Evaluation of a midwifery initiated oral health-dental service program to improve oral health and birth outcomes for pregnant women: A multi-centre randomised controlled trial

Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries

BACKGROUND

Dental caries, a common chronic disease of childhood, is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC). This review updates one published in 2019.

OBJECTIVES

To assess the effects of interventions undertaken with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years).

SEARCH METHODS

We searched Cochrane Oral Health's Trials Register, Cochrane Pregnancy and Childbirth's Trials Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL EBSCO, the US National Institutes of Health Ongoing Trials Register (clinicaltrials.gov) and WHO International Clinical Trials Registry Platform (apps.who.int/trialsearch). The latest searches were run on 3 January, 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing interventions with pregnant women, or new mothers and other primary caregivers of infants in the first year of life, against standard care, placebo or another intervention, reporting on a primary outcome: caries presence in primary teeth, dmfs (decayed, missing, filled primary surfaces index), or dmft (decayed, missing, filled teeth index), in children up to six years of age. Intervention types include clinical, oral health promotion/education (hygiene education, breastfeeding and other dietary advice) and policy or service.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence (GRADE).

MAIN RESULTS

We included 23 RCTs (5 cluster-randomised), involving 25,953 caregivers (mainly mothers) and their children. Fifteen trials assessed oral health education/promotion interventions against standard care. Six trials assessed a clinical intervention for mother dentition, against placebo, or a different type of clinical intervention. Two trials assessed oral health/education promotion plus clinical intervention (for mother's dentition) against standard care. At most, five trials (maximum of 1326 children and 130 mothers) contributed data to any comparison. Enamel-only caries were included in the diagnosis of caries in some studies. For many trials, the risk of bias was unclear due to lack of methodological details reported. In thirteen trials, participants were socioeconomically disadvantaged. No trial indicated receiving funding that was likely to have influenced their results. Oral health education/promotion interventions Child diet and feeding practice advice versus standard care: We observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a slightly lower mean dmfs (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, the evidence is very uncertain regarding the difference between groups in mean dmft (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence). Breastfeeding promotion and support versus standard care: We observed little or no difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence) and in mean dmft (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). dmfs was not reported. Child diet advice compared with standard care: We are very uncertain about the effect on the risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). dmfs and dmft were not reported. Oral hygiene, child diet and feeding practice advice versus standard care: The evidence is very uncertain about the effect on the risk of caries presence in primary teeth (RR 0.73, 95% CI 0.50 to 1.07; 5 trials; 1326 participants; very low-certainty evidence) and there maybe little to no difference in mean dmfs (MD -0.87, 95% CI -2.18 to 0.43; 2 trials; 657 participants; low-certainty evidence) and mean dmft (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; low-certainty evidence). High-dose versus low-dose vitamin D supplementation during pregnancy: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.99, 95% CI 0.70 to 1.41; 1 trial; 496 participants; very low-certainty evidence). dmfs and dmft were not reported. Clinical interventions (for mother dentition) Chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo: We are very uncertain regarding the difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment for mother dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trial reported dmfs or dmft. Xylitol compared with CHX antimicrobial treatment: We are very uncertain about the effect on caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence), but we observed there may be a lower mean dmft with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence). No trial reported dmfs. Oral health education/promotion plus clinical interventions (for mother dentition) Diet and feeding practice advice for infants and young children plus basic dental care for mothers compared with standard care: We are very uncertain about the effect on risk of caries presence in primary teeth (RR 0.44, 95% CI 0.05 to 3.95; 2 trials, 324 participants; very low-certainty evidence) or on mean dmft (1 study, not estimable). No trial reported dmfs. No trials evaluated policy or health service interventions.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very-low certainty and is insufficient for determining which, if any, other intervention types and features may be effective for preventing ECC, and in which settings. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine the effects and relative effects of different interventions and inform practice. We have identified 13 ongoing studies. Future studies should consider if and how effects are modified by intervention features and participant characteristics (including socioeconomic status).

Exploring the experiences and perspectives of women on oral health during pregnancy: A qualitative study in Tasmania, Australia

OBJECTIVE

To explore women's oral health experiences and barriers to dental care and identify potential strategies to improve oral health during pregnancy.

METHODS

A qualitative descriptive study design was used. Purposively elected antepartum and postpartum women ≥18 years of age from Tasmania, Australia, were recruited using maximum variation sampling. Semi-structured interviews were conducted, and all qualitative data were analysed using an inductive thematic approach.

RESULTS

Fifteen women were interviewed with a mean ± SD age of 32.3 ± 4.5 years. Three key themes were generated from the data that described women's perceived changes in their oral health during pregnancy; barriers to oral health care during and after pregnancy; and perceived strategies to improve access to care. Most women acknowledged the importance of maintaining good oral health but reported a decline in their oral health status during pregnancy. Women also identified several barriers to dental care, including treatment costs, competing maternal priorities, limited oral health knowledge and negative perceptions towards dentistry. The provision of preventative oral health care by ANC providers was also limited. Community awareness, patient education resources and assessment tools could support the promotion of oral health care. Women also perceived that interprofessional collaboration between antenatal and dental providers played a key role in promoting oral health.

CONCLUSION

This study explored women's varied oral health experiences and perceptions during pregnancy and highlighted critical barriers and enablers to dental care. Policy-level strategies that promote interprofessional collaboration between antenatal and dental providers and expand dental care access are suggested to overcome barriers to oral health for women during pregnancy.

Knowledge and attitudes on oral health of women during pregnancy and their children: an online survey

BACKGROUND

Life-long healthy behaviors are established during pregnancy and the first years of life. In this cross-sectional survey, new mothers with a high level of schooling living in Northern Italy (Lombardy Region) were interviewed to assess their knowledge and attitudes towards their and child oral health.

METHODS

A questionnaire (27 items) was developed to assess socio-demographic factors, knowledge, and attitudes towards maternal and child oral health. The questionnaire was disseminated in perinatal courses, private gynecological clinics, and via social media. Mothers aged ≥18 years, with at least a child aged 0-36 months, with a high school diploma or higher, were included in the survey.

RESULTS

A total of 1340 women completed the questionnaire, 1297 of whom had a child aged 0-36 months, 792 lived in Lombardy, and 600 had a high level of education and were finally included. About half of the sample (44.67%) was aged between 31 and 35 years, 76.50% were employed, and the majority had only one child (81.50%). During pregnancy, 28.33% of the sample reported problems with teeth and gums, while only 36.00% visited a dentist. More than 40% of the sample said they were not aware of a possible link between oral health and pregnancy, and 73.17% had not received any advice about their oral health or the future health of their baby's mouth. Less than 20% of women were aware of the increased caries risk associated with prolonged or night-time breastfeeding. Better knowledge/attitude was associated with the age of the child (p < 0.05), the number of children (p < 0.05) and whether the mother had received advice during pregnancy (p < 0.05).

CONCLUSIONS

The results of this survey show a lack of dental care during pregnancy, a lack of information about oral health from health professionals during and after pregnancy, and consequently gaps in the knowledge needed to care for the oral health of the woman and her child. There is a need for training in oral health for pregnant women and new mothers, but also a need for behavioural change among health professionals who care for pregnant women.

Oral health knowledge, attitudes and practices of dietitians in Australia: A national survey

AIM

Dietitians are a well-placed profession to be providing pre-emptive oral health promotion. Despite recommendations that oral health promotion should be routinely part of dietetic practice, there is limited data informing the current practices of clinical dietitians in this area across Australia. Hence, the aim of this study was to investigate the knowledge and practices of Australian dietitians and oral health promotion.

METHODS

A cross-sectional survey was undertaken involving registered clinical dietitians in Australia using purposive and snowballing sampling (social media/dietetic organisations/public databases). Data were analysed using descriptive and inferential statistics.

