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Women normally experience physiological, psychological and lifestyle changes during pregnancy and some of those changes can affect their dental health.1 The oral health of pregnant women has been receiving attention, both internationally and in New Zealand,2 with growing evidence that poor oral health can have detrimental effects, not only for the women (for example, increasing risk of pre-eclampsia)3 but also for the health of the fetus/baby.4-6Periodontal disease combines a number of diseases of the periodontal tissue that can be broadly divided into gingivitis and periodontitis. Gingivitis is an inflammation of the soft tissue surrounding a tooth, which commonly manifests as bleeding gums. Periodontitis is characterised by inflammation of the supporting structures of teeth resulting in attachment and bone loss.7 Periodontal disease is relatively common among pregnant women due to hormonal and vascular changes which occur during pregnancy leading to the promotion of an accentuated response to plaque.4There has been extensive discussion about the potential of periodontal disease to affect pregnancy outcomes. Some studies suggest that periodontitis is a risk factor for preterm and low birth weight infants, even after adjusting for other risk factors such as smoking, previous adverse pregnancies, race, age or socioeconomic status (SES).4-6 However, a recent study on the effect of maternal periodontal disease treatment on reducing the incidence of preterm birth failed to confirm this connection.8Studies show that preventive measures, including adequate diet and plaque control, for expectant mothers, can have a positive impact on both the woman's oral health and that of their child.9-11 In addition, because mothers are normally responsible for the introduction of dietary and hygiene habits to the infant, pregnancy is an ideal time in which to promote and reinforce healthy messages which will have long-term benefits for the woman as well as their family.12There is some international evidence of inequalities in oral health status and access to dental care for pregnant women of different ethnic and socio-economic groups.13-16 In New Zealand, two national oral health surveys conducted in 1976 and 1988 showed a decrease in dental caries generally over this period, but this was not consistent across all population groups.17,18Marked differences were reported in the levels of oral health of Māori compared to non-Māori, and also differences by SES with regard to access to oral health care services, according to the latest New Zealand Health survey conducted in 2006/2007.19 None of these surveys presented data on pregnant women.A recent qualitative study of Māori women, found that current oral health services are not meeting Māori needs and participants reported a number of dental problems during their pregnancies.20Improving oral health and decreasing disparities in health are goals of the New Zealand government. The Ministry of Health has highlighted pregnant women as a priority group.21Currently, there is a lack of information in New Zealand about the oral health care of pregnant women. The aims of this study were to gain an understanding of women's oral health care practices, access to oral health information and use of dental care services both prior to and during pregnancy, and to investigate if these differed between sociodemographic groups.Methods Participants—Eligible participants were pregnant women, over 16 years of age, attending antenatal classes during a 6-month period (June-November 2008) in the Wellington region. There are approximately 3,500 babies born per year in the region and about 78% of first time mothers attend antenatal classes.22 Antenatal classes may be either government-funded programmes which are offered to women at no charge, or be taught by a range of private antenatal education providers at a cost of anything up to NZ$150 for a course of classes. Participants in the study were drawn from a range of available classes, both private and government funded. The private classes were run by Parents Centre, Wellington High School Adult Community Education Centre, Newlands and Onslow College Adult Community Education Centre and Tawa College Community Education. The government funded classes were the breastfeeding classes at Wellington Hospital Women's Health Service and the Wellington Maternity Project (MATPRO). The composition of the classes provided by MATPRO in 2003 were 20.5% Māori, 17.5% Pacific, 8% Asian, 7% other/not stated, and 47% of European New Zealand ethnicity.23 The women attending antenatal classes are typically in the last trimester of their pregnancy. Data collection—The researcher arranged with the childbirth educator from each of the classes to attend one antenatal session in order to explain the study and leave women with an information sheet, questionnaires and self-addressed envelope for posting back the questionnaires which were self-completed by the women at home. Completed questionnaires could also be left at a ‘drop box' at the antenatal class venue if the woman preferred. Demographic information collected included, ethnic group, education level, and household income, based on definitions taken from the New Zealand Census 2001.24 Ethnicity was subsequently categorised as New Zealand European (which included New Zealand European and other European groups), and ‘Others' group which, due to small numbers, included Māori and Pacific Islanders as well as Chinese and Indian ethnic groups. Education was grouped as ‘high school' level, ‘tertiary', which includes any tertiary education program such as a certificate, diploma or incomplete degree and 'post-graduate'. Information on household income per year was collected in the follow categories: $1-5,000/$5,001-10,000/$10,001-15,000/$15,001-20,000/$20,001-$25,001/25,001-30,000/$30,001-40,000/$40,001-50,000/$50,001-70,000/$70,001-100,000 and $100,001+. For the analyses, due to the majority of participants being in the highest income group, the income bands were reclassified into the following three groups: less than $70,000 (low income), $70,000 to 100,000 (medium income) and more than $100,000 (high income). The participants were asked their date of birth with the age bands created being based on the data: 16-25 years, 26-30 years, 31-35 years and 36+ years age group. Questions relating to oral care practices, including use of floss and mouth care products, frequency of brushing and visits to a dentist (both prior to and during pregnancy), and the presence of dental problems during pregnancy were included, based on questions that had previously been validated in other international studies.13-16,25-28 Additional information was sought on changes to eating habits during pregnancy. Questions on sources/content of dental health information were developed specifically for use in the current study. Women were asked if they had received any information on dental health during their pregnancy, what the information was about (care of gums and teeth, dietary advice, use of fluorides, oral diseases and early childhood oral health) and who provided the information, such as a dentist, dental healthcare worker, Lead Maternity Carer (LMC) (a health professional who may be a midwife, general practitioner (GP) or obstetrician and is responsible for providing or organising a woman's maternity care including throughout the pregnancy, birth and the post-natal period), or other sources (media/internet/books). The questionnaire was piloted and refined prior to the final version used for the survey. Ethical approval for this study was obtained from the Massey University Human Ethics Committee. Analyses—All data was entered on Microsoft Access and analysed using STATA software package. Descriptive analysis, such as chi-squared tests and t-tests were used to investigate differences in knowledge/behaviour between the sociodemographic groups. Multivariable logistic regression was used to compare the prevalence of various risk factors between these groups, controlling for potential confounding variables, i.e. one or more of ethnicity, income, age and SES. To investigate the effect of confounding, the models were built adding in one variable at a time. Results Description of the sample—A total of 730 questionnaires were handed out to pregnant women at 69 antenatal classes and 405 questionnaires were completed, a response rate of 55.4%. New Zealand European made up 79.2% of the study population with the remaining 19.7% ‘Others' ethnic group comprising 8.8% Māori, 1.9% Pacific and 8.6% Indian/ Chinese/other. Over half of the participants had a tertiary education (57.7%), and most of the sample studied had a high income (with NZ$100,001 or more annual income). The majority of women in the study were over 30 years of age (Table 1). Dental visiting—About half of the women reported seeing their dentist at least once a year prior to pregnancy (Table 2). This was more common among New Zealand European, women with a higher education and income; and older women. A total of 23.2% of the women saw the dentist just when they had problems and this was more common among ‘Others', lower education and income; and younger women. However, just 32.3% of women reported seeing a dentist during their current pregnancy. Women with higher income/education level, those who were older; and New Zealand European were all more likely to have visited a dentist during their pregnancy. Table 1. Demographics of the 405 pregnant women who completed the survey Variables N (%) Age 16-25 26-30 31-35 36+ 46 (11.3) 111 (27.4) 140 (34.4) 108 (26.6) Ethnicity New Zealand European Māori Pacific Others Not stated 321 (79.2) 36 (8.8) 8 (1.9) 3.5 (8.6) 5 (1.2) Education High school Tertiary Postgraduate Not stated 47 (11.6) 234 (57.7) 118 (29.1) 6 (1.4) Household income ($NZ/year) <70,000 70,001-100,000 100,001-or more Not stated 52 (12.8) 94 (23.2) 214 (52.8) 45 (11.1) Table 2. Dental visits pre and during pregnancy Variables Normally see a dentist once/year N (%) Normally see a dentist symptoms related N (%) Have seen a dentist during pregnancy N (%) Ethnicity NZ European Others 168 (52.2) 33 (41.7) 72 (22.4) 22 (27.8) 108 (33.6) 18 (22.7) Education Postgraduate Tertiary High School 67 (56.7) 112 (47.8) 22 (46.7) 21 (17.8) 57 (24.3) 16 (34) 39 (33) 72 (30.7) 15 (31.9) Income ($NZ/year) 100,000 or more 70-100,000 Less than 70,000 121 (56.5) 44 (46.7) 16 (30.7) 39 (18.2) 26 (27.6) 21 (40.3) 18 (40) 31 (32.9) 11 (21.1) Age (years) 16-25 26-30 31-35 36 + All combined 15 (32.5) 59 (53.1) 70 (50) 62 (57.3) 206 (50.8) 21 (45.6) 32 (28.8) 23 (16.4) 18 (16.6) 94 (23.2) 12 (26) 33 (29.7) 39 (27.8) 47 (43.5) 131 (32.3) Women were asked why they did not see a dentist (information not shown in table). The main reasons given were being unaware that they needed to see a dentist (37%), cost (18.7%) and believing it was not recommended to see a dentist when pregnant (14.5%). Nearly 5% of women expressed fear of dentists as being the primary reason for not seeing a dentist during pregnancy. Not seeing a dentist for economic reasons was more common among ‘Other' women (27.8%), compared to New Zealand European women (16.5%); women with lower education (29.7%) compared to those with a higher education level (11.8%); those of lower income (42.3%) compared to a higher income level (11.2%); and younger (45.6%) compared to older (12%) women. Oral health care—Table 3 presents information on the oral health care practices of women in the study. In general, women presented with good oral hygiene habits, with most brushing their teeth twice or more a day and approximately 20% flossing daily. Forty-two percent of women reported increased sugar consumption during their pregnancy, which was more common among New Zealand European, young, medium income women; and those with up to high school education. Bleeding gums was the main problem reported during pregnancy (60%) by all women, followed by sensitive teeth (15%), toothaches (5.4%) and cavities (5.1%). There was no difference between sociodemographic groups for these outcomes. Table 3. Oral health care practices and changes during pregnancy Variables Brush twice or more/day N (%) Floss once/day N (%) Use mouth rinse N (%) Eating more sugar N (%) Bleeding gums N (%) Ethnicity NZ European Others 264 (82.5) 64 (82) 48 (15) 17 (21.7) 95 (29.6) 21 (26.5) 139 (43.3) 33 (41.4) 197 (61.3) 48 (60.7) Education Postgraduate Tertiary High school 102 (86.4) 192 (82.7) 33 (70.2) 22 (18.6) 36 (15.5) 7 (14.8) 31 (26.2) 70 (29.9) 15 (31.9) 51 (43.2) 97 (41.1) 24 (51) 78 (66.1) 139 (59.4) 27 (57.4) Income ($NZ/year) 100,000 or more 70-100,000 Less than 70,000

