You are on page 1of 9


Oral Health in Pregnancy

Erin Hartnett, Judith Haber, Barbara Krainovich-Miller, Abigail Bella, Anna Vasilyeva, and Julia Lange Kessler

Correspondence ABSTRACT
Erin Hartnett, DNP, APRN-
BC, CPNP, NYU College of Oral health is crucial to overall health. Because of normal physiologic changes, pregnancy is a time of particular
Nursing, 433 1st Ave., 6th vulnerability in terms of oral health. Pregnant women and their providers need more knowledge about the many
oor, New York, NY 10003. changes that occur in the oral cavity during pregnancy. In this article we describe the importance of the recognition, prevention, and treatment of oral health problems in pregnant women. We offer educational strategies that integrate
interprofessional oral health competencies.
gingivitis JOGNN, 45, 565573; 2016.
oral health Accepted April 2016
periodontal disease
womens health care

n the last decade, the importance of oral health During pregnancy, many changes occur in the
Erin Hartnett, DNP, APRN-
BC, CPNP, is the Program during pregnancy has garnered the attention oral cavity that can be linked to periodontal dis-
Director of the Oral Health
Nursing Education and of policymakers, foundations, agencies, and ease, which includes gingivitis and periodontitis.
Practice & Teaching Oral- health care providers who serve pregnant women Studies have indicated that there is a connection
Systemic Health programs, and young children. The U.S. Surgeon General between increased plasma levels of pregnancy
New York University Rory
(U.S. Department of Health and Human Services, hormones and a decline in periodontal health
Meyers College of Nursing,
New York, NY. 2000), World Health Organization (Petersen, status (Wu, Chen, & Jiang, 2015, p. 8). Approx-
2008), and American College of Obstetricians imately 60% to 75% of pregnant women have
Judith Haber, PhD, APRN,
BC, FAAN, is the Ursula and Gynecologists (American College of gingivitis (American Dental Association Council
Springer Leadership Obstetricians and Gynecologists Womens on Access, Prevention, and Interprofessional
Professor in Nursing and the Health Care Physicians & Committee on Health Relations, 2006). Although various numbers
Executive Director of Oral
Care for Underserved Women, 2013) have all have been reported for the prevalence of peri-
Health Nursing Education
and Practice & Teaching recognized that oral health is an integral part of odontitis in pregnancy, almost half of adults in the
Oral-Systemic Health preventive health care for pregnant women and United States have this condition (Eke, Dye, Wei,
programs, New York their newborns. Three Institute of Medicine re- Thornton-Evans, & Genco, 2012).
University Rory Meyers
College of Nursing, New ports (2011, 2013; Institute of Medicine &
York, NY. National Research Council, 2011) highlighted During pregnancy, a womans oral health can
the significance of addressing oral health as a affect her health and the health of her unborn
Barbara Krainovich-Miller,
EdD, RN, PMHCNS-BC, population health issue for pregnant women. In child. The purpose of this article is to present in-
ANEF, FAAN, is a clinical 2012, the Oral Health Care During Pregnancy formation on the importance of womens health
professor, New York Expert Workgroup highlighted the importance of care providers in the recognition, prevention, and
University Rory Meyers
College of Nursing, New the provision of oral health care to pregnant management of oral health problems during
York, NY. women in their landmark document, Oral Health pregnancy. Strategies that integrate interprofes-
During Pregnancy: A National Consensus State- sional oral health competencies into womens
ment. The U.S. Department of Health and Human health care provider education and practice are
Services, Health Resources and Services provided.
Administration (HRSA) released Integration of
Oral Health and Primary Care Practice (2014),
which outlines interprofessional oral health core Periodontal Disease in Pregnancy
clinical competencies appropriate for primary Periodontal disease, including gingivitis and
care providers including nurse practitioners periodontitis, has been associated with preg-
(NPs), nurse-midwives (NMs), medical doctors nancy (Wu et al., 2015). According to the Amer-
The authors report no con-
ict of interest or relevant (MDs), doctors of osteopathic medicine (DOs), ican Academy of Periodontology, periodontal
nancial relationships. and physician assistants (PAs). disease is an inflammatory disease that affects 2016 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses. 565
Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
PRINCIPLES & PRACTICE Oral Health in Pregnancy

