Self-Perceived Oral Health and Use of Dental Services by Pregnant Women in Surrey, British Columbia

Maintaining good oral health and preventing oral disease before, during and after pregnancy is an important aspect of general health for both mother and newborn.¹ Receiving oral health care — including a compressive dental examination and periodontal assessment, radiographs, pain medication, most dental treatments and professional scaling — is considered safe during pregnancy. In fact, it is recommended that pregnant women visit a dental professional if they have not done so in the last 6 months.²

Poor maternal oral health can not only affect the mother's nutrition and oral health-related quality of life, but it is also believed to be associated with early childhood caries and long-term systemic disorders for the newborn.³ The harmful effects of poor oral health during pregnancy can be even more prominent among women who are vulnerable because of their race, ethnicity, economic disparities and other psychosocial and environmental factors.⁴

In 2014, there were 386 000 pregnancies in Canada, 43 700 of them in British Columbia.⁵ Yet,there are no baseline data describing the oral health status of Canadian pregnant women in general or of British Columbians in particular. Determining the oral health status and needs and the use of dental services by pregnant women, especially those who are vulnerable during pregnancy, may help inform future interventions for this patient group.³ Therefore, the aim of this study was to explore those issues in a sample of pregnant women living in British Columbia.

Methods

Study Participants and Data Collection

Fraser Health is one of 6 health authorities in British Columbia serving more than 1.6 million people, including a large population of Indo-Canadians, Korean-Canadians and Filipino-Canadians. Current oral health promotion initiatives include fluoride varnish application for children up to the age of 4 years, oral health education in elementary schools, preschool dental resource kits for children at age 3, and oral health care programs tailored for adults with developmental disabilities. We collaborated with the prenatal program called Best Beginnings, which is similar to programs offered by other provincial health authorities in British Columbia to support pregnant women and their newborns.

Study participants were pregnant women from the family planning and birth unit at Surrey Memorial Hospital (SMH), the largest hospital in the Fraser Health Authority area. SMH is enrolled in the Best Beginnings program, which is designed to provide public health services to pregnant women, new mothers, babies, children to age 2 years and their families.

SMH sees more than 5000 pregnancies a year, and the diversity and size of the target population offered us the opportunity to carry out data collection. Seven dental questions from the Canadian Health Measures Survey (CHMS) were adapted for this study. After pilot testing the adapted questions, data were collected using the Best Beginnings form (Appendix 1) and an attached list of 7 dental-focused questions (Appendix 2). These forms were distributed to all women attending prenatal registration at SMH from October 2012 to February 2013.

Those who agreed to participate in the study were advised to detach a cover page as the consent form for their records while filling out the Best Beginnings form and the dental survey. The Best Beginnings forms were kept in the reception area where a public health nurse collected them twice a week. An identification code was assigned to match the dental survey questions with the Best Beginnings form while de-identifying the forms by blacking out all personal information, such as name, address, postal code, care card number, date of birth, telephone number and other contact information. All forms were photocopied before the public health nurse picked them up. All data were numerically coded and entered into a password-protected spreadsheet for statistical analysis.

The 740 respondents provided enough statistical power to tease out the potential relationships and correlations between the different variables presented below.

Variable Construction

Andersen and Newman's⁶ framework of health service utilization was used to inform the selection of outcome and independent variables.Self-reported oral health and use of dental services during pregnancy were the outcome variables; predisposing, enabling and need factors were independent variables. However, the focus of this paper is on predisposing and enabling factors only. The framework helped to determine the sociodemographic variables that would likely make these women vulnerable to inadequate oral health care during pregnancy.

Predisposing Factors

The predisposing factors in Andersen and Newman's model comprise variables that represent the tendency to use available health services. In the context of this study, the included variables were age, education (high school education: yes/no), immigration status (born in Canada or elsewhere and number of years living in Canada), refugee status, Aboriginal heritage and smoking status (smoker or non-smoker).⁶

The model emphasizes that both financial and personal enabling factors must be present for most people to use available health services. Therefore, the enabling variables included were having difficulty living within total household income (yes or no), having dental insurance (yes or no), type of insurance, having children (yes or no), needing assistance with transportation (yes or no), feeling depressed during the last month (yes or no) and time of last dental visit.⁶

Vulnerability was assessed from the self-reported answers on the Best Beginnings form, grouped according to the Andersen and Newman model to identify the personal and societal factors that could affect the overall health of the pregnant women and their newborns, including difficulties with living and transportation, immigration status, smoking status, inadequate income and depression. Having 1 or more of these factors was an indicator of vulnerability.