Summary

Abstract

Aim

The aims of this study were to gain an understanding of pregnant womens oral health care practices, access to information, and dental care usage in New Zealand, and to investigate whether these differed between sociodemographic groups.

Method

One researcher visited 69 antenatal classes in the Wellington region to explain the study. Women self-completed the questionnaire and returned it by post.

Results

A total of 405 women (55% response rate) took part. 79.2% of participants identified as New Zealand European and most were of high income and education levels, 32% visited the dentist during pregnancy and more than 60% reported bleeding gums. Women with a household income under NZ$70,000 per year were significantly less likely to report access to oral health information (OR 0.27, 95%CI 0.10-0.76) and more likely to report the need to see a dentist (OR 2.55, 95%CI 1.08-5.99) compared to women with an income over NZ$100,000 per year.

Conclusion

Visits to the dentist and access to oral health information were more common among New Zealand European women with higher education achievements and higher socioeconomic backgrounds with only a third of women went seeing a dentist during pregnancy. Improving the oral health of pregnant women will have follow-on benefits of improved oral health outcomes for their children.

Author Information

Bianca M Claas, Research Fellow, Centre for Public Health Research, Massey University, Wellington, NZ; Lis Ellison-Loschmann, HRC Postdoctoral Research Fellow, Centre for Public Health Research, Massey University, Wellington, NZ; Mona Jeffreys, Senior Lecturer in Epidemiology, Department of Social Medicine, University of Bristol, Bristol, UK

Acknowledgements

The researchers thank the women who participate in this study and the childbirth educators for the facilitation of the data collection. Bianca Muriel Claas was funded by the Massey University Masterate Scholarship and the Centre for Public Health Research receives funding from the Health Research Council of New Zealand.

Correspondence

Bianca Muriel Claas, Centre for Public Health Research, Massey University, Wellington, NZ. PO Box 756, Wellington, New Zealand. Fax +64 (0)4 3800600

Correspondence Email

b.m.claas@massey.ac.nz

Competing Interests

None.

