Written by Sreya Peddi and Sara Ibrahim

Prenatal care is usually associated with visits to the obstetrician, ultrasound screenings, and prenatal vitamins, however oral health is just as important. There has been a tremendous amount of progress and advocacy for health conditions like cancer and infectious diseases, but progress and advocacy for maternal health often lags, especially in countries where data on the issue is either hidden or inadequate. Maternal health involves both maternal mortality and overall health during pregnancy. Every country faces the issue of dying mothers, but the United States of America, a first-world country, has been experiencing a rapid increase in its maternal mortality rates recently. 

In the U.S., the maternal mortality rate was 23.8 deaths per 100,000 live births in 2020, and since then, it has only increased. There are many factors that contribute to maternal mortality and a decline in maternal health, but one that is often overlooked is oral health and access to dental care. 

The Importance of Oral Care?

When women are pregnant, their hormone levels are constantly fluctuating. As a result, the microbial composition of the oral cavity is affected. A balanced microbial flora of the oral cavity helps maintain oral health, but this balance is impacted during pregnancy. The imbalance can not only harm the health of the mom, but also the health of the infant. 

To gain further insight on how pregnancy impacts oral health, Health Righters conducted an interview with Dr. Omar Garada DDS, the chief resident at the University of Virginia (UVA) Department of Dentistry. According to Dr. Garada, even if an expecting mother has good oral health habits, her gums and teeth are still extremely sensitive as the buildup of hormones have a large impact on the tissues in that area, causing gingivitis, the inflammation of gums. About 60-70% of pregnant women have gingivitis, so proper and timely treatment is needed to be able to reverse the effects of gingivitis and prevent the condition from developing into more serious diseases.

Patients who have gingivitis are also more likely to develop lesions, extremely painful mouth ulcers or sores,  like a pyogenic granuloma. Although lesions are not life threatening, they are related to gingivitis as the build up of fluctuating hormones also causes them. If left untreated, gingivitis can turn into periodontitis, the more serious gum disease which damages the soft tissue and the bone that surrounds the teeth. 

Periodontitis is dangerous to both the health of the mother and the child as it is associated with diabetes and pre-eclampsia, one of the causes of maternal mortality, and low birth weight. Dr. Garada emphasizes that the state of a child’s oral health starts with the mother.

 Demineralization of teeth, which occurs when the mineral content of the teeth begins to wear away, and high bacterial load in the mouth are the most common impacts poor maternal oral care can have on children. Teeth demineralization can be caused by something as simple as the mother letting their baby sleep with a bottle in their mouth, and it has significant impacts. Demineralization, especially with primary teeth, can lead to cavities, and if serious, some patients have to go to the operating room since there is a cavity on each tooth and infections are at a high possibility. In general, mothers with poor oral health have high levels of bacteria in their saliva, which can be transmitted to the baby when being cared for. The baby adopts a similar bacterial flora, making them prone to gingivitis and other diseases. It is shown that a mother’s child is three times more likely to have a dental disease if the mother neglects their oral health. 

Educating pregnant patients on the importance of their oral healthcare

Dr. Garada details that for some patients, their pregnancy serves as a wake-up call to seek medical and dental care.

“​​I’ve seen a pretty common theme in pregnant patients that they’ll either like, never seek care during the first 26 years of their life and then as soon as they get pregnant, they’re like, oh, shoot, you know, I need to go see the dentist. So sometimes it’s like a wake up call for patients,” Garada said. 

However, for other pregnant patients, Garada explains, they only come see the dentist when they reach a critical condition or when they are in pain.

“I still get patients that are, you know, 28 weeks pregnant and they have […]  all of their first molars are […] essentially bogged down with cavities,” Garada said. “They were probably cavitated beforehand, and they only just started noticing […] so they only seek care when it’s painful, unfortunately. So it’s not always a big wake up call for everyone. But I would say for some of them, it definitely does help them kind of get back on track, you know, to regular recalls.”

Dr. Garada gives insight on how he approaches encounters with pregnant patients and how he provides them with critical education on how their oral health contributes to their overall health and that of their baby’s. 

“For pregnant patients, I spend the majority of the appointment–– I think the whole appointment–– [on]  just education. I don’t usually treat them on the same day that I’m meeting them.” 