RESULTS

A total of 149 dietitians participated in the national survey. Overall, dietitians were knowledgeable about oral health risk factors and preventative measures across general health domains. Majority of dietitians agreed that oral health can affect nutrition interventions (95.5%) and dietitians should be discussing oral health (88.0%). However, nearly half were not confident in providing counselling or education and felt that undergraduate training for oral health promotion was inadequate (78.2%). A small proportion (6.0%) of dietitians were already providing oral health promotion regularly. Key barriers included a lack of clear guidelines for practice, limited training opportunities and indistinct referral pathways.

CONCLUSION

Dietitians have acknowledged that oral health promotion should be incorporated into their practice. However, they are challenged by a lack of resources and training to support this in clinical practice. SO WHAT?: Capacity building dietitians to promote oral health allows opportunity for improvement in the oral health, nutritional status and quality of life of priority population groups.

Supporting the oral health of people with intellectual disability: A survey of disability staffs' knowledge, perceptions, disability service barriers, and training

BACKGROUND

People with intellectual disabilities experience poorer oral health outcomes, which can negatively impact their quality of life. Disability support staff who support peoplewith an intellectual disability have the potential to assist with oral hygiene. However, there is limited understanding of the current practices of disability support staff around oral health, particularly in Australia.

OBJECTIVE

To describe disability support staff knowledge about oral health, explore their practice perceptions when supporting people with intellectual disabilities around oral health and their experiences of oral health training.

METHODS

A national cross-sectional survey was undertaken with 156 disability support staff across Australia. Recruitment was via publicly available websites of disability services and social media.

RESULTS

Disability staff were generally knowledgeable about appropriate oral hygiene practices and risks to oral health. They were less knowledgeable about the links between poor oral health and chronic diseases (<40%) and the importance of oral care for individuals who are fed enterally. Most participants (>80%) felt oral health was an important part of their care and were interested in further oral health training. Staff in semi-assisted living felt they had more time for oral health tasks compared to home-based living and residential facilities (p = 0.007). Lack of oral health training programs was the main barrier cited (44%), with only a quarter receiving any training in this area.

CONCLUSIONS

Disability support staff are receptive to promoting oral health. More training around oral health and intellectual disability is needed for this workforce to support them in undertaking this role.

Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Adults: A Systematic Review for the US Preventive Services Task Force

Importance

Dental caries and periodontal disease are common adult oral health conditions and potentially amenable to primary care screening and prevention.

Objective

To systematically review the evidence on primary care screening and prevention of dental caries and periodontal disease in adults to inform the US Preventive Services Task Force.

Data Sources

MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to October 3, 2022); surveillance through July 21, 2023.

Study Selection

Diagnostic accuracy studies of primary care screening instruments and oral examination; randomized and nonrandomized trials of screening and preventive interventions; cohort studies on primary care oral health screening and preventive intervention harms.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Diagnostic accuracy data were pooled using a bivariate mixed-effects binary regression model.

Main Outcomes and Measures

Dental caries, periodontal disease, morbidity, quality of life, harms; and diagnostic test accuracy.

Results

Five randomized clinical trials, 5 nonrandomized trials, and 6 observational studies (total 3300 participants) were included. One poor-quality trial (n = 477) found no difference between oral health screening during pregnancy vs no screening in caries, periodontal disease, or birth outcomes. One study (n = 86) found oral health examination by 2 primary care clinicians associated with low sensitivity (0.42 and 0.56) and high specificity (0.84 and 0.87) for periodontal disease and with variable sensitivity (0.33 and 0.83) and high specificity (0.80 and 0.93) for dental caries. Four studies (n = 965) found screening questionnaires associated with a pooled sensitivity of 0.72 (95% CI, 0.57-0.83) and specificity of 0.74 (95% CI, 0.66-0.82) for periodontal disease. For preventive interventions no study evaluated primary care counseling or dental referral, and evidence from 2 poor-quality trials (n = 178) of sealants, and 1 fair-quality and 4 poor-quality trials (n = 971) of topical fluorides, was insufficient. Three fair-quality trials (n = 590) of persons with mean age 72 to 80 years found silver diamine fluoride solution associated with fewer new root caries lesions or fillings vs placebo (mean reduction, -0.33 to -1.3) and decreased likelihood of new root caries lesion (2 trials; adjusted odds ratio, 0.4 [95% CI, 0.3-0.7]). No trial evaluated primary care-administered preventive interventions.

Conclusions and Relevance

Screening questionnaires were associated with moderate diagnostic accuracy for periodontal disease. Research is needed to determine benefits and harms of oral health primary care screening and preventive interventions.

Screening and Preventive Interventions for Oral Health in Adults: US Preventive Services Task Force Recommendation Statement

Importance

Oral health is fundamental to health and well-being across the life span. Dental caries (cavities) and periodontal disease (gum disease) are common and often untreated oral health conditions that affect eating, speaking, learning, smiling, and employment potential. Untreated oral health conditions can lead to tooth loss, irreversible tooth damage, and other serious adverse health outcomes.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate screening and preventive interventions for oral health conditions in adults.

Population

Asymptomatic adults 18 years or older.

Evidence Assessment

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults.

Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement).

Unfavourable beliefs about oral health and safety of dental care during pregnancy: a systematic review

BACKGROUND

Oral conditions such as gingivitis and periodontitis are correlated with adverse pregnancy outcomes such as preeclampsia, preterm birth and low birth weight. Oral health-related unfavourable beliefs can have negative influences on oral health behaviours including hesitation in accessing preventative dental treatments and dental service utilization. The objective of this systematic review was to examine unfavourable beliefs that expectant or new mothers frequently hold about oral health and the safety of dental care during pregnancy.

METHODS

An electronic database search on PubMed, Scopus, CINAHL, and MEDLINE (Ovid) followed by forward and backward citation tracing of the included studies was conducted. All English primary studies regardless of the year of publication were independently screened by two reviewers to identify studies addressing unfavourable beliefs about oral health and dental care during pregnancy. The CLARITY tool was applied to assess the risk of bias in the included studies.

RESULTS

Out of a total of 5766 records, 39 quantitative and six qualitative studies met the inclusion criteria. The commonly held unfavourable beliefs were regarding the safety of dental services utilization and dental treatment procedures, the adverse impacts of pregnancy on oral health, and oral hygiene necessity during pregnancy. The most discussed unfavourable beliefs included "pregnant women lose their teeth because of pregnancy" (n = 18), "dental treatments are not safe and harm the fetus" (n = 17), and "the developing baby absorbs calcium from the mother's teeth" (n = 14).

CONCLUSIONS

Unfavourable beliefs about oral health and dental care utilization are common among pregnant women and new mothers. The literature suggests that a low level of oral health knowledge and seeking information from social networks can contribute to such beliefs. This has implications for health promotion.

The effect of dental problems on pregnancy and birth outcomes in pregnant women registered in family health centers in a city center: A prospective study

The researchers aimed to determine the effects of oral-dental health of pregnant women on their pregnancy and fetus health. In this descriptive observational study, the researchers prospectively followed up 64 pregnant women three times, who were registered in two family health centers that were selected by using a simple random sampling method. As the follow-ups progressed, an increase was determined in the DMF-S (Decayed-Missing-Filled-Surface) index and DEBRIS (Caries Surface Distribution Form) scores in the areas observed (p < 0.05). No significant relationship was found between the increased scores and the infant's birth length, weight, and birth week.

Strategies to integrate oral health into primary care: a systematic review

OBJECTIVES

Integration of oral health into primary care has been proposed as a primary healthcare approach for efficient and sustainable delivery of oral health services, and the effective management of oral diseases. This paper aimed to synthesise evidence on the effectiveness of strategies to integrate oral health into primary care.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar were searched without date limits until the third week of June 2022. Reference lists of eligible studies were also searched. Experts in the field and existing professional networks were consulted.

ELIGIBILITY CRITERIA

Only studies that evaluated integration strategies were included in the review. Eligibility was restricted to English language studies published in academic peer-reviewed journals.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and performed the risk of bias assessments. A narrative synthesis approach was used to report review findings. Heterogeneity among included studies precluded a meta-analysis.