Laine M. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60(5):257-264.Murdoch Children's Research Institute. Maternal and child oral health systematic review and analysis. A report for the Ministry of Health. Wellington (NZ): Ministry of Health, 2008.Vergnes J. Studies suggest an association between maternal periodontal disease and pre-eclampsia. Evidence Based Dentistry 2008;9(1):46-47.Offenbacher S, Boggess K, Murtha A, et al. Progressive periodontal disease and risk of very preterm delivery. Obstetrics and Gynecology 2006;107(1):29-36.Jeffcoat MK, Geurs NC, Reddy MS, et al. Periodontal infection and preterm birth. Journal American Dental Association - JADA 2001;132(July):875-880.Lopez N, Smith PC, Gutierrez. Higher risk of preterm birth and low birth weight in women with periodontal disease. Journal Dent Res 2002;81(1):58-63.Highfield J. Diagnosis and classification of periodontal disease. Australian Dental Journal 2009;54(1):11-26.Offenbacher S, Beck DJ, Jared H, et al. Effects of Periodontal Therapy on Rate of Preterm Delivery, A Randomized Controlled Trial. Obstetrics and Gynecology 2009;114(3):551-559.Gunay H, Dmoch-Bockhorn, Gunay Y, Geurtsen W. Effect on caries experience of a long-term preventive program for mothers and children starting during pregnancy. Clin Oral Invest 1998;2:137-142.Brambilla E, Felloni A, Gagliani M, et al. Caries prevention during pregnancy: results of a 30-month study. Journal American Dental Association - JADA 1998;129:871-877.Zanata R, Navarro M, Pereira J, et al. Effect of caries preventive measures directed to expectant mothers on caries experience in their children. Brazil Dent Journal 2003;14(2):75-81.Ministry of Health. Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding women. Wellington: Ministry of Health, 2006a.Habashneh R, Guthmiller J, Levy S, et al. Factors related to utilization of dental services during pregnancy. Journal of Clinical Periodontology 2005;32:815-821.Honkala S, Al-Ansari. Self-reported oral health, oral hygiene habits, and dental attendance of pregnant women in Kuwait. Journal of Clinical Periodontology 2005;32:809-814.Hullah E, Turok Y, Nauta M, Yoong W. Self-reported oral hygiene habits, dental attendance and attitudes to dentistry during pregnancy in a sample of immigrant women in North London. Arch Gynecol Obstet 2007.Thomas N, Middleton P, Crowther C. Oral and dental health care practices in pregnant women in Australia: a postnatal survey. Biomed Central Pregnancy and Childbirth 2008;8(13):1-6.Cutress T, Hunter P, Davis P, et al. Adult Oral Health and Attitudes to Dentistry in New Zealand 1976. In: Unit. DR, ed. Wellington: Medical Research Council of New Zealand, 1979.Hunter P, Kirk R, Liefde B. The study of Oral Health Outcomes. The 1988 New Zealand section of the WHO second international collaborative study. Wellington: Health Research Services, 1992.Ministry of Health. A Portrait of Health - Key results of the 2006/2007 New Zealand Health Survey. Wellington: Ministry of Health, 2008.Makowharemahihi C. A community-based health needs assessment of the oral health needs of Maori mothers in Porirua. University of Otago, 2006.Ministry of Health. Good oral health for all, for life. The strategic vision for oral health in New Zealand. Wellington: Ministry of Health, 2006b.Ministry of Health. Report on maternity, Maternal and Newborn Information. Wellington: Ministry of Health, 2004.Capital and Coast, District Health Board. Maternity Services in Capital and Coast District Health Board - Working towards a Maternity Strategy. Wellington, 2004.Statistics New Zealand. 2001 Census of Populations and Dwellings; National Summary. Wellington (NZ): Statistics NZ, 2002.Gaffield M, Gilbert B, Malvitz D, Romaguera R. Oral Health during pregnancy, an analysis of information collected by the pregnancy risk assessment monitoring system. Journal American Dental Association - JADA 2001;132(7):1009-1016.Ressler-Maerlender J, Krishna R, Robosin V. Oral health during pregnancy: current research. Journal of women's health 2005;14(10):880-882.Stevens J, Lida H, Ingersoll G. Implementing and oral health program in a group prenatal practice. JOGNN 2007;36(6):581-591.Christensen L, Jeppe-Jensen D, Petersen P. Self-reported gingival conditions and self-care in the oral health of Danish women during pregnancy. Journal of Clinical Periodontology 2003;30:949-953.Thomson W. Use of dental services by 26-years-old New Zealanders. New Zealand Dental Journal 2001;97:44-48.Lydon-Rochelle M, Krakowiak P, Hujoel P, Peters R. Dental care use and self-reported dental problems in relation to pregnancy. American Journal of Public Health 2004;94(5):765-771.Nutbeam D. 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Women normally experience physiological, psychological and lifestyle changes during pregnancy and some of those changes can affect their dental health.1 The oral health of pregnant women has been receiving attention, both internationally and in New Zealand,2 with growing evidence that poor oral health can have detrimental effects, not only for the women (for example, increasing risk of pre-eclampsia)3 but also for the health of the fetus/baby.4-6Periodontal disease combines a number of diseases of the periodontal tissue that can be broadly divided into gingivitis and periodontitis. Gingivitis is an inflammation of the soft tissue surrounding a tooth, which commonly manifests as bleeding gums. Periodontitis is characterised by inflammation of the supporting structures of teeth resulting in attachment and bone loss.7 Periodontal disease is relatively common among pregnant women due to hormonal and vascular changes which occur during pregnancy leading to the promotion of an accentuated response to plaque.4There has been extensive discussion about the potential of periodontal disease to affect pregnancy outcomes. Some studies suggest that periodontitis is a risk factor for preterm and low birth weight infants, even after adjusting for other risk factors such as smoking, previous adverse pregnancies, race, age or socioeconomic status (SES).4-6 However, a recent study on the effect of maternal periodontal disease treatment on reducing the incidence of preterm birth failed to confirm this connection.8Studies show that preventive measures, including adequate diet and plaque control, for expectant mothers, can have a positive impact on both the woman's oral health and that of their child.9-11 In addition, because mothers are normally responsible for the introduction of dietary and hygiene habits to the infant, pregnancy is an ideal time in which to promote and reinforce healthy messages which will have long-term benefits for the woman as well as their family.12There is some international evidence of inequalities in oral health status and access to dental care for pregnant women of different ethnic and socio-economic groups.13-16 In New Zealand, two national oral health surveys conducted in 1976 and 1988 showed a decrease in dental caries generally over this period, but this was not consistent across all population groups.17,18Marked differences were reported in the levels of oral health of Māori compared to non-Māori, and also differences by SES with regard to access to oral health care services, according to the latest New Zealand Health survey conducted in 2006/2007.19 None of these surveys presented data on pregnant women.A recent qualitative study of Māori women, found that current oral health services are not meeting Māori needs and participants reported a number of dental problems during their pregnancies.20Improving oral health and decreasing disparities in health are goals of the New Zealand government. The Ministry of Health has highlighted pregnant women as a priority group.21Currently, there is a lack of information in New Zealand about the oral health care of pregnant women. The aims of this study were to gain an understanding of women's oral health care practices, access to oral health information and use of dental care services both prior to and during pregnancy, and to investigate if these differed between sociodemographic groups.Methods Participants—Eligible participants were pregnant women, over 16 years of age, attending antenatal classes during a 6-month period (June-November 2008) in the Wellington region. There are approximately 3,500 babies born per year in the region and about 78% of first time mothers attend antenatal classes.22 Antenatal classes may be either government-funded programmes which are offered to women at no charge, or be taught by a range of private antenatal education providers at a cost of anything up to NZ$150 for a course of classes. Participants in the study were drawn from a