Statistical Analysis

Continuous variables were compared by using two sample t tests, while categorical variables were tested using Fisher's exact test and the χ² test of association. Multivariable logistic regression was used to estimate the odds ratio and 95% confidence interval (CI) for self-reported oral health and use of dental services. A receiver operating characteristic analysis was conducted to determine which of either the predisposing or enabling factors was most associated with dental service use. Results were considered significant for p < 0.05. Data analysis was carried out using SPSS software, v. 22 (SPSS, Inc., Chicago, Ill.).

Ethical Approval

This study was approved by the Research Ethics Boards of both the Fraser Health Authority and the University of British Columbia.

Results

The study reached 835 registrants over the 4-month period. Of these, 740 (87%) responded fully to the survey. Given that the prenatal registration program is also voluntary, the actual number of pregnant women seen at SMH during this period was probably larger.

Participants included a high proportion of high school graduates (85.2%) who were able to live within their income (85.8%) (Table 1). Few reported recent depression (9.3%) or lack of a social network, i.e., "someone to talk with" (8.1%). Although some of the pregnant women (5.6%) identified themselves as smokers, almost one-quarter (22.7%) were exposed to secondhand smoke.

Surrey has a large immigrant population, with almost 75% born in Asia.⁷ Of the women who participated in the survey, almost two-thirds were immigrants (Table 1), with the largest proportion born in India (50%). In all, 18 birth countries were identified. Few women identified as a refugee (5.5%) or of aboriginal heritage (5.5%). When asked to describe their oral health, most respondents reported it as excellent or good, while 16.7% rated it as fair (14%) or poor (3%) (Table 2).

Almost 50% had seen a dental professional in the last year and 23% reported they visited a dental professional for emergency purposes only. Nine percent of the respondents had never visited a dental professional; of these, almost two-thirds came from India (data not shown). Women who visited a dental professional within the last 2 years were more likely to rate their oral health as excellent or good (89%) than women who hadn't consulted a dental professional in more than 2 years (72%) (p < 0.001) (data not shown).

Tables 2–4 show the relation of predisposing and enabling factors to self-reported oral health and dental service use, respectively. Of all the predisposing factors, only decreasing exposure to secondhand smoke was associated with better self-reported oral health (Table 2). Women exposed to secondhand smoke on a daily or weekly basis were at least 60% less likely to report their oral health as excellent or good. For enabling factors, financial issues were the dominant limiting factor; lack of dental insurance, type of dental insurance and difficulty living within their income were all associated with fair or poor self-reported oral health (Table 3). Women with dental insurance were 3 times more likely to report their oral health as excellent or good. However, women on government programs or First Nations/Inuit insurance programs were up to 90% less likely to report good oral health. Women who used dental care more recently rated their oral health higher than women who had not seen a dental professional in more than 2 years (Table 3).

Lack of financial means also appeared to limit dental visits (Table 4). Women who reported difficulty living on their income and/or who had no dental insurance reported a greater elapsed time since their last dental visit. Almost 46% of the women had visited a dental professional within the last year for regular care (data not shown).

Multiple logistic regression analysis was used to evaluate the effect of the psychosocial variables mentioned by Anderson and Newman⁶ on self-reported level of oral health and use of dental services (Table 5). All variables that were significant in univariate analysis were included in the multivariate model. The presence of dental insurance significantly predicted both better self-reported oral health (p < 0.001) and receiving dental care within the previous 2 years (p < 0.001). To determine which predisposing or enabling factors were most associated with dental service use, a receiver operating characteristic curve was plotted (Fig. 1). The area under the curve is greater for enabling factors (72.5%) versus predisposing factors (63.6%) and perceived need of care (69.9%).