RESULTS

The search identified 8731 unique articles, of which 49 were included in the review. Majority of the studies explored provision of oral healthcare by primary care professionals in primary care settings, where integration was primarily via training/education and/or policy changes. Most studies reported results favouring the integration strategy, such as improvements in referral pathways, documentation processes, operating efficiencies, number of available health staff, number of visits to non-dental primary care professionals for oral health issues, proportion of children receiving fluoride varnish applications/other preventive treatment, proportion of visits to an oral health professional and dental caries estimates.

CONCLUSION

The findings from this review demonstrate that the majority of identified strategies were associated with improved outcomes and can be used to inform decision-making on strategy selection. However, more research and evaluation are required to identify best practice models of service integration.

PROSPERO REGISTRATION NUMBER

CRD42020203111.

Physiology of pregnancy and oral local anesthesia considerations

Background

Safe and effective local anesthesia is a prerequisite for emergency oral surgeries and most dental treatments. Pregnancy is characterized by complex physiological changes, and increased sensitivity to pain. Pregnant women are particularly vulnerable to oral diseases, such as caries, gingivitis, pyogenic granuloma and third molar pericoronitis. Maternally administered drugs can affect the fetus through the placenta. Therefore, many physicians and patients are reluctant to provide or accept necessary local anesthesia, which leads to delays in the condition and adverse consequences. This review is intended to comprehensively discuss the instructions for local anesthesia in the oral treatment of pregnant patients.

Methodology

An in-depth search on Medline, Embase, and the Cochrane Library was performed to review articles concerned with maternal and fetal physiology, local anesthetic pharmacology, and their applications for oral treatment.

Results

Standard oral local anesthesia is safe throughout the pregnancy. At present, 2% lidocaine with 1:200,000 epinephrine is considered to be the anesthetic agent that best balances safety and efficacy for pregnant women. Maternal and fetal considerations must be taken into account to accommodate the physiological and pharmacological changes in the gestation period. Semi-supine position, blood pressure monitoring, and reassurance are suggested for high-risk mothers to reduce the risk of transient changes in blood pressure, hypoxemia, and hypoglycemia. For patients with underlying diseases, such as eclampsia, hypertension, hypotension, and gestational diabetes, the physicians should use epinephrine cautiously and control the dose of anesthetic. New local anesthesia formulations and equipment, which contribute to minimizing injection pain and relieving the anxiety, have and are being developed but remain understudied.

Conclusions

Understanding the physiological and pharmacological changes during pregnancy is essential to ensure the safety and efficiency of local anesthesia. Optimal outcomes for the mother and fetus hinge on a robust understanding of the physiologic alterations and the appropriate selection of anesthetic drugs and approaches.

Long-term effectiveness of the midwifery initiated oral health-dental service program on maternal oral health knowledge, preventative dental behaviours and the oral health status of children in Australia

BACKGROUND

The Midwifery Initiated Oral Health-Dental Service was developed to train midwives to promote maternal oral health, and a large trial showed it substantially improved the oral health, knowledge and behaviours of pregnant women.

AIM

Evaluate the long-term effectiveness of the program (post-trial) on maternal oral health knowledge, dental behaviours, and early childhood caries in offspring.

METHODS

A prospective cohort study involving 204 women and children 3-4 years (followed after trial) was conducted in Sydney, Australia from 2017 to 2019.

RESULTS

The program did not have a significant impact on the study measures. Mothers who received the program did have comparatively better knowledge around preventative behaviours to reduce early childhood caries and significantly more mothers were engaging in a key behaviour of using a cup to feed their child. Overall maternal oral health knowledge and level of education did have a protective effect on the dental decay of children. Higher knowledge and levels of education reduced the odds of having a dmft of one or more by over half (OR 0.473), and almost 80% (OR 0.212) respectively.

CONCLUSIONS

Although the MIOH-DS program was not effective, there is still value in exploring other complementary interventions to improve maternal oral health, especially for disadvantaged families. Future research should focus on co-designing an antenatal and postnatal oral health intervention and exploring its long-term impact on the oral health of children.

Oral healthcare attendance and the effectiveness of referrals for rural antenatal women

OBJECTIVES

To analyse the effectiveness of targeted stakeholder engagement strategies and the impact they have on antenatal referrals, oral health admission, attendance and education of pregnant women in a rural public dental clinic.

METHOD

Key stakeholders (obstetric trained general practitioners [GPs] and midwives) were educated and motivated to refer pregnant women to the rural public dental clinic via priority referral pathways. A 10-month pre- and post-intervention period of oral health assessments and treatments was compared and contrasted.

DESIGN

Quasi-experimental study.

SETTING

A rural health service in the Loddon Mallee region, Victoria.

PARTICIPANTS

Local pregnant women, 18 years of age or older, eligible for public dental care.

MAIN OUTCOME MEASURES

Increased oral health admission, attendance and education of pregnant women.

RESULTS

Active engagement with key stakeholders significantly increased the oral health referral, admission and attendance of eligible antenatal women. Prior to the intervention, only 15.04% of eligible antenatal women sought oral health treatment, in comparison with 40.37% post-intervention. Of the 62 women referred, 44 actively received dental care.

CONCLUSION

Active engagement with key stakeholders has demonstrated a clinically effective method of increasing antenatal referrals of socially disadvantaged women to a rural public dental clinic. Further collaboration between healthcare professionals can improve the oral health admission rates, attendance and education of antenatal women and their children.

The Impact of Dental Care Programs on Individuals and Their Families: A Scoping Review

BACKGROUND

Despite significant global improvements in oral health, inequities persist. Targeted dental care programs are perceived as a viable approach to both improving oral health and to address inequities. However, the impacts of dental care programs on individual and family oral health outcomes remain unclear.

OBJECTIVES

The purpose of this scoping review is to map the evidence on impacts of existing dental programs, specifically on individual and family level outcomes.

METHODS

We systematically searched four scientific databases, MEDLINE, EMBASE, CINAHL, and Sociological Abstracts for studies published in the English language between December 1999 and November 2021. Search terms were kept broad to capture a range of programs. Four reviewers (AG, VD, AE, and KKP) independently screened the abstracts and reviewed full-text articles and extracted the data. Cohen's kappa inter-rater reliability score was 0.875, indicating excellent agreement between the reviewers. Data were summarized according to the PRISMA statement.

RESULTS

The search yielded 65,887 studies, of which 76 were included in the data synthesis. All but one study assessed various individual-level outcomes (n = 75) and only five investigated family outcomes. The most common program interventions are diagnostic and preventive (n = 35, 46%) care, targeted children (n = 42, 55%), and delivered in school-based settings (n = 28, 37%). The majority of studies (n = 43, 57%) reported a significant improvement in one or more of their reported outcomes; the most assessed outcome was change in dental decay (n = 35).

CONCLUSIONS

Dental care programs demonstrated effectiveness in addressing individual oral health outcomes. However, evidence to show the impact on family-related outcomes remains limited and requires attention in future research.

Socio-demographic and familial factors associated with hospital admissions and repeat admission for dental caries in early childhood: A population-based study

OBJECTIVES

Dental caries remains a complex childhood condition often requiring preventable hospital admissions. There are limited population-based epidemiological studies that use large and linked data sets to quantify the clinical, socio-demographic and familial risk factors related to hospital admissions for dental caries. The aim of this study was to describe and quantify the rates, socio-demographic, clinical characteristics and familial factors including repeat admissions associated with young children admitted to hospital for dental caries.

METHODS

This cohort study (n = 33,438) used longitudinally linked hospital admission data among all children aged <six years in NSW, Australia. Socio-demographic and admission characteristics of children and those with one versus two or more admissions for dental caries were compared. Familial risk factors were analysed for a restricted cohort of families with two or more children (n = 18,174) using multivariable logistic regression to assess the familial factors associated with multiple hospital admissions for dental caries adjusting for other socio-demographic characteristics.

RESULTS

There were 33,438 children aged <six years who had 34,446 hospital admissions for dental caries between 2001 and 2014. The annual rate of 4.3 per 1000 children remained unchanged over the period. Most admissions required general anaesthesia (96%), and 8.4% of children had repeat admissions. Children living in disadvantaged or in regional and rural areas attending public hospitals were more likely to have dental extractions during the admission. Children from the same family had a 2.7-fold increased odds of admission if the first child admitted was less than three years of age (adjusted odd ratio 2.69; 95% CI: 2.36-3.07), a 1.5 fold increase for socioeconomic disadvantage (aOR 1.45; 1.19 - 1.77) and a 1.9 fold increase of admission if the family had 4 or more children (aOR1.88; 1.47 - 2.42).