range of available classes, both private and government funded. The private classes were run by Parents Centre, Wellington High School Adult Community Education Centre, Newlands and Onslow College Adult Community Education Centre and Tawa College Community Education. The government funded classes were the breastfeeding classes at Wellington Hospital Women's Health Service and the Wellington Maternity Project (MATPRO). The composition of the classes provided by MATPRO in 2003 were 20.5% Māori, 17.5% Pacific, 8% Asian, 7% other/not stated, and 47% of European New Zealand ethnicity.23 The women attending antenatal classes are typically in the last trimester of their pregnancy. Data collection—The researcher arranged with the childbirth educator from each of the classes to attend one antenatal session in order to explain the study and leave women with an information sheet, questionnaires and self-addressed envelope for posting back the questionnaires which were self-completed by the women at home. Completed questionnaires could also be left at a ‘drop box' at the antenatal class venue if the woman preferred. Demographic information collected included, ethnic group, education level, and household income, based on definitions taken from the New Zealand Census 2001.24 Ethnicity was subsequently categorised as New Zealand European (which included New Zealand European and other European groups), and ‘Others' group which, due to small numbers, included Māori and Pacific Islanders as well as Chinese and Indian ethnic groups. Education was grouped as ‘high school' level, ‘tertiary', which includes any tertiary education program such as a certificate, diploma or incomplete degree and 'post-graduate'. Information on household income per year was collected in the follow categories: $1-5,000/$5,001-10,000/$10,001-15,000/$15,001-20,000/$20,001-$25,001/25,001-30,000/$30,001-40,000/$40,001-50,000/$50,001-70,000/$70,001-100,000 and $100,001+. For the analyses, due to the majority of participants being in the highest income group, the income bands were reclassified into the following three groups: less than $70,000 (low income), $70,000 to 100,000 (medium income) and more than $100,000 (high income). The participants were asked their date of birth with the age bands created being based on the data: 16-25 years, 26-30 years, 31-35 years and 36+ years age group. Questions relating to oral care practices, including use of floss and mouth care products, frequency of brushing and visits to a dentist (both prior to and during pregnancy), and the presence of dental problems during pregnancy were included, based on questions that had previously been validated in other international studies.13-16,25-28 Additional information was sought on changes to eating habits during pregnancy. Questions on sources/content of dental health information were developed specifically for use in the current study. Women were asked if they had received any information on dental health during their pregnancy, what the information was about (care of gums and teeth, dietary advice, use of fluorides, oral diseases and early childhood oral health) and who provided the information, such as a dentist, dental healthcare worker, Lead Maternity Carer (LMC) (a health professional who may be a midwife, general practitioner (GP) or obstetrician and is responsible for providing or organising a woman's maternity care including throughout the pregnancy, birth and the post-natal period), or other sources (media/internet/books). The questionnaire was piloted and refined prior to the final version used for the survey. Ethical approval for this study was obtained from the Massey University Human Ethics Committee. Analyses—All data was entered on Microsoft Access and analysed using STATA software package. Descriptive analysis, such as chi-squared tests and t-tests were used to investigate differences in knowledge/behaviour between the sociodemographic groups. Multivariable logistic regression was used to compare the prevalence of various risk factors between these groups, controlling for potential confounding variables, i.e. one or more of ethnicity, income, age and SES. To investigate the effect of confounding, the models were built adding in one variable at a time. Results Description of the sample—A total of 730 questionnaires were handed out to pregnant women at 69 antenatal classes and 405 questionnaires were completed, a response rate of 55.4%. New Zealand European made up 79.2% of the study population with the remaining 19.7% ‘Others' ethnic group comprising 8.8% Māori, 1.9% Pacific and 8.6% Indian/ Chinese/other. Over half of the participants had a tertiary education (57.7%), and most of the sample studied had a high income (with NZ$100,001 or more annual income). The majority of women in the study were over 30 years of age (Table 1). Dental visiting—About half of the women reported seeing their dentist at least once a year prior to pregnancy (Table 2). This was more common among New Zealand European, women with a higher education and income; and older women. A total of 23.2% of the women saw the dentist just when they had problems and this was more common among ‘Others', lower education and income; and younger women. However, just 32.3% of women reported seeing a dentist during their current pregnancy. Women with higher income/education level, those who were older; and New Zealand European were all more likely to have visited a dentist during their pregnancy. Table 1. Demographics of the 405 pregnant women who completed the survey Variables N (%) Age 16-25 26-30 31-35 36+ 46 (11.3) 111 (27.4) 140 (34.4) 108 (26.6) Ethnicity New Zealand European Māori Pacific Others Not stated 321 (79.2) 36 (8.8) 8 (1.9) 3.5 (8.6) 5 (1.2) Education High school Tertiary Postgraduate Not stated 47 (11.6) 234 (57.7) 118 (29.1) 6 (1.4) Household income ($NZ/year) <70,000 70,001-100,000 100,001-or more Not stated 52 (12.8) 94 (23.2) 214 (52.8) 45 (11.1) Table 2. Dental visits pre and during pregnancy Variables Normally see a dentist once/year N (%) Normally see a dentist symptoms related N (%) Have seen a dentist during pregnancy N (%) Ethnicity NZ European Others 168 (52.2) 33 (41.7) 72 (22.4) 22 (27.8) 108 (33.6) 18 (22.7) Education Postgraduate Tertiary High School 67 (56.7) 112 (47.8) 22 (46.7) 21 (17.8) 57 (24.3) 16 (34) 39 (33) 72 (30.7) 15 (31.9) Income ($NZ/year) 100,000 or more 70-100,000 Less than 70,000 121 (56.5) 44 (46.7) 16 (30.7) 39 (18.2) 26 (27.6) 21 (40.3) 18 (40) 31 (32.9) 11 (21.1) Age (years) 16-25 26-30 31-35 36 + All combined 15 (32.5) 59 (53.1) 70 (50) 62 (57.3) 206 (50.8) 21 (45.6) 32 (28.8) 23 (16.4) 18 (16.6) 94 (23.2) 12 (26) 33 (29.7) 39 (27.8) 47 (43.5) 131 (32.3) Women were asked why they did not see a dentist (information not shown in table). The main reasons given were being unaware that they needed to see a dentist (37%), cost (18.7%) and believing it was not recommended to see a dentist when pregnant (14.5%). Nearly 5% of women expressed fear of dentists as being the primary reason for not seeing a dentist during pregnancy. Not seeing a dentist for economic reasons was more common among ‘Other' women (27.8%), compared to New Zealand European women (16.5%); women with lower education (29.7%) compared to those with a higher education level (11.8%); those of lower income (42.3%) compared to a higher income level (11.2%); and younger (45.6%) compared to older (12%) women. Oral health care—Table 3 presents information on the oral health care practices of women in the study. In general, women presented with good oral hygiene habits, with most brushing their teeth twice or more a day and approximately 20% flossing daily. Forty-two percent of women reported increased sugar consumption during their pregnancy, which was more common among New Zealand European, young, medium income women; and those with up to high school education. Bleeding gums was the main problem reported during pregnancy (60%) by all women, followed by sensitive teeth (15%), toothaches (5.4%) and cavities (5.1%). There was no difference between sociodemographic groups for these outcomes. Table 3. Oral health care practices and changes during pregnancy Variables Brush twice or more/day N (%) Floss once/day N (%) Use mouth rinse N (%) Eating more sugar N (%) Bleeding gums N (%) Ethnicity NZ European Others 264 (82.5) 64 (82) 48 (15) 17 (21.7) 95 (29.6) 21 (26.5) 139 (43.3) 33 (41.4) 197 (61.3) 48 (60.7) Education Postgraduate Tertiary High school 102 (86.4) 192 (82.7) 33 (70.2) 22 (18.6) 36 (15.5) 7 (14.8) 31 (26.2) 70 (29.9) 15 (31.9) 51 (43.2) 97 (41.1) 24 (51) 78 (66.1) 139 (59.4) 27 (57.4) Income ($NZ/year) 100,000 or more 70-100,000 Less than 70,000