Discussion

This study examined self-reported oral health and dental service use among a diverse population of pregnant women from the city of Surrey, in British Columbia. The results suggest that pregnant women do not differ, with some exceptions, from the general Canadian population as reported in the oral health component of the CHMS.⁸ The self-reported oral health of the women in our study was similar to that reported in the CHMS study (excellent/good 83% v. 84%, respectively). Fewer pregnant women had dental insurance than those in the CHMS population (53% v. 62%) and only slightly more pregnant women in our study reported avoiding dental treatment because of cost (19% v. 16%).⁸ The disparity between those avoiding dental treatment may be a result of this population having more financial barriers than other Canadians as a result of a lower socioeconomic status in the area reached by Fraser Health.

As recommended in the guidelines of both the American Dental Association and the American Association of Periodontology, all pregnant women should receive a comprehensive dental and periodontal checkup during pregnancy at least once, and most types of dental treatment as needed.⁹ However, according to the findings of this study, financial barriers may be a major risk factor for women not receiving regular basic dental care.⁴ This barrier has been identified as a factor that can substantially impact overall oral health status and use of dental services.⁶

Use of dental services by our study population is similar to that in other studies of pregnant women as almost half of those in our study reported having consulted a dental professional within the last year. Gaffield et al.¹⁰ and Lyndon-Rochelle et al.¹ suggest similar patterns of dental service use during pregnancy in Arkansas, Illinois, Louisiana and North Dakota. Roger et al.¹¹ concluded that 30–50% of women seek dental care during pregnancy and consult a dental professional more frequently during pregnancy than at other times. Hence, pregnancy would appear to be a good time to introduce oral-health-related behavioural modifications that could be beneficial for both mother and infant.¹²

This study also identified financial affordability as the most important enabling factor in the use of dental services by pregnant women: having dental insurance and the financial means to pay for dental care is a common finding across similar and different populations in other studies.¹³ Not surprisingly, more than a third of those reporting income difficulties had never consulted a dental professional or had done so only for emergency purposes, as Dinas et al. found in Greece.¹³ It would appear that, like other marginalized groups, pregnant women of lower socioeconomic status face further difficulties in accessing the care they need and remain vulnerable to adverse pregnancy outcomes.¹⁴ This research informs the need for publicly funded programs covering at least basic dental treatment for pregnant women.¹⁴

Self-reported oral health seems to be influenced by the same predisposing and enabling factors as dental care use. Of interest, almost two-thirds of the pregnant women who rated their oral health fair or worse did not have dental insurance; those with financial difficulties were almost twice as likely to rate their oral health fair or poor. The inability to access dental care because of financial constraints could adversely affect the self-esteem and quality of life of these women. These results are similar to those of other studies where dental insurance and/or being able to afford dental care were strongly associated with both oral health status and use of dental care.¹⁰ A possible solution to the issue of affordability could include training midwives and other allied health care professionals to do basic dental examinations and make referrals for proper care even though that would not necessarily improve access to dental treatment.¹⁵

Limitations

Because the information in the dental survey was self-reported, we do not know how respondents interpreted the questions. Because of the limited number of questions, we were not able to find out why some women had not visited a dental professional within the last year. We do not know if they avoided the dental visit because of anxiety or cultural or ethnic beliefs, which may have influenced their use of dental services. Although most women reported having completed high school, we were unsure whether spouses, family members or accompanying persons had translated the questions for respondents. The focus on 1 specific jurisdiction in British Columbia that has a particular ethnocultural composition may prevent full generalization of our findings.

Despite these limitations, this study provides comprehensive self-reported data on the overall oral health of pregnant women at the sub-population level of a diverse ethnic community within the Fraser Health Authority. However, more work is needed to substantiate our self-reported findings with clinical examinations and further explore the roots of the most commonly held dental beliefs during pregnancy.

Conclusion

This study provides a baseline of self-reported oral health status and needs and use of dental services by pregnant women in the city of Surrey in British Columbia. It highlights the predisposing and enabling psychosocial factors that most influence the overall oral health of pregnant women and their use of dental services. Based on recent evidence, we emphasize the importance and safety of oral care during pregnancy. It is important to reassure both pregnant women and their health care providers that oral care — including the use of radiography, analgesics and local anesthesia — is safe during pregnancy. Pregnant women should be encouraged to seek oral care, practise good oral hygiene and follow the recommendations of their health care providers to maintain a healthy mouth during pregnancy.²

THE AUTHORS

	Dr. Jessani is PhD candidate and graduate periodontics resident, faculty of dentistry, University of British Columbia, Vancouver, British Columbia.
	Dr. Laronde is associate professor, faculty of dentistry, University of British Columbia, Vancouver, British Columbia.
	Dr. Mathu-Muju is assistant professor, faculty of dentistry, University of British Columbia, Vancouver, British Columbia.
	Dr. Brondani is associate professor and director, dental public health, faculty of dentistry, University of British Columbia, Vancouver, British Columbia.