CONCLUSIONS

Findings highlight socio-demographic inequities associated with hospital admission for dental caries. The provision of targeted dental care programs for 'at-risk' families should address these inequalities and presents an opportunity to reduce dental caries related hospitalizations.

Dietitians' Experiences of Providing Oral Health Promotion to Clients with an Eating Disorder: A Qualitative Study

(1) Background: Eating disorders (EDs) can seriously impact oral health, leading to irreversible dental damage. Dietitians play a key role in the care of people with an ED and are well-placed to promote oral health. However, there is currently little understanding of how dietitians perceive their role in this space. This study aimed to explore the perceptions and role of dietitians in providing oral health promotion to their clients in an ED clinical setting. (2) Methods: This descriptive qualitative study used semi-structured interviews to explore the perceptions of 14 registered dietitians practicing across seven states in Australia. Participants were recruited using a combination of purposive and snowball sampling. A hybrid thematic analysis approach was undertaken to identify and describe the key themes generated from the data. (3) Results: Generally, dietitians were insightful and knowledgeable of the oral health issues that clients with an ED may be experiencing. However, dietitians' practices across education, screening, and referrals were inconsistent. Challenges such as inadequate training, unknown referral pathways, and clear guidelines were cited as significant barriers to practice. (4) Conclusions: The results reinforce the need for education and the development of targeted strategies that address challenges to oral health promotion in dietetic practice.

Oral Health Knowledge, Attitudes and Practices of People Living with Diabetes in South Asia: A Scoping Review

Diabetes increases the risk of oral health complications. This review aimed to synthesise the current evidence on the oral health knowledge, attitudes and practices of people living with diabetes in South Asian countries and provide recommendations on possible strategies for addressing the gaps in oral health care in this population, including the role of non-dental professionals. Using a scoping review framework, six electronic databases (Ovid Medline, CINAHL, ProQuest Central, Scopus, Web of Science and Embase) were searched to identify the relevant literature published between January 2000 and December 2021. The data were extracted into three main categories based on the review's aims, and further refined into sub-categories. A total of 23 studies were included. The review identified that while people with diabetes living in South Asian countries had some level of awareness about oral health and limited care practices to maintain good oral health, there were gaps in knowledge, and there were areas where their oral health practices and attitudes could be improved. The findings suggest a need for developing targeted oral health policies as well as implementing integrated oral health care interventions involving non-dental professionals to improve the oral health outcomes of people with diabetes.

Bibliometric Analysis of the Global Scientific Production on Oral Health during Pregnancy

AIM

To analyze the bibliometric characteristics of the global scientific production indexed in Scopus on oral health during pregnancy.

MATERIALS AND METHODS

Cross-sectional study with bibliometric methodology, using scientific publications indexed in Scopus as a unit of analysis. For the search, MESH terms, Boolean operators ("AND" and "OR"), and search topics (TITLE and ABSTRACT) were used. SciVal was the tool selected for the analysis of bibliometric parameters.

RESULTS

Most of the articles were published in Q1 (30.2%) and Q2 (29.6%) quartile journals. The country with the most scientific publications was the United States (451 articles), while Spain had only 14 publications. The University of Sydney, with 16 articles, was the most productive institution and the one with the most citations per publication was Saveetha University (19.7). The author with the most articles and citations related to the topic was George Ajesh with 13 and 136, respectively. Johnson Marre had the highest impact (15.1) and expected citations with respect to the global average (FWCI: 2.49).

CONCLUSIONS

The scientific production on oral health in pregnancy has increased, with a greater preference by authors for scientific journals in the Q1 and Q2 quartile. The United States is the country with the most publications, although Australia has a greater number of institutions among the most productive.

CLINICAL SIGNIFICANCE

The clinical relevance could be addressed later in relation to oral health during pregnancy, however, analyzing the bibliometric characteristics of the global scientific production is essential to understand the dynamics of scientific publications on this topic.

Effect of oral health promotion interventions on pregnant women dental caries: a field trial

Background

Dental caries is a costly and very common disease, especially in pregnant women. Reasons such as not paying attention to oral health, poor diet and also lack of adequate education in this regard cause this to happen. Performing well-designed educational interventions using primary health system’s forces, can improve oral health of pregnant women and help control this disease. We conducted this study to evaluate the effectiveness of some oral health interventions on pregnant women dental caries.

Methods

A field trial study was done in comprehensive Health Centers in Varamin, Tehran, Iran to assess 439 mothers’ dental health status from pregnancy up to 2 years after delivery in intervention (n = 239) and control groups (n = 200). Mothers in intervention groups received oral health-related education consisted of nutritional and behavioral messages via either of four methods: A: comprehensive method including all following methods together (n = 74), B: group discussion by dentists (n = 59), C: face to face education by primary health care providers (n = 53), and D: social network applications (n = 53); while those in control group only received routine maternal and oral health care. We used a questionnaire to collect mothers’ demographic, socioeconomic and dental care behavior data and also performed oral examinations to assess their DMFT at baseline and 24 months after delivery to evaluate the effectiveness of these educational oral health interventions.

Results

From 454 mothers participated the examination session, 18 pregnant women discontinued during the follow-ups and 439 were remained with mean age of 27.47. In the intervention group, the frequency of daily brushing among women increased from 64% at baseline to 85.6% at the last follow-up and the mean D significantly decreased nearly 1unit at same period (P < 0.05). Most and least dental caries changes were in comprehensive intervention group and social network intervention group compared to other intervention groups, respectively.

Conclusions

Performing educational interventions during and after pregnancy using various message delivery methods and messengers (oral health professionals and trained PHCPs), could improve oral health status and behaviors of pregnant and lactating mothers in a feasible and applicable manner.

Clinical practice guidelines and consensus statements for antenatal oral healthcare: An assessment of their methodological quality and content of recommendations

OBJECTIVES

To review the content of recommendations within antenatal oral healthcare guidance documents and appraise the quality of their methodology to inform areas of development, clinical practice, and research focus.

METHOD

A systematic search of five electronic databases, Google search engine, and databases from relevant professional and guideline development groups published in English, developed countries, and between 2010 and 2020 was undertaken to identify guidance documents related to antenatal oral healthcare. Quality of documents was appraised using the Appraisal of Guidelines Research and Evaluation II tool, and a 3-step quality cut-off value was used. Inductive thematic analysis was employed to categories discreet recommendations into themes.

RESULTS

Six guidelines and one consensus statement were analysed. Two documents developed within Australia scored ≥60% across five of the six domains of the quality appraisal tool and were recommended for use. Four documents (developed in the United States and Canada) were recommended for use with modifications, whilst one document (developed in Europe) was not recommended. A total of 98 discreet recommendations were identified and demonstrated considerable unanimity but differed in scope and level of information. The main content and number of recommendations were inductively categorised within the following clinical practice points: risk factor assessments (n = 2), screening and assessment (n = 10), pre-pregnancy care (referral, n = 1), antenatal care (health education and advice, n = 14; management of nausea and vomiting, n = 7; referral, n = 2), postnatal care (health education and advice, n = 1; anticipatory guidance, n = 6), documentation (n = 4), coordinated care (n = 4), capacity building (n = 6), and community engagement (n = 1).

CONCLUSION

The methodological rigour of included guidance documents revealed areas of strengths and limitations and posit areas for improvement. Further research could centre on adapting antenatal oral healthcare guidelines and consensus statements to local contexts. More high-quality studies examining interventions within antenatal oral healthcare are needed to support the development of recommendations.