Summary

Abstract

Aim

The aims of this study were to gain an understanding of pregnant womens oral health care practices, access to information, and dental care usage in New Zealand, and to investigate whether these differed between sociodemographic groups.

Method

One researcher visited 69 antenatal classes in the Wellington region to explain the study. Women self-completed the questionnaire and returned it by post.

Results

A total of 405 women (55% response rate) took part. 79.2% of participants identified as New Zealand European and most were of high income and education levels, 32% visited the dentist during pregnancy and more than 60% reported bleeding gums. Women with a household income under NZ$70,000 per year were significantly less likely to report access to oral health information (OR 0.27, 95%CI 0.10-0.76) and more likely to report the need to see a dentist (OR 2.55, 95%CI 1.08-5.99) compared to women with an income over NZ$100,000 per year.

Conclusion

Visits to the dentist and access to oral health information were more common among New Zealand European women with higher education achievements and higher socioeconomic backgrounds with only a third of women went seeing a dentist during pregnancy. Improving the oral health of pregnant women will have follow-on benefits of improved oral health outcomes for their children.

Author Information

Bianca M Claas, Research Fellow, Centre for Public Health Research, Massey University, Wellington, NZ; Lis Ellison-Loschmann, HRC Postdoctoral Research Fellow, Centre for Public Health Research, Massey University, Wellington, NZ; Mona Jeffreys, Senior Lecturer in Epidemiology, Department of Social Medicine, University of Bristol, Bristol, UK

Acknowledgements

The researchers thank the women who participate in this study and the childbirth educators for the facilitation of the data collection. Bianca Muriel Claas was funded by the Massey University Masterate Scholarship and the Centre for Public Health Research receives funding from the Health Research Council of New Zealand.

Correspondence

Bianca Muriel Claas, Centre for Public Health Research, Massey University, Wellington, NZ. PO Box 756, Wellington, New Zealand. Fax +64 (0)4 3800600

Correspondence Email

b.m.claas@massey.ac.nz

Competing Interests

None.