This patient education serves a very crucial role to the health of the patient and they begin to realize how important their visits to the dentist can be. Dr. Garada makes it a point to educate his pregnant patients on the long term effects of their oral hygiene and how it affects that of their child’s. 

“Most mothers when they hear that […] it’s like a flick in their head,” Garada said. “So usually I take that route through education, just because, you know, even if you encounter you know, a Medicaid pregnant patient that you know, just hasn’t had the best access to care [and] they have pretty generalized cavities and not the best oral hygiene, even patients in that category, when they, you know, you kind of walk them through the […] long term effects of this, you know, most of them are pretty conducive to it.”

Disparities in access to dental care for Medicaid patients

It is not uncommon that patients refuse to receive critical medical care due to cost concerns. The National Health Institute Survey estimates that about 6.7% of adults aged 18 and older failed to obtain needed medical care due to cost. 

When asked about whether he has encountered patients who refused an important medical service due to costs or insurance coverage issues, Dr. Garada shared that it likely occurs every single day. However, he explains that UVA Health accepts Medicaid, and this has helped vulnerable Medicaid patients gain more access to healthcare. 

“UVA accepts Medicaid here and the dental clinic. So it’s helped out a lot and Medicaid actually expanded a lot of their coverage,” Garada said. “We try our best to work with patients, especially those that you know, it’ll benefit them not only mentally but also medically, and it’s just something that they should be getting done eventually.”

According to the Virginia Department of Health, only 13.03% of women with a dental problem during pregnancy see a dentist. Barriers for not seeking care include cost, safety concerns, and difficulty finding a dentist who accepts pregnant patients or Medicaid. Medicaid is a public health insurance for low income individuals and is provided for by the state and federal government. According to an article from U.S. News, it can be difficult for Medicaid patients especially to find a provider that accepts their health insurance, because reimbursement rates for the provider tend to be lower compared to other health insurances. 

Even when patients find a provider, the services covered tend to include a limited selection of items deemed medically necessary, which may not include other important and recommended services. Furthermore, according to several studies on problems with access to dental care for medicaid-insured children, Mahyar Mofidi, DMD, MPH et al. found that other barriers include difficulty in scheduling appointments, dealing with rude front desk staff, filling out long applications, and finding transportation services. Many medicaid or public insurance patients, especially children,  tend to have a lower socioeconomic status and are more vulnerable to developing dental problems  such as caries, a decay and crumbling of the tooth bone. 

The host of difficulties in finding and maintaining care, especially with a local dentist, makes it more likely for Medicaid patients to seek healthcare services, and may wait, as Dr. Garada previously mentioned, until they are in a critical health condition to seek care.This delay in seeking care puts pregnant patients at risk of neglecting their oral health until pain has emerged. 

Dr. Garada shares that most pregnant patients that he and his colleagues see are referred to them by the obstetrics department at UVA, after they undergo preliminary screening by their obstetrician. 

“And then that’s how the patient gets […] on our radar, and if they don’t have a dental home, either because it’s Medicaid or they’ve just been moving around for whatever reason […] we usually take them on as a patient,” Garada said. 

Teamwork between healthcare providers is crucial to the overall health of patients, especially pregnant patients who do not realize or know the impact of oral hygiene on their overall systemic health and that of their baby’s. 

Medicaid, has made an effort to accommodate pregnant patients to provide for them needed medical services during their pregnancy. According to Virginia Medicaid, pregnant women who are 21 years and older and have Medicaid and FAMIS MOMS are eligible to receive comprehensive dental benefits, excluding orthodontics, through the Smiles for Children (SFC) program. Through SFC, they receive coverage until 60 days after giving birth. Dental benefits will be discontinued at the end of the month following their 60th day postpartum.

Although impactful progress has been made, the same disparities which are present with maternal mortality are also present in accessing dental care. Racial disparities and socioeconomic barriers lead to pregnant African American women and American-Indian women having high rates of dental disease because they are least likely to have access to dental care. At the moment, only a few states offer full dental coverage for pregnant women through Medicaid. There are many benefits of ensuring access to dental care for pregnant women, but the most important benefit, besides securing her health and that of her baby’s, is to prevent life threatening complications and prevent maternal mortality. Securing access to dental care for pregnant women is a crucial step in the long pathway to closing the gaps in oral and reproductive healthcare in the United States.