An interprofessional model of care for oral health during pregnancy

The study aim was to appraise the relevance and appropriateness of an interprofessional prenatal oral care model among pregnant women and healthcare providers in British Columbia (BC), Canada. Audio-recorded semi-structured interviews with 39 purposefully selected participants (13 pregnant women and 26 healthcare professionals) were used qualitatively to appraise relevance of an existing model. The existing model emphasizes communication and collaboration among multiple health providers for the delivery of integrated prenatal oral care. All interviews were transcribed verbatim and analyzed using an inductive thematic approach and N-Vivo® software. During the first round of interviews, most participants considered the existing model as simple and well-defined but not fully relevant to the BC context. The participants suggested revisions to Steven's model to incorporate facilitators of integrated care, including interprofessional education, oral health funding, and advocacy for oral healthcare. Participants suggested a different graphical portrayal for the revised model; an implementation guide was also suggested. A revised model based on participants' feedback, was shared with 14 of the initial participants during secondary interviews. Further evaluation of the appropriateness of the revised model is warranted.

A Successful Dental Care Referral Program for Low-Income Pregnant Women in New York

Despite evidence-based guidelines that advocate for dental care during pregnancy, dental utilization among pregnant women remains low, especially among low-income and racial-ethnic minority women. We investigated self-reported dental care referral and self-reported dental care attendance among a group of 298 low-income, largely racial-ethnic minority pregnant women attending two suburban prenatal care clinics that had integrated dental care referrals into their prenatal care according to these guidelines. We administered a questionnaire that asked women: (1) whether they had been referred for care by their prenatal care provider; (2) whether they had been seen by a dentist during pregnancy. Among those women who were eligible for a dental care referral (those who reported having dental symptoms, and those not having a recent dental visit), we found that 73.0% reported that they had indeed been referred for dental care by their prenatal provider, while the remaining women reported either no referral (23.5%, n = 67) or were not sure whether they had been referred (3.5%, n = 10). Among those who reported a dental care referral, 67.3% (n = 140) reported that they saw a dentist during their pregnancy, while of those who reported no dental care referral only 35.1% (n = 27) reported a dental visit (Chi-Sq. = 24.1, df = 1, p < 0.001). Having received a dental referral was a significant predictor of reporting a dental visit during pregnancy, with women who received a referral being 4.6 times more likely to report a dental visit during pregnancy compared to those women who did not report a referral. These results demonstrate that vulnerable pregnant women referred for dental care by their prenatal provider will indeed seek and utilize dental care when offered. This dental referral program may serve as a model for improving the utilization of dental care among this population.

Associations between dental care approachability and dental attendance among women pregnant with an Indigenous child: a cross-sectional study

Background

Oral health during pregnancy is vital for both mother and child. Indigenous Australians face many barriers in accessing dental care. Service approachability is one of the key domains in accessing health services. There is little empirical evidence of the association between service approachability and dental care attendance or oral health outcome. The aim of this study is to examine the relationship between dental service approachability on dental care attendance and self-reported gum disease among South Australian women pregnant with an Aboriginal child.

Methods

Four hundred and twenty-seven women pregnant with an Aboriginal child completed questionnaires in both metropolitan and regional health settings in South Australia in 2011. Four variables related to approachability of dental services: (1) perception of need; (2) service-related health literacy; (3) oral health beliefs and; (4) trust and expectation of dental service. The association between service approachability-related factors, dental utilisation and self-reported gum disease during pregnancy were assessed using Generalised Poisson regression models, after adjusting for age, remoteness, employment status and education. Estimates were presented as adjusted prevalence ratios (APR).

Results

Most participants (85.8%) reported a need for dental care, had positive oral health beliefs (88.3%) and had expectations towards dental care (86.2%). Dental service utilisation during pregnancy was low (35.7%). Many participants (78.0%) expressed knowing what to do if they needed dental care, while most (39.8%) doubted that dental care would be available the next day. Poor health service literacy was identified as a risk factor for non-optimal dental attendance (APR = 0.86, 95%CI 0.74–0.99). Perceived need for dental care was positively associated with self-reported gum disease (APR = 1.24, 95%CI 1.06–1.45).

Conclusion

Inability to navigate the dental care system was a risk factor for poor dental attendance among South Australian women pregnant with an Aboriginal child. Perceived need for dental care was associated with gum disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01816-5.

Aboriginal Health Workers Promoting Oral Health among Aboriginal and Torres Strait Islander Women during Pregnancy: Development and Pilot Testing of the Grinnin' Up Mums & Bubs Program

BACKGROUND

this study aimed to develop and pilot test the model of care, Grinnin' Up Mums & Bubs, to train Aboriginal Health Workers to promote oral health among Aboriginal and Torres Strait Islander pregnant women.

METHODS

Participatory Action Research was employed to develop the different components of the model (oral health promotion resources, training workshop, and a culturally safe referral pathway to dental services). The model was piloted (pre-post), using an embedded mixed-methods design, to determine the acceptability, satisfaction, and any recommendations made by seven Aboriginal Health Workers at an antenatal service in Western Sydney, Australia.

RESULTS

there was a high level of satisfaction with the components of the model of care among the participants, who believed that the model could be integrated into practice. The training showed some improvement in oral health knowledge and confidence. The participants recommended strategies for discussing oral health with Aboriginal and Torres Strait Islander pregnant women, and changes in public health dental policy to ensure that all women would be able to access affordable dental services through the referral pathway.

CONCLUSION

the findings suggest a high level of satisfaction with the model of care among the Aboriginal Health Workers. Further evaluation is needed to confirm the short and long-term impact of the model.

Economic evaluation of the Midwifery Initiated Oral Health-Dental Service programme in Australia

OBJECTIVES

To critically evaluate the cost-effectiveness of the Midwifery Initiated Oral Health-Dental Service (MIOH-DS) designed to improve oral health of pregnant Australian women. Previous efficacy and process evaluations of MIOH-DS showed positive outcomes and improvements across various measures.

DESIGN AND SETTING

The evaluation used a cost-utility model based on the initial study design of the MIOH-DS trial in Sydney, Australia from the perspective of public healthcare provider for a duration of 3 months to 4 years.

PARTICIPANTS

Data were sourced from pregnant women (n=638), midwives (n=17) and dentists (n=3) involved in the MIOH trial and long-term follow-up.

COST MEASURES

Data included in analysis were the cost of the time required by midwives and dentists to deliver the intervention and the cost of dental treatment provided. Costs were measured using data on utilisation and unit price of intervention components and obtained from a micro-costing approach.

OUTCOME MEASURES

Utility was measured as the number of Disability Adjusted Life Years (DALYs) from health-benefit components of the intervention. Three cost-effectiveness analyses were undertaken using different comparators, thresholds and time scenarios.

RESULTS

Compared with current practice, midwives only intervention meets the Australian threshold (A$50 000) of being cost-effective. The midwives and accessible/affordable dentists joint intervention was only 'cost-effective' in 6 months or beyond scenarios. When the midwife only intervention is the comparator, the midwife/dentist programme was 'cost-effective' in all scenarios except at 3 months scenario.

CONCLUSIONS

The midwives' only intervention providing oral health education, assessment and referral to existing dental services was cost-effective, and represents a low cost intervention. Midwives' and dentists' combined interventions were cost-effective when the benefits were considered over longer periods. The findings highlight short and long term economic benefits of the programme and support the need for policymakers to consider adding an oral health component into antenatal care Australia wide.

TRIAL REGISTRATION NUMBER

ACTRN12612001271897; Post-results.

A Qualitative Study Exploring the Experiences and Perspectives of Australian Aboriginal Women on Oral Health during Pregnancy

The aim of this study was to explore whether oral health was an important consideration for Aboriginal and Torres Strait Islander women during pregnancy, whether oral health could be promoted by Aboriginal health staff, and strategies that would be appropriate to use in a new model of care. A qualitative descriptive methodology underpinned the study. All participants in this study identified as Aboriginal, with no Torres Strait Islander participants, and were from New South Wales, Australia. The interviews were analysed using inductive thematic analysis. From the data, two themes were constructed. The first theme identified that oral health was not always the first priority for participants as poor accessibility alongside other competing commitments were challenges to accessing oral health services. The second theme highlighted how relationships with personal networks and healthcare providers were essential and could be used to support maternal oral health during pregnancy. Effective strategies to promote oral health during pregnancy for Aboriginal and Torres Strait Islander women should involve key stakeholders and health care providers, like Aboriginal Health Workers, to facilitate culturally safe support and tailored oral health advice.