Laine M. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60(5):257-264.Murdoch Children's Research Institute. Maternal and child oral health systematic review and analysis. A report for the Ministry of Health. Wellington (NZ): Ministry of Health, 2008.Vergnes J. Studies suggest an association between maternal periodontal disease and pre-eclampsia. Evidence Based Dentistry 2008;9(1):46-47.Offenbacher S, Boggess K, Murtha A, et al. Progressive periodontal disease and risk of very preterm delivery. Obstetrics and Gynecology 2006;107(1):29-36.Jeffcoat MK, Geurs NC, Reddy MS, et al. Periodontal infection and preterm birth. Journal American Dental Association - JADA 2001;132(July):875-880.Lopez N, Smith PC, Gutierrez. Higher risk of preterm birth and low birth weight in women with periodontal disease. Journal Dent Res 2002;81(1):58-63.Highfield J. Diagnosis and classification of periodontal disease. Australian Dental Journal 2009;54(1):11-26.Offenbacher S, Beck DJ, Jared H, et al. Effects of Periodontal Therapy on Rate of Preterm Delivery, A Randomized Controlled Trial. Obstetrics and Gynecology 2009;114(3):551-559.Gunay H, Dmoch-Bockhorn, Gunay Y, Geurtsen W. Effect on caries experience of a long-term preventive program for mothers and children starting during pregnancy. Clin Oral Invest 1998;2:137-142.Brambilla E, Felloni A, Gagliani M, et al. Caries prevention during pregnancy: results of a 30-month study. Journal American Dental Association - JADA 1998;129:871-877.Zanata R, Navarro M, Pereira J, et al. Effect of caries preventive measures directed to expectant mothers on caries experience in their children. Brazil Dent Journal 2003;14(2):75-81.Ministry of Health. Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding women. Wellington: Ministry of Health, 2006a.Habashneh R, Guthmiller J, Levy S, et al. Factors related to utilization of dental services during pregnancy. Journal of Clinical Periodontology 2005;32:815-821.Honkala S, Al-Ansari. Self-reported oral health, oral hygiene habits, and dental attendance of pregnant women in Kuwait. Journal of Clinical Periodontology 2005;32:809-814.Hullah E, Turok Y, Nauta M, Yoong W. Self-reported oral hygiene habits, dental attendance and attitudes to dentistry during pregnancy in a sample of immigrant women in North London. Arch Gynecol Obstet 2007.Thomas N, Middleton P, Crowther C. Oral and dental health care practices in pregnant women in Australia: a postnatal survey. Biomed Central Pregnancy and Childbirth 2008;8(13):1-6.Cutress T, Hunter P, Davis P, et al. Adult Oral Health and Attitudes to Dentistry in New Zealand 1976. In: Unit. DR, ed. Wellington: Medical Research Council of New Zealand, 1979.Hunter P, Kirk R, Liefde B. The study of Oral Health Outcomes. The 1988 New Zealand section of the WHO second international collaborative study. Wellington: Health Research Services, 1992.Ministry of Health. A Portrait of Health - Key results of the 2006/2007 New Zealand Health Survey. Wellington: Ministry of Health, 2008.Makowharemahihi C. A community-based health needs assessment of the oral health needs of Maori mothers in Porirua. University of Otago, 2006.Ministry of Health. Good oral health for all, for life. The strategic vision for oral health in New Zealand. Wellington: Ministry of Health, 2006b.Ministry of Health. Report on maternity, Maternal and Newborn Information. Wellington: Ministry of Health, 2004.Capital and Coast, District Health Board. Maternity Services in Capital and Coast District Health Board - Working towards a Maternity Strategy. Wellington, 2004.Statistics New Zealand. 2001 Census of Populations and Dwellings; National Summary. Wellington (NZ): Statistics NZ, 2002.Gaffield M, Gilbert B, Malvitz D, Romaguera R. Oral Health during pregnancy, an analysis of information collected by the pregnancy risk assessment monitoring system. Journal American Dental Association - JADA 2001;132(7):1009-1016.Ressler-Maerlender J, Krishna R, Robosin V. Oral health during pregnancy: current research. Journal of women's health 2005;14(10):880-882.Stevens J, Lida H, Ingersoll G. Implementing and oral health program in a group prenatal practice. JOGNN 2007;36(6):581-591.Christensen L, Jeppe-Jensen D, Petersen P. Self-reported gingival conditions and self-care in the oral health of Danish women during pregnancy. Journal of Clinical Periodontology 2003;30:949-953.Thomson W. Use of dental services by 26-years-old New Zealanders. New Zealand Dental Journal 2001;97:44-48.Lydon-Rochelle M, Krakowiak P, Hujoel P, Peters R. Dental care use and self-reported dental problems in relation to pregnancy. American Journal of Public Health 2004;94(5):765-771.Nutbeam D. Health literacy as a public goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 2006;15(3):259-267.Berkowitz RJ. Causes, treatment and prevention of early childhood caries: a microbiological perspective. Journal of the Canadian Dental Association 2003b;69(5):304-307b.Murray E, Keirse M, Neilson J, et al. A guide to effective care in pregnancy and childbirth. Third Edition ed. New York: Oxford University Press, 2000.Abel S, Park J, Tipene-Leach D, et al. Infant care practices in New Zealand: a cross-cultural qualitative study Social Science & Medicine 2001;53(9):1135-1148.Thomson W, Poulton R, Milne B, et al. Socioeconomic inequalities in oral health in childhood and adulthood in a birth cohort. Community Dentistry and Oral Epidemiology 2004;32:345-353.Poulton R, Caspi A, Milne B, et al. Association between children's experience of socioeconomic disadvantage and adult health: a life-course study. The lancet 2002;360(November):1640-1645.

