Even among advantaged women, there’s still a need for enhanced education about the importance of dental care before, during, and after pregnancy. One of the things that we know is a lack of routine oral health prior to pregnancy is also related to a lack of oral health utilization during pregnancy. So, we always look at the Life Span approach, and if the point of entry into the health care system is pregnancy, then let’s begin there during pregnancy. Then, continue through the rest of the life span.
So, there are many reasons why women are less likely to go to oral health care providers during pregnancy, and some of them are personal factors such as finances and employment, not being able to get out work during the hours available for them during the work day when they’re working, and also poor domestic relationships. I think we can never underestimate the personal stressors in a woman’s life when we’re trying to get some sort of compliance with any kind of recommendation we make.
Then, women also have personal perceptions about dental care. Studies show that these are also barriers to their receiving care. So, women have the wrong attitude towards dental providers that we need to listen to, and they have an opinion about the importance and value of oral health. In some populations, it’s not a cultural norm to receive the same kind of oral health care or any kind of oral health care.
I oversee several OB clinics, and we have woman here from all over the world. There’s some women who come in for pregnancy, and they’ve never seen a dentist their whole entire life. They’re really actually very severe periodontal disease. So, we’re dealing with all sorts of people who bring to the health care experience their own attitudes and beliefs.
So, women have perceptions about the dental experience. One the things we talk about was oral health and how it could be frightening for women during pregnancy. So, women with a history of trauma, and Rene’s going to speak with you in detail about this, the dental visit itself can be quite frightening, a woman’s reclined. She can’t speak. So, it can really evoke past trauma experience. So, the perception of the dental experience is really important, something that we have to be cognizant of when we’re trying to advocate women receiving dental care during pregnancy.
Then, we have, again, the problem with perception to pay. Whether women have dental coverage during pregnancy or whether they don’t, the perception or understanding of whether or not they have coverage is really important for us to sit down and talk with them about.
Then, finally, women’s perception about the attitudes of dental providers and their staff might have towards a patient. Again, I always that we have to have services that are accessible to patients. So, we also need to have services that are acceptable. How people perceive providers’ offices, their treatment, and how they’re seen, may or may not be true, but when we’re dealing with perceptions, we need to treat them seriously.
I just want to say a little bit about the impact of domestic violence. In 30% of women who experience abuse, the first incidence occurs during pregnancy. It’s also important to note that during pregnancy and soon after the baby’s born, a woman’s at risk for being murdered by her abuser. So, this is an important issue for oral health, prenatal health. All of the provider teams that are working with pregnant women, it’s important for us to be aware of that because of the compliance and treatment perception of care and outcomes. It’s very important for us to be aware of and really understand her pregnancy will focus on the relevance of trauma-informed care and how it relates to oral health care services.
I just want to mention that one of the preventive health benefits for women under the Affordable Health Care Act is for which there is not a cost share is domestic violence screening and counseling. You can access more information for preventive health services for women under the Affordable Health Care Act at the link I provided for you.
So, I’m going to go back now and tie in what I started with, the health center I work with to the maternity home approach to prenatal care that we have. During our pregnancy risk assessment, we have an extensive section of that risk assessment around oral health. So, the questions we ask all pregnant women, every single woman comes so she can have the risk assessment, and the general education and screening we have for them is the first questions is, “When was your last dental cleaning?” We’ll break it down into within 6 months, 6 months to a year, 1 year, 2 years, 3 years, 4 years, 5 years, or over 5 years.
Bringing up the insurance piece again, many of them say to me they can identify their last cleaning from the last time they had insurance. So, the insurance piece of really important. Then, we ask, “Do your gums bleed?” We ask, “Do you floss daily?” Then, we provide a lengthy piece of health education around oral health, why it’s important to take care of your teeth during pregnancy, not only for the possible relationship to birth outcomes but also because of how pregnancy can impact your teeth and how bad teeth can affect your health in many ways, not just birth outcomes.
We also do an extensive piece on caring for your teeth. Dr. DeFrancesco mentioned earlier, the whole flossing once a day, brushing twice a day with fluoridated toothpaste. We talk about using a nonalcoholic mouthwash. We talk about the last thing you should do before you go to bed at night and explain how bacteria grows. So, if they have anything but water, they’re likely to grow bacteria during the night. The heath education thing that impressed me after doing this for so many years is that there’s many things we provide education about like smoking and people know that, but I’ve been really impressed on people not understanding the whole oral health piece. So, what we do is we offer people an appointment for a cleaning and exam after we do this oral health thing, and we schedule the appointment right on the spot. We ask them what time is convenient for them. So, do they want a morning appointment, afternoon, weekend, whatever. So, we schedule is at their convenience, and we impress it on them that the exam and the cleaning is going to be free of charge. Whether they have insurance or they don’t, it’s written into their prenatal care package.
After collecting this data for five years, we actually went back, and we went through our day-to-day results. We did a little study about oral health uptake in this particular population. So, we included all women who did not have a cleaning within the past six months and who agreed to a referral. All of the women were either with state Medicaid, which is HUSKY A Connecticut, or they were uninsured and were able to have a free cleaning and exam.
The thing that we assessed for were race, ethnicity, marital status, smoking, age, insurance status, anxiety, depression, and interval since their last pregnancy. We also assessed for location of dental provider. We were looking at two different prenatal clinics. One was in rural setting, and the dental office that we have is two towns down county. The other prenatal clinic is in an urban setting, and we consider that to be a co-located dental office because it’s right across the street from the prenatal care office.
If you can just take a look at what the population looked like, what the breakdown was. I’ll give you just a second to look at that. So, what we found was the only factors that were related to lack of oral health uptake were anxiety and depression. So, it didn’t make a difference if it was co-located, the dental office, or not. Anxiety and depression were the only factors related to decreased dental uptake. Again, many of the women with anxiety and depression, we do formal screening and testing around these areas, and many of these women have trauma background. So, again, I cannot press to any extent how important the whole trauma healthcare piece is when looking at how deliver the oral health services.
So, the recommendations based on my experiences and the literature are to start oral health care early, and we want to look at that Life Span approach. We want to start our kids in that Home by One, the first visit before they’re one year old and have routine oral health care based on the recommendations that are given to us and continues through pregnancy and after pregnancy. We want that Life Span approach, and the other thing is a person-centered maternity or pregnancy home with primary care, behavioral health, dental services co-located is ideal, but if we can’t do that and many of us can’t, if we have coordination services which can provide referrals and linkages in the community for dental providers, that’s the next best thing.
Again, we need to enhance the education we’re providing on the important and safety of oral health during pregnancy, not just for the women that we serve but for all of our providers, prenatal providers, dental health providers. So, as many people as possible, we really need to get this message out there.
Then, I always recommend that we transform how we deliver care to vulnerable populations, and, again, services not only need to be accessible. We need to have access to services for women, but we also need to have services that are acceptable to them. So, we need to start listening on what would be a comfortable environment that women will feel comfortable receiving these services, and that lends itself to the trauma-informed care practices.
I want to make a few acknowledgments. One is to Margaret Flinter and Marian Mohegan and to the USDHHS Office on Woman’s Health Region 1 and to Jennifer Sharp. Thank you all so very much, and if you have any questions for me about anything related to this at all, please feel free to give me a call, shoot me an e-mail. I’ve included for you a couple of pages of references. Everything I’ve said is referenced here.
So, thank you all very much.