negative consequences in pregnancy; however,

Lack of oral health care during pregnancy can negatively this association was weak (Corbella et al., 2016).
affect mother and newborn.
Xiong et al. (2009) found that periodontitis was
associated with GDM (77.4% of pregnant women
the soft and hard structures that support the
with GDM had periodontis) with an adjusted odds
teeth (n.d., The Causes and Symptoms, para.
ratio of 2.6 and a confidence interval of 95% in
2). Gingivitis, the early stage of periodontal dis-
their case-control study of 53 pregnant women
ease, occurs when the gums become swollen
with GDM and 106 without GDM. Ha et al. (2014)
and red due to inflammation, and periodontitis,
found a significant relationship between peri-
the most serious form of periodontal disease,
odontitis and preeclampsia in never smokers (p.
occurs when the gums pull away from the tooth
869) in their prospective cohort study of 283
and supporting gum tissues are destroyed
pregnant women who had never smoked, 67 with
(American Academy of Periodontology, n.d., The
periodontitis and 216 without periodontitis.
Causes and Symptoms, para. 2).
Although these studies did not show conclusive
Gingivitis evidence of the link between periodontal disease
Figuero, Carrillo-de-Albornoz, Martn, Tobas, and and negative pregnancy outcomes, periodontal
Herrera (2013) reported in their systematic review treatment is safe for pregnant women, avoids the
that the relationship between pregnancy and adverse consequences of periodontitis (e.g.,
gingivitis confirmed the existence of a significant pain, tooth loss) for the mother, and is not asso-
increase in gingivitis throughout pregnancy ciated with any negative infant or maternal out-
and between pregnant versus post-partum or non comes (Wrzosek & Einarson, 2009).
pregnant women (p. 457). Ehlers, Callaway,
Hortig, Kasaj, and Willershausen (2013)
compared the dental evaluation and gingival Access to Care
crevicular fluid from 40 pregnant women and 40 Access to dental care is reported to be related to
age-matched nonpregnant control subjects. They multiple factors and situations that may be con-
found that 80% of pregnant women had gingival current. Examples of these factors and situations
inflammation compared with 40% of control sub- include the following: (a) race/ethnicity (Azofeifa,
jects. Gogeneni et al. (2015) reported that preg- Yeung, Alverson, & Beltran-Aguilar, 2014; Hwang,
nant women with gingivitis and pregnant women Smith, McCormick, & Barfield, 2011), (b) age
with gingivitis and gestational diabetes mellitus and income level (Azofeifa et al., 2014), (c) per-
(GDM) had high levels of systemic C-reactive sonal stressors (Le, Riedy, Weinstein, & Milgrom,
protein. These findings indicate that gingivitis is a 2009), (d) lack of education (Azofeifa et al.,
problem in pregnant women. 2014), (e) lack of perceived need (Marchi,
Abigail Bella, MPH, is the Fisher-Owens, Weintraub, Yu, & Braveman, 2010),
Program Coordinator of the (f) insurance coverage (Cigna Corporation, 2015),
Teaching Oral-Systemic
Health program, New York Periodontitis and (g) sociodemographic differences (Azofeifa
University Rory Meyers Recent studies have shown an association et al., 2014; Hwang et al., 2011).
College of Nursing, New between periodontitis during pregnancy and
York, NY.
low birth weight (LBW), very low birth weight Hwang et al. (2011) analyzed Pregnancy Risk
Anna Vasilyeva, MPH, is (VLBW), preeclampsia, and GDM (Corbella Assessment Monitoring System data from 2004
the Program Coordinator of et al., 2016; Guimaraes et al., 2012; Ha, Jun, through 2006 and found significant disparities in
the Oral Health Nursing
Education and Practice Ko, Paik, & Bae, 2014; Xiong et al., 2009). race and ethnicity in the oral health experiences
program, New York Guimaraes et al. (2012) showed in their cross- of pregnant women. Black non-Hispanic and
University Rory Meyers sectional study of 1,206 postpartum women Hispanic women were significantly less likely to
College of Nursing, New
that maternal periodontitis was associated with receive dental care during pregnancy than White
York, NY.
a decrease in mean birth weight, as well as LBW non-Hispanic women. Through their use of data
Julia Lange Kessler, CM, and VLBW (p. 1024). Corbella et al. (2016) from the 1999 through 2004 National Health and
DNP, FACNM, is the
Program Director of the conducted a meta-analysis of studies in which Nutrition Examination Survey, Azofeifa et al.
Nurse Midwifery/WHNP researchers controlled for periodontitis as a risk (2014) showed significant sociodemographic
Program and an assistant factor associated with negative pregnancy out- disparities in dental service use and self-reported
professor, Georgetown
comes. They chose 22 out of 422 studies, which oral health among U.S. women in general and
University, School of
Nursing & Health Studies, included 17,053 subjects. They found that there between pregnant and nonpregnant women. The
Washington, DC. was an association between periodontitis and probability of having a dental visit within the year