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Women normally experience physiological, psychological and lifestyle changes during pregnancy and some of those changes can affect their dental health.1 The oral health of pregnant women has been receiving attention, both internationally and in New Zealand,2 with growing evidence that poor oral health can have detrimental effects, not only for the women (for example, increasing risk of pre-eclampsia)3 but also for the health of the fetus/baby.4-6Periodontal disease combines a number of diseases of the periodontal tissue that can be broadly divided into gingivitis and periodontitis. Gingivitis is an inflammation of the soft tissue surrounding a tooth, which commonly manifests as bleeding gums. Periodontitis is characterised by inflammation of the supporting structures of teeth resulting in attachment and bone loss.7 Periodontal disease is relatively common among pregnant women due to hormonal and vascular changes which occur during pregnancy leading to the promotion of an accentuated response to plaque.4There has been extensive discussion about the potential of periodontal disease to affect pregnancy outcomes. Some studies suggest that periodontitis is a risk factor for preterm and low birth weight infants, even after adjusting for other risk factors such as smoking, previous adverse pregnancies, race, age or socioeconomic status (SES).4-6 However, a recent study on the effect of maternal periodontal disease treatment on reducing the incidence of preterm birth failed to confirm this connection.8Studies show that preventive measures, including adequate diet and plaque control, for expectant mothers, can have a positive impact on both the woman's oral health and that of their child.9-11 In addition, because mothers are normally responsible for the introduction of dietary and hygiene habits to the infant, pregnancy is an ideal time in which to promote and reinforce healthy messages which will have long-term benefits for the woman as well as their family.12There is some international evidence of inequalities in oral health status and access to dental care for pregnant women of different ethnic and socio-economic groups.13-16 In New Zealand, two national oral health surveys conducted in 1976 and 1988 showed a decrease in dental caries generally over this period, but this was not consistent across all population groups.17,18Marked differences were reported in the levels of oral health of Māori compared to non-Māori, and also differences by SES with regard to access to oral health care services, according to the latest New Zealand Health survey conducted in 2006/2007.19 None of these surveys presented data on pregnant women.A recent qualitative study of Māori women, found that current oral health services are not meeting Māori needs and participants reported a number of dental problems during their pregnancies.20Improving oral health and decreasing disparities in health are goals of the New Zealand government. The Ministry of Health has highlighted pregnant women as a priority group.21Currently, there is a lack of information in New Zealand about the oral health care of pregnant women. The aims of this study were to gain an understanding of women's oral health care practices, access to oral health information and use of dental care services both prior to and during pregnancy, and to investigate if these differed between sociodemographic groups.Methods Participants—Eligible participants were pregnant women, over 16 years of age, attending antenatal classes during a 6-month period (June-November 2008) in the Wellington region. There are approximately 3,500 babies born per year in the region and about 78% of first time mothers attend antenatal classes.22 Antenatal classes may be either government-funded programmes which are offered to women at no charge, or be taught by a range of private antenatal education providers at a cost of anything up to NZ$150 for a course of classes. Participants in the study were drawn from a range of available classes, both private and government funded. The private classes were run by Parents Centre, Wellington High School Adult Community Education Centre, Newlands and Onslow College Adult Community Education Centre and Tawa College Community Education. The government funded classes were the breastfeeding classes at Wellington Hospital Women's Health Service and the Wellington Maternity Project (MATPRO). The composition of the classes provided by MATPRO in 2003 were 20.5% Māori, 17.5% Pacific, 8% Asian, 7% other/not stated, and 47% of European New Zealand ethnicity.23 The women attending antenatal classes are typically in the last trimester of their pregnancy. Data collection—The researcher arranged with the childbirth educator from each of the classes to attend one antenatal session in order to explain the study and leave women with an information sheet, questionnaires and self-addressed envelope for posting back the questionnaires which were self-completed by the women at home. Completed questionnaires could also be left at a ‘drop box' at the antenatal class venue if the woman preferred. Demographic information collected included, ethnic group, education level, and household income, based on definitions taken from the New Zealand Census 2001.24 Ethnicity was subsequently categorised as New Zealand European (which included New Zealand European and other European groups), and ‘Others' group which, due to small numbers, included Māori and Pacific Islanders as well as Chinese and Indian ethnic groups. Education was grouped as ‘high school' level, ‘tertiary', which includes any tertiary education program such as a certificate, diploma or incomplete degree and 'post-graduate'. Information on household income per year was collected in the follow categories: $1-5,000/$5,001-10,000/$10,001-15,000/$15,001-20,000/$20,001-$25,001/25,001-30,000/$30,001-40,000/$40,001-50,000/$50,001-70,000/$70,001-100,000 and $100,001+. For the analyses, due to the majority of participants being in the highest income group, the income bands were reclassified into the following three groups: less than $70,000 (low income), $70,000 to 100,000 (medium income) and more than $100,000 (high income). The participants were asked their date of birth with the age bands created being based on the data: 16-25 years, 26-30 years, 31-35 years and 36+ years age group. Questions relating to oral care practices, including use of floss and mouth care products, frequency of brushing and visits to a dentist (both prior to and during pregnancy), and the presence of dental problems during pregnancy were included, based on questions that had previously been validated in other international studies.13-16,25-28 Additional information was sought on changes to eating habits during pregnancy. Questions on sources/content of dental health information were developed specifically for use in the current study. Women were asked if they had received any information on dental health during their pregnancy, what the information was about (care of gums and teeth, dietary advice, use of fluorides, oral diseases and early childhood oral health) and who provided the information, such as a dentist, dental healthcare worker, Lead Maternity Carer (LMC) (a health professional who may be a midwife, general practitioner (GP) or obstetrician and is responsible for providing or organising a woman's maternity care including throughout the pregnancy, birth and the post-natal period), or other sources (media/internet/books). The questionnaire was piloted and refined prior to the final version used for the survey. Ethical approval for this study was obtained from the Massey University Human Ethics Committee. Analyses—All data was entered on Microsoft Access and analysed using STATA software package. Descriptive analysis, such as chi-squared tests and t-tests were used to investigate differences in knowledge/behaviour between the sociodemographic groups. Multivariable logistic regression was used to compare the prevalence of various risk factors between these groups, controlling for potential confounding variables, i.e. one or more of ethnicity, income, age and SES. To investigate the effect of confounding, the models were built adding in one variable at a time. Results Description of the sample—A total of 730 questionnaires were handed out to pregnant women at 69 antenatal classes and 405 questionnaires were completed, a response rate of 55.4%. New Zealand European made up 79.2% of the study population with the remaining 19.7% ‘Others' ethnic group comprising 8.8% Māori, 1.9% Pacific and 8.6% Indian/ Chinese/other. Over half of the participants had a tertiary education (57.7%), and most of the sample studied had a high income (with NZ$100,001 or more annual income). The majority of women in the study were over 30 years of age (Table 1). Dental visiting—About half of the women reported seeing their dentist at least once a year prior to pregnancy (Table 2). This was more common among New Zealand European, women with a higher education and income; and older women. A total of 23.2% of the women saw the dentist just when they had problems and this was more common among ‘Others', lower education and income; and younger women. However, just 32.3% of women reported seeing a dentist during their current pregnancy. Women with higher income/education level, those who were older; and New Zealand European were all more likely to have visited a dentist during their pregnancy. Table 1. Demographics of the 405 pregnant women who completed the survey Variables N (%) Age 16-25 26-30 31-35 36+ 46 (11.3) 111 (27.4) 140 (34.4) 108 (26.6) Ethnicity New Zealand European Māori Pacific Others Not stated 321 (79.2) 36 (8.8) 8 (1.9) 3.5 (8.6) 5 (1.2) Education High school Tertiary Postgraduate Not stated 47 (11.6) 234 (57.7) 118 (29.1) 6 (1.4) Household income ($NZ/year) <70,000 70,001-100,000 100,001-or more Not stated 52 (12.8) 94 (23.2) 214 (52.8) 45 (11.1) Table 2. Dental visits pre and during pregnancy Variables Normally see a dentist once/year N (%) Normally see a dentist symptoms related N (%) Have seen a dentist during pregnancy N (%) Ethnicity NZ European Others 168 (52.2) 33 (41.7) 72 (22.4) 22 (27.8) 108 (33.6) 18 (22.7) Education Postgraduate Tertiary High School 67 (56.7) 112 (47.8) 22 (46.7) 21 (17.8) 57 (24.3) 16 (34) 39 (33) 72 (30.7) 15 (31.9) Income ($NZ/year) 100,000 or more 70-100,000 Less than 70,000 121 (56.5) 44 (46.7) 16 (30.7) 39 (18.2) 26 (27.6) 21 (40.3) 18 (40) 31 (32.9) 11 (21.1) Age (years) 16-25 26-30 31-35 36 + All combined 15 (32.5) 59 (53.1) 70 (50) 62 (57.3) 206 (50.8) 21 (45.6) 32 (28.8) 23 (16.4) 18 (16.6) 94 (23.2) 12 (26) 33 (29.7) 39 (27.8) 47 (43.5) 131 (32.3) Women were asked why they did not see a dentist (information not shown in table). The main reasons given were being unaware that they needed to see a dentist (37%), cost (18.7%) and believing it was not recommended to see a dentist when pregnant (14.5%). Nearly 5% of women expressed fear of dentists as being the primary reason for not seeing a dentist during pregnancy. Not seeing a dentist for economic reasons was more common among ‘Other' women (27.8%), compared to New Zealand European women (16.5%); women with lower education (29.7%) compared to those with a higher education level (11.8%); those of lower income (42.3%) compared to a higher income level (11.2%); and younger (45.6%) compared to older (12%) women. Oral health care—Table 3 presents information on the oral health care practices of women in the study. In general, women presented with good oral hygiene habits, with most brushing their teeth twice or more a day and approximately 20% flossing daily. Forty-two percent of women reported increased sugar consumption during their pregnancy, which was more common among New Zealand European, young, medium income women; and those with up to high school education. Bleeding gums was the main problem reported during pregnancy (60%) by all women, followed by sensitive teeth (15%), toothaches (5.4%) and cavities (5.1%). There was no difference between sociodemographic groups for these outcomes. Table 3. Oral health care practices and changes during pregnancy Variables Brush twice or more/day N (%) Floss once/day N (%) Use mouth rinse N (%) Eating more sugar N (%) Bleeding gums N (%) Ethnicity NZ European Others 264 (82.5) 64 (82) 48 (15) 17 (21.7) 95 (29.6) 21 (26.5) 139 (43.3) 33 (41.4) 197 (61.3) 48 (60.7) Education Postgraduate Tertiary High school 102 (86.4) 192 (82.7) 33 (70.2) 22 (18.6) 36 (15.5) 7 (14.8) 31 (26.2) 70 (29.9) 15 (31.9) 51 (43.2) 97 (41.1) 24 (51) 78 (66.1) 139 (59.4) 27 (57.4) Income ($NZ/year) 100,000 or more 70-100,000 Less than 70,000

