%–55% made adental visit.1 Self-reported estimates of dentalproblems would likely underestimate the trueprevalence of oral disease in this population be-cause many persons would not be aware that theyhad oral disease. In 2005, we will be reportingdata for four additional states: Colorado, Wash-ington, Nebraska, and Alabama.

Qualitative research

The qualitative analysis of PRAMS data at-tempts to identify women’s perceptions of oralhealth as well as barriers and motivations forseeking dental care during pregnancy. Thisanalysis is currently in progress and includes datafrom 12 states. Comments written voluntarily byrespondents on the survey’s back pages and sidemargins were searched for relevance using termsincluding tooth, teeth, mouth, gums, pain, anddentist. The search yielded 152 comments fromapproximately 3600 surveys.

Examples of women’s comments in this analysisare: “I hope Medicaid will help more mothers withdental needs so that our babies will be healthier.With all three of my babies, my teeth were reallybad.” “I was afraid to go to the dentist when I waspregnant. I had several bad teeth and my baby wasborn small.” and “Because of medical advice I re-ceived regarding medication safe to take during mypregnancy, I felt nothing could be done for thetoothache that plagued me.” These comments willbe classified by three coders into variables, includ-ing fear of treatment, myths about treatment,myths about pregnancy, lack of insurance, lack ofmoney, and no provider available, and will be an-alyzed using EasyText™ software.

Qualitative research cannot be generalized,even to describe the sample population. There-fore, all results of this qualitative analysis will beused only to identify and describe themes aboutwomen’s knowledge, attitudes, and behaviors re-garding oral healthcare and pregnancy.

DISCUSSION

PRAMS is unique in that it offers state-specificdata for surveillance of oral health during preg-nancy. In this ongoing investigation using both

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quantitative and qualitative methods, a clearerpicture of women’s use of oral healthcare duringpregnancy is beginning to take shape. Quantita-tive analysis has revealed details about thePRAMS population, its reporting of dental prob-lems, and its use of dental services. Qualitativeanalysis will focus on understanding this popu-lation’s attitudes, knowledge, and behaviors re-garding oral healthcare and pregnancy.

State health personnel may be able to use esti-mates of low dental care and unmet need todemonstrate that additional resources should bedirected toward oral health during preconceptioncare and prenatal care. States that use oral healthquestions regularly on their PRAMS surveys willbe able to monitor trends in oral health and showthe impact of interventions intended to boost den-tal care or to increase oral health education duringprenatal care. The CDC’s Behavioral Risk FactorSurveillance System (BRFSS), with its questions ondental visits, dental cleanings, and tooth loss wouldoffer another source of state-based data for the sub-set of pregnant women in its sample.7

The low use of dental services reported byPRAMS respondents points to a need to increaseaccess to dental care for this population. How-ever, increasing access may not lead to improvedcare-seeking behaviors or health outcomes unlesswe understand women’s beliefs, attitudes, andbehaviors about their oral health during thisunique time. Both types of research are vital tothe goal of these projects: translating research intoeffective practice. Together, the findings of bothstudies will provide important information for re-searchers, health educators, and policymakersaddressing this issue.

ACKNOWLEDGMENTS

We gratefully acknowledge the contribution ofpersonnel at the PRAMS project at the CDC’s Di-

vision of Reproductive Health and the contribu-tion of PRAMS state coordinators.

REFERENCES

1. Gaffield ML, Colley-Gilbert BJ, Malvitz DM, Roma-guera R. Oral health during pregnancy: An analysis ofinformation collected by the Pregnancy Risk Assess-ment Monitoring System. J Am Dent Assoc 2001;132:1009.

2. Offenbacher S, Katz, V, Fertik G, et al. Periodontal in-fection as a possible risk factor for preterm low birthweight. J Peridontol 1996;67 (Suppl 10):1103.

3. American Academy of Periodontology. AAP state-ment on the periodontal management of the pregnantpatient. Available at www.perio.org. Accessed on Janu-ary 26, 2005.

4. American Dental Association. Women’s oral health is-sues. Chicago: American Dental Association, 1995.

5. Centers for Disease Control and Prevention, Divisionof Reproductive Health: Surveillance and Research:Pregnancy Risk Assessment Monitoring System. Avail-able at www.cdc.gov/reproductivehealth/srv_prams.htm.Accessed January 14, 2005.

6. U.S. Department of Health and Human Services.Healthy people 2010, 2nd ed. With understanding andimproving health and objectives for improving health.Washington, DC: U.S. Government Printing Office,2000.

7. Behavioral Risk Factor Surveillance System. Availableat apps.nccd.cdc.gov/BRFSSQuest/. Accessed January 26,2005.

Address reprint requests to:Valerie Robison, Ph.D., D.D.S., M.P.H.

Division of Tuberculosis EliminationCenters for Disease Control and Prevention

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Atlanta, GA 30329

E-mail: vcr6@cdc.gov

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