566 JOGNN, 45, 565573; 2016.

Hartnett, E. et al. PRINCIPLES & PRACTICE

significantly increased as the pregnant womans

age, education, and income increased. Health care providers lack information on the oral health
care needs of pregnant women.
There is evidence that a high percentage of
pregnant women do not visit a dentist. For
example, the Cigna Corporation (2015) recently Oral Health Practice Behavior of
conducted a national survey of 801 pregnant Womens Health Care Providers
women, only half of whom had dental insurance. Many health professionals are aware of the
They found that although 76% of pregnant women importance of oral health, but often they do not
reported that they had a dental problem, only address it as part of their provision of precon-
57% reported a dental visit during pregnancy. ception, prenatal, or well woman care (Hashim &
Those with dental insurance were twice as likely Akbar, 2014; Morgan et al., 2009). Hashim and
to visit the dentist. Akbar found that 95.4% of gynecologists sur-
veyed had knowledge about the association be-
Le et al. (2009) and Marchi et al. (2010) studied tween oral health and pregnancy and that
why women did not access dental care during 85.2% recommended dental visits for their pa-
pregnancy. Le et al. conducted a telephone tients. However, they also found that many gy-
interview with 51 randomly selected pregnant necologists mistakenly believed that dental x-ray
women who participated in an Oregon oral health imaging (73%) and local dental anesthesia
pilot study. They reported that both personal (59.3%) were unsafe. Similarly, Morgan et al.
stressors (e.g., financial, employment, and do- found that 84% of obstetrician-gynecologists
mestic) and dental care issues (e.g., time, cost, were aware of the importance of oral health in
attitudes of dental providers, and comprehension pregnancy but that 54% did not ask about oral
of importance of oral health) were some of the health issues and 69% did not provide informa-
barriers that prevented pregnant women from tion on oral health. Furthermore, only 62% rec-
accessing dental care during pregnancy. Marchi ommended dental visits for their patients. In a
et al. (2010) used a population-based survey of summary of its survey of pregnant patients, Cigna
over 21,000 pregnant patients and found that the Corporation (2015) reported that only 44% of
primary reason the women did not access dental women surveyed say their doctor talked to them
care was because of lack of perceived need and about oral health during their pregnancy visits
that the second most common reason was (p. 2). Many dentists are unwilling to see preg-
financial barriers. In a study conducted by nant patients because of liability concerns, yet
Morgan, Crall, Goldenberg, and Schulkin (2009), they may face more liability from not treating
77% of obstetrician-gynecologists reported that pregnant patients than from treating them
their patients had been refused dental services (National Maternal and Child Oral Health Policy
because of pregnancy. Center, 2012). This suggests that dentists may
still lack knowledge about the oralsystemic
Unfortunately, dental care is not a mandated connection.
essential for adults in the Patient Protection and
Affordable Care Act (2010). Many women do
not have a dental benefit with their public or pri- Essential Oral Health Competencies
vate health plans. Although many states provide Women and their health care providers, including
a Medicaid dental benefit during pregnancy dentists, need more knowledge and clarification
(National Health Law Program, 2012), these about the safety of dental treatments during
benefits may end when the woman gives birth or pregnancy. Dental care during pregnancy is safe,
shortly thereafter, so timely oral assessment by and there are appropriate guidelines for the
health professionals and the facilitation of access treatment of pregnant patients (Oral Health Care
to appropriate dental care is a priority. Further- During Pregnancy Expert Workgroup, 2012).
more, access to dental care during pregnancy Dental visits can take place during any trimester
remains limited because only 32% of the 193,300 and, if urgent, should never be delayed (Silk,
U.S. dentists in 2011 reported that they accepted Douglass, Douglass, & Silk, 2008). The risk of
Medicaid (Medicaid-CHIP State Dental radiation exposure is extremely low when lead
Association, n.d.). These findings on access to aprons are used during dental x-ray imaging
care highlight the need to improve education in (Kurien et al., 2013). The most common medica-
oral health and access for U.S. women of child- tions and anesthetics prescribed by dentists are
bearing age. in U.S. Food and Drug Administration Category B,