Knowledge, Attitudes, and Practices of Spanish Midwives and Midwifery Students toward Oral Healthcare during Pregnancy

Pregnancy can affect the mother's oral health, increasing their susceptibility to oral diseases that have been associated with harmful effects on the newborn. Despite the severity of oral diseases during pregnancy, the demand for dental care during the gestational period is low, which may improve with the participation of midwives in promoting oral health activities. The objectives of this study were: (i) to determine the knowledge, attitudes, and practices of Spanish midwives and midwifery students regarding oral health in pregnant women; and (ii) to identify the barriers faced by these healthcare professionals in addressing oral health promotion during pregnancy. An observational cross-sectional descriptive study was conducted. A total of 128 midwives and/or midwifery students ≥ 18 years old and of both sexes were invited to self-complete a questionnaire between January and April 2020. A total of 85 people participated in the study. Participants had a regular level of knowledge about oral health during pregnancy (overall knowledge score: 6.53), and although they were interested in activities that promote oral healthcare, their oral healthcare practices during pregnancy were limited. As midwives play an important role in promoting health, their training in oral healthcare could help to improve pregnant women's oral health.

Sociodemographic, Behavioral and Oral Health Factors in Maternal and Child Health: An Interventional and Associative Study from the Network Perspective

Oral healthcare during pregnancy needs to be part of the assistance routine given to pregnant women by health professionals as a way to encourage self-care and strengthen the general health of the mother and the baby. The aim of this study was to evaluate the effectiveness of an integrated oral healthcare intervention for pregnant women and to analyze the association of sociodemographic, behavioral, oral health and general maternal and child health factors in prenatal care at usual risk in primary care in a city in the northeast of Brazil, in 2018–2019. A controlled, randomized, single-blinded community trial was conducted. The intervention group (IG) received dental assistance and collective health education actions in conversation circles, while the control group (CG) received the usual assistance. All pregnant women (146 in total, 58 from IG and 88 from CG) that took part in the trial answered a questionnaire and underwent a dental examination at the beginning of prenatal care and at the puerperal visit. To assess the effect of the intervention, a network analysis was used. The results have shown that being in the control group was associated with neonatal complications (0.89) and prematurity (0.54); the use of tobacco and alcohol are associated with high risk in initial and final oral health; lower educational level of the pregnant women implicates high risk for initial oral health (−0.19), final oral health (−0.26), pregnancy complications (−0.13), low birth weight (−0.23), prematurity (−0.19) and complications in the newborn (−0.14). Having a low family income (≤261.36 USD) has shown a high risk for initial oral health (−0.14), final oral health (−0.20) and prematurity (−0.15). The intervention based on integrated oral healthcare for pregnant women indicated that socioeconomic and behavioral factors must be considered as determinants for the quality of women and children’s health and that multi-professional performance during prenatal care contributes to the positive outcomes of pregnancy.

"Got to build that trust": the perspectives and experiences of Aboriginal health staff on maternal oral health

BACKGROUND

In Australia, models of care have been developed to train antenatal care providers to promote oral health among pregnant women. However, these models are underpinned by Western values of maternity care that do not consider the cultural needs of Aboriginal and Torres Strait Islander women. This study aimed to explore the perceptions and experiences of Aboriginal health staff towards oral health care during pregnancy. It is part of a larger program of research to develop a new, culturally safe model of oral health care for Aboriginal women during pregnancy.

METHODS

A descriptive qualitative methodology informed the study. Focus groups were convened to yarn with Aboriginal Health Workers, Family Partnership Workers and Aboriginal management staff at two antenatal health services in Sydney, Australia.

RESULTS

A total of 14 people participated in the focus groups. There were four themes that were constructed. These focused on Aboriginal Health Workers and Family Partnership Workers identifying their role in promoting maternal oral health, where adequate training is provided and where trust has been developed with clients. Yet, because the Aboriginal health staff work in a system fundamentally driven by the legacy of colonisation, it has significantly contributed to the systemic barriers Aboriginal pregnant women continue to face in accessing health services, including dental care. The participants recommended that a priority dental referral pathway, that supported continuity of care, could provide increased accessibility to dental care.

CONCLUSIONS

The Aboriginal health staff identified the potential role of Aboriginal Health Workers and Family Partnership Workers promoting oral health among Aboriginal pregnant women. To develop an effective oral health model of care among Aboriginal women during pregnancy, there is the need for training of Aboriginal Health Workers and Family Partnership Workers in oral health. Including Aboriginal staff at every stage of a dental referral pathway could reduce the fear of accessing mainstream health institutions and also promote continuity of care. Although broader oral health policies still need to be changed, this model could mitigate some of the barriers between Aboriginal women and both dental care providers and healthcare systems.

A Qualitative Study of Health Care Providers' Views on Integrating Oral Health into Prenatal Care

OBJECTIVE

Providing preventive oral health during prenatal care is a recognized strategy for improving pregnant women's access to oral health care. This study sought to qualitatively explore the views of health care providers in British Columbia (BC), Canada, on strategies for integrating preventive oral health into prenatal care.

METHODS

Twenty-four purposefully selected health care providers (13 oral health and 11 prenatal care providers) in Vancouver and Surrey BC participated in audio-recorded semistructured interviews. Interviews lasted from 31 to 61 min, were transcribed verbatim, and were analyzed using an inductive thematic analysis with N-Vivo software. Study validity was ensured via memoing, fieldnotes, member checking, and external audit.

RESULTS

Thematic analysis revealed 5 major themes: perception of integrated care, relevance of integrated prenatal oral health, strategies for achieving integrated prenatal oral health, drivers of the integration process, and barriers to integrating oral health during pregnancy. Interprofessional collaboration based on information sharing and communication was identified as a critical factor for integrated care. Oral health checks should be a component of prenatal assessments for achieving integrated prenatal oral health. Participants recommended that prenatal providers should offer oral health education and use screening questions to identify the pregnant woman's oral health needs. The establishment of referral systems was advocated, while dental assessments and oral prophylaxis via the medical services plan were proposed. The inclusion of dental providers in prenatal teams and educating health care providers on interprofessional collaboration were also supported.

CONCLUSION

Oral health and prenatal providers in BC are positively disposed to adopting integrated preventive prenatal oral health care based on interprofessional collaborative practices. The inclusion of oral health providers in prenatal teams was suggested.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policymakers for advocacy and decision making when planning care delivery programs for women during pregnancy. Including the suggested strategies could lead to increased access to, and utilization of, oral health services among pregnant women.

The oral health of Indigenous pregnant women: A mixed-methods systematic review

BACKGROUND

Western models of care to improve the oral health of pregnant women have been successfully implemented in the healthcare setting across various developed countries. Even though Indigenous women experience poorer pregnancy and birth outcomes compared to other women, these models have not been developed with Indigenous communities to address the oral health needs of Indigenous pregnant women. This review aimed to understand the oral health knowledge, practices, attitudes and challenges of Indigenous pregnant women globally.

METHODS

A comprehensive search including six electronic databases and grey literature up to September 2018 was undertaken (PROSPERO Registration Number: 111402). Quantitative and qualitative evidence exploring at least one of the four oral health domains relating to Indigenous pregnant women worldwide, including women pregnant with an Indigenous child, were retrieved.

RESULTS

Eleven publications related to nine studies were included. Indigenous pregnant women's attitudes, practices and challenges relating to their oral health were influenced by socioeconomic and psychosocial factors, and their healthcare context. Availability of dental services varied depending on the healthcare model, whether services were public or private, and whether services met their needs. Although there was little evidence related to oral health knowledge, the literature suggests some misconceptions within this population.