Correspondence to: Dr. Mario Brondani, Faculty of Dentistry, University of British Columbia, 122-2199 Wesbrook Mall, Vancouver BC V6T 1Z3. Email: brondani@dentistry.ubc.ca

Acknowledgements: We thank all the participants and the entire team and staff at Surrey Memorial Hospital – Family Planning and Birthing Unit. A special acknowledgment to Dr. Victoria Lee, chief medical health officer and VP population health at Fraser Health Authority, for her insights during the study and to Drs. Heather Bush and Li Hsin-Fang (Grace) for their statistical analysis for the earlier version of this work. This paper originated as part of the requirements for AJ's master of sciences degree in craniofacial sciences, which were successfully completed in February 2014. The initial data from this work were presented at the annual conference of the Canadian Association of Public Health Dentistry, September 2013, Toronto, Canada. The authors are also grateful for the editorial work provided by Samantha Song and Adrian Carney.

The authors have no declared financial interests.

This article has been peer reviewed.

References

1. Lydon-Rochelle MT, Krakowiak P, Hujoel PP, Peters RM. Dental care use and self-reported dental problems in relation to pregnancy. Am J Public Health. 2004;94(5):765-71.
2. Oral Health Care During Pregnancy Expert Workgroup. Oral health care during pregnancy: a national consensus statement. Summary of an expert workgroup meeting. Washington, DC: National Maternal and Child Resource Center; 2012. [cited 2016 May 5]. Available: www.cdph.ca.gov/programs/MCAHOralHealth/Documents/MCAH-OHP-OralHealthPregnancyConsensus2011.pdf
3. Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand. 2002;60(5):257-64.
4. Chung LH, Gregorich SE, Armitage GC, Gonzalez-Vargas J, Adams SH. Sociodemographic disparities and behavioral factors in clinical oral health status during pregnancy. Community Dent Oral Epidemiol. 2014 Apr;42(2):151-9.
5. Government of Canada, Statistics Canada. Births, estimates, by province and territory [Internet]. 2015 [cited 2016 May 6]. Available from: www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo04a-eng.htm
6. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Q. 2005;83(4):10.1111/j.1468-0009.2005.00428.x. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690261/
7. Community demographic profiles. Surrey, BC: City of Surrey; 2016. [cited 2016 May 5]. Available: www.surrey.ca/business-economic-development/1417.aspx
8. Elani HW, Harper S, Allison PJ, Bedos C, Kaufman JS. Socio-economic inequalities and oral health in Canada and the United States. J Dent Res. 2012;91(9):865-70.
9. Manau C, Echeverria A, Agueda A, Guerrero A, Echeverria JJ. Periodontal disease definition may determine the association between periodontitis and pregnancy outcomes. J Clin Periodontol. 2008;35(5):385-97.
10. Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc.2001;132(7):1009-16.
11. Rogers SN. Dental attendance in a sample of pregnant women in Birmingham, UK. Community Dent Health. 1991;8(4):361-8.
12. Bates SB, Riedy CA. Changing knowledge and beliefs through an oral health pregnancy message. J Public Health Dent. 2012;72(2):104-11.
13. Dinas K, Achyropoulos V, Hatzipantelis E, Mavromatidis G, Zepiridis L, Theodoridis T, et al. Pregnancy and oral health: utilisation of dental services during pregnancy in northern Greece. Acta Obstet Gynecol Scand. 2007;86(8):938-44.
14. Lin DL, Harrison R, Aleksejuniene J. Can a prenatal dental public health program make a difference? J Can Dent Assoc. 2011;77:b32.
15. Schwarz E. Access to oral health care — an Australian perspective. Community Dent Oral Epidemiol. 2006;34(3):225-31.

Appendix 1 Dental questionnaire that was attached to the Best Beginnings prenatal registration form 2012, Fraser Health Authority.

Appendix 2 Best Beginnings prenatal registration form 2012, Fraser Health Authority.