JOGNN 2016; Vol. 45, Issue 4 567

PRINCIPLES & PRACTICE Oral Health in Pregnancy

and these drugs have not been found to be a risk

to the fetus (Oral Health Care During Pregnancy Table 1: Oral Health History From Smiles
Expert Workgroup, 2012; Silk, Douglass, & for Life Prenatal Oral Health Pocket Card
Douglass, 2012).
1. Do you brush twice a day and floss daily?
The perinatal period offers a teachable moment
for oral health care and can potentially have an 2. Do you have a dentist, dental insurance?
effect on maternal and infant health (American 3. Have you seen the dentist in the past 6 months for a
College of Obstetricians and Gynecologists regular check-up and cleaning?
Womens Health Care Physicians, Committee
4. Do you need any dental treatment completed?
on Health Care for Underserved Women,
2013; California Dental Association Foundation Note. Adapted from Prenatal Oral Health Pocket Card, by
& American College of Obstetricians and H. Silk, A. Douglass, & J. Douglass, 2012, Smiles for Life:
A National Oral Health Curriculum. Copyright 2012 by Smiles for
Gynecologists, District IX, 2010). The 2013 Life. Adapted with permission.
Committee Opinion from the American College
of Obstetricians and Gynecologists recom-
mends that all health care providers assess Although many health care providers may voice
oral health at the first prenatal visit (American concern over the amount of time involved, an oral
College of Obstetricians and Gynecologists examination typically takes 1 minute to perform.
Womens Health Care Physicians, Committee During the physical examination, the provider
on Health Care for Underserved Women, examines the lips, mucous membranes, teeth,
2013). Subsequent prenatal visits provide gums, and tongue. A plan of care, which includes
numerous opportunities to implement oral education for prevention of oral health problems,
health promotion interventions, including antic- maintenance of good oral health, and referral for
ipatory guidance and referrals for dental care. any oral health problems is integral to the provi-
Womens health care providers can incorporate sion of whole-person care. Prevention includes
oralsystemic health into all patient encounters information about oral hygiene, such as regular
from preconception counseling through prena- brushing twice a day and flossing daily. Women
tal and postpartum anticipatory guidance by who experience vomiting should be instructed to
transitioning the traditional HEENT (i.e., head, rinse afterward with a solution of baking soda to
eyes, ears, nose, and throat) examination to the prevent erosion of tooth enamel (Silk et al., 2008).
HEENOT (i.e., head, eyes, ears, nose, oral Mothers need to know that Streptococcus
cavity, and throat) examination (Haber et al., mutans, the bacteria associated with dental
2015). The four essential questions to include caries, can be transmitted to the child, infect the
in an oral history are presented in Table 1. childs teeth, and increase the risk for early
Hummel, Phillips, Holt, and Hayes (2015) childhood caries (Berkowitz, 2006; California
introduced the Oral Health Delivery Frame- Dental Association Foundation & American
work (see Figure 1) that guides the integration College of Obstetricians and Gynecologists,
of the HEENOT (Haber et al., 2015) approach District IX, 2010). In a population-based study,
into the history, physical examination, and Weintraub, Prakash, Shain, Laccabue, and
treatment plan. Gansky (2010) showed that the odds of children

Figure 1. Oral Health Delivery Framework. Reprinted from Oral Health: An Essential Component of Primary Care, by
J. Hummel, K. E. Phillips, B. Holt, & C. Hayes, 2015, Seattle, WA: Qualis Health. Copyright 2015 by Qualis Health. Reprinted
with permission.