CONCLUSIONS

The availability of culturally appropriate dental services that fulfilled the needs of Indigenous pregnant women varied between developed countries. This review highlighted the need for community-tailored dental services and a care coordinator to provide both education and assistance to those navigating services.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Implementing and evaluating the effectiveness of an oral health module for the bachelor of midwifery program at an Australian university

OBJECTIVE

Although guidelines recommend antenatal care providers such as midwives promote oral health during pregnancy, oral health training is not routinely provided in undergraduate midwifery curricula. The aim of this study was to implement an oral health module into an Australian undergraduate midwifery program, and evaluate its effectiveness in improving the oral health knowledge and confidence of midwifery students.

DESIGN

Pre-test post-test study (2015-2017).

SETTING

An undergraduate midwifery program within an Australian university.

PARTICIPANTS

All first-year undergraduate midwifery students enrolled in two core units at the above university (N = 56).

METHODS

Oral health modules were implemented into each of the two core units within the first year of the Bachelor of Midwifery course. Changes in knowledge and confidence were measured using a standardised questionnaire, administered at baseline, immediately following module completion, and at 2 and 3 years following module completion.

RESULTS

44 students participated in the baseline survey (79% response rate), of which 41 completed the first post-module questionnaire, 21 completed the second post-questionnaire, and 24 completed the third post-questionnaire. Knowledge scores significantly increased from baseline (mean 13.12) to follow-up (mean 17.78, p < 0.001), with increases being retained through to the 3-year mark (mean 18.29, p < 0.001). Confidence scores also showed a sustained increase following the module, particularly regarding introducing oral health in the first antenatal appointment (62.1% increase, p < 0.001) and referring pregnant women to a dentist (48.2% increase, p < 0.001). However, the 48.2% increase (p < 0.001) in confidence in conducting a visual mouth check on a pregnant woman following the module was not sustained at subsequent time points, reducing to a 31.5% increase (p = 0.118) by the third year post-module.

CONCLUSIONS

The module is effective in improving and sustaining the knowledge and confidence of midwifery students to promote maternal oral health. Ongoing updates may be required to keep confidence high regarding visual mouth checks.

Integrating Oral Health Screening Into Primary Care to Promote Dental Referrals in Maryland

BACKGROUND

Vulnerable populations are more likely to present to non-dental healthcare locations with dental issues. Oral health screening in those settings, such as primary care, is an effective way to identify individuals with unmet oral health needs and facilitate dental referrals.

OBJECTIVE

To implement and evaluate the integration of oral health screening at an outpatient transitional primary care clinic in Maryland.

METHODS

The quality improvement project occurred over 12 weeks. The project leader obtained support from institutional stakeholders, collaborated with dentistry, provided evidence-based resources, and developed referral strategies. Patients received a pre-screen at registration. Primary care providers used an oral health assessment tool (OHAT) for further screening and/or gave a dental referral.

RESULTS

Approximately 108 patients completed pre-screen: 73% had not seen dentist in the past 12 months; 12% had current oral problem or pain; 53% had no established dentist; <5% had a completed OHAT; 20% referred to existing dentist; 56% received dental resource listing.

CONCLUSIONS

Oral health disparity continues to exist among vulnerable populations.

IMPLICATIONS FOR NURSING

Oral screening by advanced practice nurses is an effective way to identify patients with unmet oral health needs and to promote dental referral.

Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries

BACKGROUND

Dental caries is one of the most common chronic diseases of childhood and is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC).

OBJECTIVES

To assess the effects of interventions with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years of age).

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 January 2019), Cochrane Pregnancy and Childbirth Group's Trials Register (to 22 January 2019), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Register of Studies, to 14 January 2019), MEDLINE Ovid (1946 to 14 January 2019), Embase Ovid (1980 to 14 January 2019) and CINAHL EBSCO (1937 to 14 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing one or more interventions with pregnant women, mothers, or other caregivers of infants in the first year of life (intervention types included clinical, oral health education/promotion such as hygiene education, breastfeeding and other dietary advice, and policy or health service), versus standard care or placebo or another intervention. For inclusion, trials had to report at least one caries outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 17 RCTs (4 cluster-randomised), involving 23,732 caregivers (mainly mothers) and their children. Eleven RCTs assessed four oral health education/promotion interventions against standard care: child diet advice, child diet and feeding practice advice, breastfeeding promotion and support, and oral hygiene with child diet and feeding practice advice. Six trials assessed clinical interventions in mother's dentition, four trials chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo, and two trials xylitol against CHX or CHX + xylitol. At most, three trials (maximum of 1148 children and 130 mothers) contributed data to any comparison. For many trials, risk of bias was judged unclear due to lack of methodological details reported, and there was high risk of attrition bias in some trials. None of the included trials indicated receiving funding that is likely to have influenced their results. The trials were performed in high-, middle- and low-income countries. In nine trials, participants were socioeconomically disadvantaged. For child diet and feeding practice advice versus standard care, we observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a lower mean dmfs (decayed, missing, filled primary surfaces) score (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, we are uncertain regarding the difference between the groups in mean dmft (decayed, missing, filled teeth) score (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence). For breastfeeding promotion and support versus standard care, we observed that there may be little or no a difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence), or mean dmft score (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). Dmfs was not reported for this comparison. We are uncertain whether child diet advice only compared with standard care reduces risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). Dmfs and dmft were not reported for this comparison. For oral hygiene, child diet and feeding practice advice versus standard care, we observed little or no reduced risk of caries presence in primary teeth (RR 0.91, 95% CI 0.75 to 1.10; 2 trials; 365 participants; low-certainty evidence), and are uncertain regarding difference between the groups in mean dmfs score (MD -0.99, 95% CI -2.45 to 0.47; 1 trial; 187 participants; very low-certainty evidence) and dmft score (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; very low-certainty evidence). We observed there may be little or no difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment in mother's dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trials assessing this comparison reported dmfs or dmft. For xylitol compared with CHX antimicrobial treatment, we observed there may be a lower mean dmft score with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence); however, we are uncertain regarding the difference between groups in caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence). Neither trial evaluating this comparison reported dmfs. No trials assessed a health policy or service intervention.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very low certainty and is insufficient for determining which, if any, other interventions types and features may be effective for preventing ECC. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine effects and relative effects of different interventions and inform practice. We have identified 12 studies currently in progress. Those designing future studies should describe the intervention components, setting and participants, consider if and how effects are modified by intervention features and participant characteristics, and adopt a consistent approach to measuring and reporting ECC.

[Interprofessional collaboration for prenatal dental follow up in primary health care]

The aim of this study is to understand interprofessional teams' collaborative practices for prenatal dental follow-up in primary health care. An exploratory, qualitative and descriptive study was carried out, in which workers directly involved in prenatal care in the city of Fortaleza, Brazil were included. A total of 24 individual semi structured in depth interviews were conducted between June and August of 2018. The information was organized based on a thematic analysis, and the hermeneutic dialectic method was used for the theoretical foundation and interpretation. Three discursive categories were identified: professional perceptions about collaborative practice, challenges in interprofessional collaboration, and collaboration practices within the team. The professionals' perception about interprofessional collaboration in maternal and child care was favorable, although in some cases the interdisciplinary work practice was not effective due to the existence of barriers that hindered its fulfillment.

Effectiveness of preventive dental programs offered to mothers by non-dental professionals to control early childhood dental caries: a review

BACKGROUND

Early childhood caries is a common chronic childhood disease and maternal oral health is a risk factor. Improving the oral health behaviours of pregnant women/young mothers can positively influence the oral health of children and reduce their caries risk. Such preventative strategies have been undertaken by non-dental professionals producing mixed results encompassing various interventions across the perinatal period. However, no comprehensive review of these studies has been undertaken. The aim of this review was to assess the effectiveness of maternal oral health programs undertaken during the antenatal and/or postnatal period by non-dental health professionals to reduce early childhood caries.

METHODS

A systematic search of five databases was undertaken using key search terms. Studies were included if they (a) involved quantitative study designs with a control; (b) were published in English; (c) reported on interventions delivered by non-dental professionals (d) delivered the intervention to expectant mothers or mothers with young infants up to 24 months; (e) measured outcomes when the child was under 5 years; (f) measured changes in oral health outcomes of children clinically and oral health behaviours of mothers or children. No restrictions were placed on the study quality and setting.

