To our knowledge, this is the first study in the region that examines and provides a strong understanding of the role of oral health practices, by both dental and medical providers, in promoting dental care during pregnancy.
Our results showed that 9 out of 10 women had at least one dental problem, yet only 48% of these women accessed dental care during their pregnancy. Furthermore, only 30% of the dentists talked to women about the importance of dental visits during pregnancy. This practice, however, was the most successful in persuading pregnant women to continue their dental care during pregnancy. Although multiple randomized controlled trials have demonstrated that dental care during pregnancy is important and safe [28-30], and despite the publication of evidence-based guidelines advocating for the provision of oral health care during pregnancy [31-32], dentists remain undecided about treating pregnant women. Insufficient knowledge in the care of pregnant women, uncertainties about the safety of dental treatment during pregnancy, fear of liability, and lack of inter-professional collaboration were some of the barriers to the provision of dental care to pregnant women reported by dentists [33-35].
Our findings also showed that women who were referred to dental care or had their mouth checked by a healthcare provider were four times more likely to visit a dentist during pregnancy. Moreover, advising expectant mothers to visit a dentist during pregnancy and asking them about their oral health increased their likelihood of visiting a dentist during pregnancy by three-fold. The Oral Health Care During Pregnancy Expert Workgroup (2012) recommended that prenatal health providers ask their pregnant patients oral health screening questions and check their mouths for problems during the first prenatal visit [36]. Our findings agreed with an analysis of the Maternal and Infant Health Assessment population-based survey of postpartum women in California, USA, which found a two-fold increase in the prevalence of dental visits during pregnancy when the medical providers asked pregnant women about their oral health or suggested that they see a dentist. However, only 42% of the health providers talked to the women about oral health, while 26% suggested they see a dentist [37]. Although many prenatal health providers are aware of the need for dental care during pregnancy, most do not screen their pregnant patients for oral health or refer them to a dentist [38]. This is unfortunate since they are usually the first point of contact when women get pregnant.
Interestingly, we found that dentists are less likely to practice oral health promotion with women who had dental problems compared to those without dental problems. The need to complete the necessary dental treatment for those with dental problems and the limited time available for patient care in PHC settings may explain this finding. Educating pregnant women about the importance of good oral heath during pregnancy, demonstrating proper tooth brushing and flossing, and providing professional prophylaxis are important in establishing a healthy oral environment in expectant mothers and can be vital in improving perinatal outcomes and maternal and child dental health [39]. The role of dental hygienists in educating patients and preventing oral disease cannot be overemphasized.
Our study findings show that most of the examined oral health promotion practices are valuable in promoting dental visits during pregnancy, albeit to various extents. The dental practice of informing women of childbearing age that they should seek dental care during pregnancy is sufficient to encourage cautious pregnant women to obtain dental care during pregnancy. Likewise, prenatal health providers should routinely ask expectant mothers about their oral health, inspect their mouths, and refer them to dental care. Most women in Saudi Arabia trust their gynecologists and dentists equally in regard to recommendations for dental treatment during pregnancy [14]. Therefore, establishing a team-based approach and training dental and medical primary care providers in the oral health care of pregnant women can increase the number of pregnant women seeking dental care during pregnancy.
Currently, pregnant women at PHCs are referred to dental clinics for dental examination and education through a written referral form. Despite this, less than half of the study women accessed dental care during pregnancy. On the one hand, physicians may be non-compliant with the required dental referral. On the other hand, the limited number of dentists working in PHCs relative to the population served, shortages in hygienists and dental educators, and the lack of supportive services prohibit these centers from meeting the women’s demand for dental care [40]. Pregnant women referred to dental clinics must either wait a long time to be seen on the same day during a fully scheduled dental clinic or forgo dental care altogether if they are expected to schedule their own dental appointments. In addition, the limited availability of dental appointments via the “Sehhaty” digital health application and potential technical difficulties may constitute other factors that deter pregnant women from seeking dental care at PHCs. Hence, the employment of case coordinators is highly recommended for effective dental referrals and continuity of dental care [40-42]. Moreover, modifying the current electronic medical record system to support an electronic referral form will facilitate coordinated patient care and effective monitoring to close the referral loop [43].
The current reform in the Saudi healthcare delivery system and the new model of care through the Safe Birth System of Care (SOC) supports women from premarriage through preconception to postdelivery to promote safe pregnancies and healthy infants [44-45]. Considering the enormous evidence linking poor oral health in expectant mothers to negative maternity and child health outcomes, it is compelling to include oral health as a basic component of SOC. This reform also underscores healthcare education and training. Therefore, training in the practice guidelines for the dental management of pregnant women [31-32] should be compulsory for all health providers, new hires or veterans, who are involved in the provision of care to pregnant women. Additionally, the support of key stakeholders in the healthcare system in Saudi Arabia will help women initiate and maintain oral health care during pregnancy and throughout their lifespan. Primarily, the Saudi Central Board for Accreditation of Health Care Institutions [46] recommends the administration of a well-structured preventive dental education program for pregnant women in PHCs as one of its standards for dental and oral health chapter 5.3 [47]. Furthermore, the Saudi Center for Disease Prevention and Control should emphasize, as part of its National Preventive Guidelines for Periodic Health Examination, oral health examination and prevention of oral diseases for women of childbearing age and pregnant women. Finally, key performance indicators, such as antenatal dental referral and the formulation of a dental care plan for the referred pregnant woman, should be established and monitored by institutional clinical authorities. These engagements ensure effective antenatal-dental collaboration and promote healthy pregnancy outcomes and a future generation of children free of oral disease.
Limitations of our study include the inherent characteristics of cross-sectional study designs. We are unable to establish that the increase in utilization of dental care by women during pregnancy is caused by prenatal health providers’ oral health promotion. Moreover, since the data were collected from pregnant women after delivery, there could be a potential for recall bias within the respondents; however, an event such as a visit to a dentist during pregnancy is unlikely to be forgotten. Despite these issues, our methodological rigor and the relatively large sample size make this study robust, and our findings highly plausible and extremely useful to the dental and obstetric community and to primary healthcare physicians worldwide.