568 JOGNN, 45, 565573; 2016.

Hartnett, E. et al. PRINCIPLES & PRACTICE

having untreated caries almost doubled when the

mother had untreated caries. To reduce the Clinicians who care for women during pregnancy should
transmission of bacteria from mother to child, it is incorporate oral health competencies into their education
important for womens health care providers and practice.
to educate mothers about good oral hygiene
practices and minimal saliva-sharing activities
(American Academy of Pediatric Dentistry, 2015, programs (90%) that responded indicated they
p. 51). Good maternal oral health practices have include oral health in the curriculum. In 2014,
the potential to influence the childs lifelong oral the PA arm of the National Interprofessional
health. Documentation of all oral health assess- Initiative on Oral Health surveyed 182 PA
ment findings and interventions is essential. The Directors of accredited programs in the United
development of a network of community dentists States. According to Langelier, Glicken, and
for collaboration and referral is invaluable to offer Surdu (2015), the survey showed that 98 of the
patients for oral health maintenance. 125 respondents (78.4%) indicated that their
programs had integrated oral health content
into their curriculum, which represented an in-
Preparing the Next Generation of crease from 2008 (p. 62).
Womens Health Care Providers
Womens health care providers may lack
adequate knowledge to distinguish between Strategies for Integrating Oral
normal changes in oral health during pregnancy Health
because they did not have this information in their In 2014, HRSA released Integration of Oral Health
curriculum. According to Ferullo, Silk, and and Primary Care Practice, which outlines
Savageau (2011), about 70% of MD degree interprofessional oral health core clinical compe-
granting (n 72) and DO degreegranting (n tencies appropriate for primary care providers,
13) schools surveyed had fewer than 5 hours of including but not limited to NPs, NMs, MDs,
oral health education. Authors of the most recent DOs, and PAs (U.S. Department of Health and
review indicate that PA and NM programs have Human Services, HRSA, 2014). Smiles for Life:
not required oral health content or competencies A National Oral Health Curriculum is an inter-
in their curricula (American College of Nurse- professional oral health curriculum designed to
Midwives, 2012; National Commission on Certifi- provide the same womens health care providers
cation of Physician Assistants, Accreditation with education in oral health promotion across the
Review Commission on Education for the Physi- lifespan (Clark et al., 2010). Three specific Smiles
cian Assistant, American Academy of Physician for Life courses, Relationship of Oral Health to
Assistants, & Physician Assistant Education Systemic Health, Oral Health and the Pregnant
Association, 2012). Patient, and The Oral Examination, are found
on the Web site (
The National Interprofessional Initiative on Oral and are recommended for qualified womens
Health has played a leadership role in raising health professionals to earn continuing education
awareness among NP, NM, and PA faculty credits. These and other essential resources that
members; oral health is beginning to be inte- contain important knowledge about oral health
grated into these curricula. The National and related interprofessional competencies for
Organization of Nurse Practitioner Faculties has womens health care providers and students can
recently included oral health in the latest Nurse be found in Table 2.
Practitioner Core Competencies With Suggested
Curriculum Content (2014). The New York Uni- Primary prevention requires more workforce ca-
versity College of Nursing Oral Health Nursing pacity than the dental community alone can pro-
Education and Practice (OHNEP) program, the vide. The development of an interprofessional
nursing arm of the National Interprofessional oral health primary care workforce capacity is
Initiative on Oral Health, has sponsored oral integral to increasing access to oral health care
health workshops at the American College of for pregnant women. Heightened awareness of
Nurse-Midwives Annual Meeting and Exhibition oralsystemic health must be included in
in 2013, 2014, and 2015. In 2016, the OHNEP womens health care provider education for
program administered a survey to all 39 Di- clinicians to translate the information into prac-
rectors of Midwifery Education in the United tice. The OHNEP program has developed an
States. The survey showed that 27 of the 30 Interprofessional Oral Health Faculty Toolkit

JOGNN 2016; Vol. 45, Issue 4 569



JOGNN, 45, 565573; 2016.

Table 2: Oral Health Resources

Organization Resource Web Site

American Academy of Pediatrics Bright Futures Oral Health Supervision
Guidelines (3rd ed.)
Bright Futures in Practice: Oral Health
Pocket Guide (2nd ed.)

American Academy of Pediatric Dentistry Pediatric Oral Health Policies and Clinical
Practice Guidelines

Association of American Medical Colleges Oral Health in Medicine Model Curriculum
Oral Health Management of Pregnant Patients

Association for Prevention Teaching Oral Health Across the Lifespan learning
and Research modules

California Dental Association Perinatal Oral Health Guidelines and Policy

Health Resources and Services Interprofessional oral health core clinical
Administration domains and competencies

National Maternal and Child Oral Oral health educational resources for patients
Health Resource Center and providers
Oral Health Care During Pregnancy: A
National Consensus Statement

Oral Health Nursing Education and Practice Oral health nursing education resources