RESULTS

Nine studies met the inclusion criteria and involved interventions delivered by diverse non-dental professionals across the antenatal (n = 1), postnatal (n = 6) and perinatal period (n = 2). Most studies were of low methodological quality (n = 6). The interventions focussed on oral health education (n = 8), dental referrals (n = 3) and oral health assessments (n = 1). Interventions conducted in either the postnatal or antenatal periods showed meaningful improvements in children's clinical and mother's behavioural oral health outcomes. The outcomes appear to be sustained when a suite of interventions were used along with referral reminders. There were mixed results from interventions across the perinatal period.

CONCLUSIONS

Non-dental professionals can promote maternal oral health by providing oral health education, risk assessment and referrals. Combining these interventions could provide a sustained improvement in oral health outcomes for children although current evidence is weak. More high-quality studies are needed to confirm these findings and determine whether the antenatal and/or postnatal period is best suited to deliver these interventions.

Maternal and child oral health interventions in Middle East and North Africa regions: a rapid review

OBJECTIVES

To conduct a rapid review to identify any maternal and/or child oral health interventions implemented and/or tested in Middle East and North Africa (MENA) countries generally, and Lebanon, Palestine and Syria specifically, and to compile information on the relative effectiveness of these interventions.

METHODS

A systematic search was conducted for primary and secondary literature indexed in five online databases, and the websites of the World Health Organisation (WHO), the International Union for Health Promotion and Education (IUHPE), the United Nations Children's Fund (UNICEF), United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), and the United Nations Refugee Agency (UNHCR).

RESULTS

Two independent researchers reviewed 1,180 records from the online databases, and 3,120 reports from the WHO, UNRWA, UNICEF and UNHCR. Four unique studies were included and conducted in Syria, Saudi Arabia and Iran. No systematic reviews were found for targeted interventions in MENA regions. However, interventions using fluoridated toothpaste (Syria), preventive treatment and fluoridated chewing gum (Saudi Arabia), and oral health education with oral health reminders (Iran) were significantly effective in reducing early child caries (ECC) experience. In Syria and Iran, mother and child oral health promotions integrated into ongoing vaccination programmes were effective in reducing ECC. These interventions formed part of WHO and Ministry of Health programmes.

CONCLUSION

Further investigation is essential to verify the effectiveness of incorporating multi-disciplinary, theory-driven oral health interventions into ongoing WHO maternal and child health programmes in MENA countries to assist in promoting oral health and wellbeing.

Prenatal Oral Health Care and Early Childhood Caries Prevention: A Systematic Review and Meta-Analysis

Despite the advancement of early childhood caries (ECC) prediction and treatment, ECC remains a significant public health burden in need of more effective preventive strategies. Pregnancy is an ideal period to promote ECC prevention given the profound influence of maternal oral health and behaviors on children's oral health. However, studies have shown debatable results with respect to the effectiveness of ECC prevention by means of prenatal intervention. Therefore, this study systematically reviewed the scientific evidence relating to the association between prenatal oral health care, ECC incidence, and Streptococcus mutans carriage in children. Five studies (3 randomized control trials, 1 prospective cohort study, and 1 nested case-control study) were included for qualitative assessment. Tested prenatal oral health care included providing fluoride supplements, oral examinations/cleanings, oral health education, dental treatment referrals, and xylitol gum chewing. Four studies that assessed ECC incidence reduction were included in meta-analysis using an unconditional generalized linear mixed effects model with random study effects and age as a covariate. The estimated odds ratio and 95% confidence intervals suggested a protective effect of prenatal oral health care against ECC onset before 4 years of age: 0.12 (0.02, 0.77) at 1 year of age, 0.18 (0.05, 0.63) at 2 years of age, 0.25 (0.09, 0.64) at 3 years of age, and 0.35 (0.12, 1.00) at 4 years of age. Children's S. mutans carriage was also significantly reduced in the intervention group. Future studies should consider testing strategies that restore an expectant mother's oral health to a disease-free state during pregnancy.

Process evaluation of the midwifery initiated oral health-dental service program: Perceptions of dental professionals

ISSUE ADDRESSED

All pregnant women should have a comprehensive oral health evaluation. Unfortunately, many pregnant women seldom seek dental care and some dentists are hesitant to treat during pregnancy. To address these issues, the Midwifery Initiated Oral Health Dental Service (MIOH-DS) program was developed in Australia. The aim of this study was to undertake a process evaluation and explore the perceptions of dental professionals involved in the program to determine the acceptability, feasibility and effectiveness of the program if it were to be upscaled.

METHODS

A qualitative approach using content analysis was conducted on data from two focus groups involving 12 dental professionals.

RESULTS

All participants were supportive of the MIOH-DS program. They thought pregnant women were receptive to their care, and reported markedly improved oral health. The provision of free dental care and the involvement of midwives were cited as major factors that improved the uptake of the program. Some of the challenges encountered were the prevailing misconceptions about the safety of dental treatment and pregnancy-related impairments.

CONCLUSIONS

Dental professionals found the MIOH-DS to be acceptable, feasible and effective in improving oral health of pregnant women and their uptake of dental services. However, some challenges need to be addressed as the MIOH-DS program is upscaled into a cost-effective model. SO WHAT?: Dental professionals are important stakeholders in the MIOH-DS model. The process evaluation of the successful dental intervention is necessary to understand how and why such interventions work, and is an important step in scaling up to a population-wide intervention.

Process evaluation of the midwifery initiated oral health-dental service program: perceptions of pregnant women

BACKGROUND

Pregnant women in Australia seldom seek dental care and are unaware of its importance. To address these gaps the midwifery-initiated oral health dental service (MIOH-DS) program was comprehensive trialled and found effective. The aim of this study was to undertake a process evaluation of the MIOH-DS using the perspectives of pregnant women who participated in the trial.

METHODS

A qualitative research design was utilized, whereby content analysis was undertaken on data from 11 semi-structured interviews with women who participated in the program.

RESULTS

All participants were receptive of the MIOH-DS intervention, and found it to be an acceptable intervention that met their needs, and encouraged future positive oral health practices and health-seeking behaviours. They expressed that midwives were an appropriate professional to conduct oral health assessments, education and referrals to affordable dental services. Although some participants were initially apprehensive towards receiving treatment during pregnancy, dental staff members were able to appropriately educate and reassure them during treatment.

CONCLUSIONS

The MIOH-DS represents a promising and acceptable intervention strategy for pregnant women to promote their oral health. Findings merit further investigation on whether positive outcomes achieved can be sustained when implemented in other national or international settings similar to the study setting.

Process evaluation of the midwifery initiated oral health-dental service program: Perceptions of midwives in Greater Western Sydney, Australia

BACKGROUND

Despite links between poor maternal oral health, adverse pregnancy outcomes and early childhood decay there is limited emphasis on maternal oral health in Australia. To address this, the Midwifery Initiated Oral Health Dental Service (MIOH-DS) program was developed in collaboration with the Australian College of Midwives.

AIMS

To undertake a process evaluation and explore perceptions of midwives involved in the MIOH-DS program to determine its practicability, acceptability and feasibility if it were to be up-scaled and implemented into clinical practice.

METHODS

Qualitative content analysis was undertaken on data from three focus groups with 21 midwives.

FINDINGS

Midwives generally found the MIOH-DS to be acceptable and feasible with potential for widespread scalability. The trust women had in midwives was an important factor in gaining women's attention about oral health in pregnancy. The program assisted in increasing midwives' knowledge and awareness, though some felt it was outside their scope of practice. The oral health assessment tool was acceptable to midwives but some concerns were expressed about undertaking a visual oral inspection. Most midwives stated they were now confident with referring individuals to a dentist. Significant barriers to widespread implementation included the cost of dental care and the continued lack of awareness and misconceptions pregnant women had towards oral health.

CONCLUSION

Midwives found the MIOH-DS to be acceptable and feasible which are two important barriers to potential implementation at scale. Misconceptions over the importance of oral health by women and cost of accessing dental services still need resolving.