Qualis Health Oral health delivery framework for primary

care providers

Oral Health in Pregnancy

Smiles for Life: A National Oral Oral health education for primary care
Health Curriculum providers

Teaching Oral Systemic Health Interprofessional oral health resources
Hartnett, E. et al. PRINCIPLES & PRACTICE

( This Toolkit uses be accomplished only through collaboration

the HEENOT approach that was previously among all health care professional educators and
described. It includes a wealth of oralsystemic providers to promote the incorporation of oral
health resources for health assessment, health health needs as a gold standard for educational
promotion, and clinical practice for faculty, stu- programs and clinical practice.
dents, and practicing clinicians to teach both the
theory and practice of the integration of oral
health into the history and physical examination.
The authors thank Donna Hallas, PhD, RN, PNP-
Examples of the Toolkits overall strategies
BC, CPNP, PMHS, FAANP; Jeanne Conroy, MD,
include (a) visual aids to supplement class dis-
PhD; Melinda Clark, MD; and Jill Fernandez,
cussions of normal versus abnormal oral findings,
MPH, for their contributions to this article.
(b) oralsystemic case studies, and (c) projects
to develop educational resources for pregnant
women, such as the development of a community
resource of dental providers willing to see preg- REFERENCES
American Academy of Pediatric Dentistry. (2015). Policy on early
nant women. It also provides specific strategies
childhood caries (ECC): Classifications, consequences, and
to teach future providers how to promote effective preventive strategies. Pediatric Dentistry, 37(6), 5052.
self-management of oral and overall health in their Retrieved from
patients through interprofessional collaborative p_eccclassifications.pdf
practice, health literacy, and community service. American Academy of Periodontology. (n.d.). Periodontal disease
The Toolkit provides a firm foundation for future fact sheet. Retrieved from
collaborative practice, highlighting that dental
American College of Nurse Midwives. (2012). ACNM core compe-
referrals for pregnant women are essential to safe
tencies for basic midwifery practice. Retrieved from http://www.
Womens health care providers, to provide quality American College of Obstetricians and Gynecologists Womens Health
and safe care, must engage their patients in an Care Physicians Committee on Health Care for Underserved

oral health discussion and offer consistent pre- Women. (2013). Committee opinion no. 569: Oral health care
during pregnancy and through the lifespan. Obstetrics and
vention messages.
Gynecology, 122(2 Pt. 1), 417422.
American Dental Association Council on Access, Prevention, and
Conclusion Interprofessional Relations. (2006). Womens oral health is-
There is sufficient evidence that the lack of oral sues [white paper]. Retrieved from
health care during pregnancy can have negative productcatalog/product.aspx?ID2313
outcomes for both mothers and their newborns. Azofeifa, A., Yeung, L. F., Alverson, C. J., & Beltran-Aguilar, E. (2014).
To improve the oralsystemic health outcomes for Oral health conditions and dental visits among pregnant and

mothers and their newborns, it is essential to in- nonpregnant women of childbearing age in the United States,
National Health and Nutrition Examination Survey, 19992004.
crease the current and future interprofessional
Preventing Chronic Disease, 11, E163.
oral health workforce capacity. Current womens 10.5888/pcd11.140212
health care providers and NP, NM, MD, DO, and Berkowitz, R. J. (2006). Mutans streptococci: Acquisition and trans-
PA students, as future womens health care pro- mission. Pediatric Dentistry, 28(2), 106109.
viders, can increase their knowledge of the oral California Dental Association Foundation American College of Obste-

health care needs of pregnant women through tricians and Gynecologists, District IX. (2010). Oral health
during pregnancy and early childhood: Evidence-based
the use of oral health educational resources.
guidelines for health professionals. Retrieved from http://www.
Essential resources include the OHNEP Inter-
professional Oral Health Faculty Toolkit and the Cigna Corporation. (2015). Healthy smiles for mom and baby:
Smiles for Life modules. These resources provide Insights into expecting and new mothers oral health habits.
a firm foundation for the integration of oral health Retrieved from
into clinical practices. By integrating the HRSA cigna-study-healthy-smiles-for-mom-and-baby-2015.pdf?WT.z_

Interprofessional Oral Health Core Clinical Com- navnewsroom%2Fdental-study%3BBody%3BDownload%

petencies, the HEENOT approach, and the Oral
Clark, M., Douglass, A., Maier, R., Deutchman, M., Douglass, J.,
Health Delivery Framework in clinical practice
Gonsalves, W., Quinonez, R. (2010). Smiles for life: A national
models, womens health care providers can use a oral health curriculum (3rd ed.). Washington, DC: Society of
best practice approach. Meeting the oral health Teachers of Family Medicine. Retrieved from http://www.
needs of pregnant women and their newborns will

JOGNN 2016; Vol. 45, Issue 4 571

PRINCIPLES & PRACTICE Oral Health in Pregnancy

Corbella, S., Taschieri, S., Del Fabbro, M., Francetti, L., Weinstein, R., populations. Washington, DC: The National Academies Press.
& Ferrazzi, E. (2016). Adverse pregnancy outcomes and peri-
odontitis: A systematic review and meta-analysis exploring Kurien, S., Kattimani, V. S., Sriram, R. R., Sriram, S. K., Prabhakara
potential association. Quintessence International, 47(3), 193 Rao, V. K., Bhupathi, A., Patil, N. (2013). Management of
204. pregnant patient in dentistry. Journal of International Oral
Ehlers, V., Callaway, A., Hortig, W., Kasaj, A., & Willershausen, B. Health, 5(1), 8897.
(2013). Clinical parameters and aMMP-8-concentrations in Langelier, M. H., Glicken, A. D., & Surdu, S. (2015). Adoption of oral
gingival crevicular fluid in pregnancy gingivitis. Clinical Labo- health curriculum by physician assistant education programs in
ratory, 59(56), 605611. 2014. The Journal of Physician Assistant Education, 26(2), 60
2012.120619 69.
Eke, P. I., Dye, B. A., Wei, L., Thornton-Evans, G. O., & Genco, R. J. Le, M., Riedy, C., Weinstein, P., & Milgrom, P. (2009). An intergener-
(2012). Prevalence of periodontitis in adults in the United ational approach to oral health promotion: Pregnancy and uti-
States: 2009 and 2010. Journal of Dental Research, 91(10), lization of dental services. Journal of Dentistry for Children,
914920. 76(1), 4652.
Ferullo, A., Silk, H., & Savageau, J. A. (2011). Teaching oral health in U. Marchi, K. S., Fisher-Owen, S. A., Weintraub, J. A., Yu, Z., & Brave-
S. medical schools: Results of a national survey. Journal of the man, P. A. (2010). Most pregnant women in California do not
Association of American Medical Colleges, 86(2), 226230. receive dental care: Findings from a population-based study. Public Health Reports, 125(6), 831842.
Figuero, E., Carrillo-de-Albornoz, A., Martn, C., Tobas, A., & Herrera, 10.2307/41434849
D. (2013). Effect of pregnancy on gingival inflammation in Medicaid-CHIP State Dental Association. (n.d.). National profile of
systemically healthy women: A systematic review. Journal of state Medicaid and CHIP oral health programs. Retrieved from
Clinical Periodontology, 40(5), 457473.
10.1111/jcpe.12053 Morgan, M. A., Crall, J., Goldenberg, R. L., & Schulkin, J. (2009). Oral
Gogeneni, H., Buduneli, N., Ceyhan-Ozturk, B., Gumus, P., Akcali, A., health during pregnancy. The Journal of Maternal-Fetal &
Zeller, I., Ozcaka, O. (2015). Increased infection with key Neonatal Medicine, 22(9), 733739.
periodontal pathogens during gestational diabetes mellitus. 14767050902926954
Journal of Clinical Periodontology, 42(6), 506512. http://dx.doi. National Commission on Certification of Physician, Assistants Accred-
org/10.1111/jcpe.12418 itation Review Commission on Education for the Physician As-
Guimaraes, A. N., Silva-Mato, A., Siqueira, F. M., Cyrino, R. M., Cota, sistant American Academy of Physician Assistants Physician
L. O. M., & Costa, F. O. (2012). Very low and low birth weight Assistant Education Association. (2012). Competencies for the
associated with maternal periodontitis. Journal of Clinical physician assistant profession. Retrieved from American Acad-
Periodontology, 39(11), 10241031. emy of Physician Assistants Web site:
jcpe.12000 WorkArea/DownloadAsset.aspx?id2178
Ha, J. E., Jun, J. K., Ko, H. J., Paik, D. I., & Bae, K. H. (2014). National Health Law Program. (2012). Dental coverage for low-income
Association between periodontitis and preeclampsia in never- pregnant women. Retrieved from
smokers: A prospective study. Journal of Clinical Periodontol- publications/dental-coverage-for-low-income-pregnant-women#.
ogy, 41(9), 869874. VjjiuLerTct
Haber, J., Hartnett, E., Allen, K., Hallas, D., Dorsen, C., Lange-Kessler, J., National Maternal and Child Oral Health Policy Center. (2012).
Wholihan, D. (2015). Putting the mouth back in the head: Improving the oral health of pregnant women and young chil-
HEENT to HEENOT. American Journal of Public Health, 105(3), dren: Opportunities for policymakers. Retrieved from http://
Hashim, R., & Akbar, M. (2014). Gynecologists knowledge and atti- National Organization of Nurse Practitioner Faculties. (2014). Nurse
tudes regarding oral health and PD leading to adverse preg- practitioner core competencies with suggested curriculum
nancy outcomes. Journal of International Society of Preventive content. Retrieved from
& Community Dentistry, 4(Suppl. 3), S166S172. http://dx.doi.
org/10.4103/2231-0762.149028 FinalNov20.pdf
Hummel, J., Phillips, K. E., Holt, B., & Hayes, C. (2015). Oral health: An Oral Health Care During Pregnancy Expert Workgroup. (2012). Oral
essential component of primary care [white paper]. Seattle, WA: health care during pregnancy: A national consensus statement
Qualis Health. Retrieved from http://www.safetynetmedicalhome. Summary of an expert workgroup meeting. Retrieved from http://
Hwang, S. S., Smith, V. C., McCormick, M. C., & Barfield, W. D. (2011). Patient Protection and Affordable Care Act 42 U.S.C. x 18001. (2010).
Racial/ethnic disparities in maternal oral health experiences in Retrieved from
10 states, pregnancy risk assessment monitoring system, 2004- %20Protection%20And%20Affordable%20Care%20Act.pdf
2006. Maternal and Child Health Journal, 15(6), 722729. http:// Petersen, P. E. (2008). World Health Organization global policy for improvement of oral healthWorld Health Assembly 2007. In-
Institute of Medicine. (2011). Advancing oral health in America. ternational Dental Journal, 58(3), 115121.
Washington, DC: The National Academies Press. http://dx.doi. 10.1111/j.1875-595X.2008.tb00185.x
org/10.17226/13086 Silk, H., Douglass, A., & Douglass, J. (2012). Prenatal oral
Institute of Medicine. (2013). Oral health literacy: Workshop summary. health pocket card. Retrieved from http://www.smiles
Washington, DC: The National Academies Press. Retrieved
from pagekey62948&userkey12230708&sessionkey2743160&
Health-Literacy.aspx tut555&customerkey84&custsitegroupkey0
Institute of Medicine & National Research Council. (2011). Improving Silk, H., Douglass, A., Douglass, J., & Silk, L. (2008). Oral health during
access to oral health care for vulnerable and underserved pregnancy. American Family Physician, 77(8), 11391144.

572 JOGNN, 45, 565573; 2016.

Hartnett, E. et al. PRINCIPLES & PRACTICE

U.S. Department of Health and Human Services. (2000). Oral health in Wrzosek, T., & Einarson, A. (2009). Dental care during pregnancy.
America: A report of the Surgeon General. Retrieved from http:// Canadian Family Physician, 55(6), 598599. Wu, M., Chen, S.-W., & Jiang, S.-Y. (2015). Relationship between
U.S. Department of Health and Human Services, Health Resources gingival inflammation and pregnancy. Mediators of
and Services Administration. (2014). Integration of oral health Inflammation, 2015, 623427.
and primary care practice. Retrieved from 623427
publichealth/clinical/oralhealth/primarycare/ Xiong, X., Elkind-Hirsch, K. E., Vastardis, S., Delarosa, R. L., Pridjian,
Weintraub, J. A., Prakash, P., Shain, S. G., Laccabue, M., & Gansky, S. G., & Buekens, P. (2009). Periodontal disease is associated with
A. (2010). Mothers caries increases odds of childrens caries. gestational diabetes mellitus: A case-control study. Journal of
Journal of Dental Research, 89(9), 954958. Periodontology, 80(11), 17421749.
10.1177/0022034510372891 jop.2009.090250

JOGNN 2016; Vol. 45, Issue 4 573