Summary

Abstract

Aim

The aims of this study were to gain an understanding of pregnant womens oral health care practices, access to information, and dental care usage in New Zealand, and to investigate whether these differed between sociodemographic groups.

Method

One researcher visited 69 antenatal classes in the Wellington region to explain the study. Women self-completed the questionnaire and returned it by post.

Results

A total of 405 women (55% response rate) took part. 79.2% of participants identified as New Zealand European and most were of high income and education levels, 32% visited the dentist during pregnancy and more than 60% reported bleeding gums. Women with a household income under NZ$70,000 per year were significantly less likely to report access to oral health information (OR 0.27, 95%CI 0.10-0.76) and more likely to report the need to see a dentist (OR 2.55, 95%CI 1.08-5.99) compared to women with an income over NZ$100,000 per year.

Conclusion

Visits to the dentist and access to oral health information were more common among New Zealand European women with higher education achievements and higher socioeconomic backgrounds with only a third of women went seeing a dentist during pregnancy. Improving the oral health of pregnant women will have follow-on benefits of improved oral health outcomes for their children.

Author Information

Bianca M Claas, Research Fellow, Centre for Public Health Research, Massey University, Wellington, NZ; Lis Ellison-Loschmann, HRC Postdoctoral Research Fellow, Centre for Public Health Research, Massey University, Wellington, NZ; Mona Jeffreys, Senior Lecturer in Epidemiology, Department of Social Medicine, University of Bristol, Bristol, UK

Acknowledgements

The researchers thank the women who participate in this study and the childbirth educators for the facilitation of the data collection. Bianca Muriel Claas was funded by the Massey University Masterate Scholarship and the Centre for Public Health Research receives funding from the Health Research Council of New Zealand.

Correspondence

Bianca Muriel Claas, Centre for Public Health Research, Massey University, Wellington, NZ. PO Box 756, Wellington, New Zealand. Fax +64 (0)4 3800600

Correspondence Email

b.m.claas@massey.ac.nz

Competing Interests

None.

Laine M. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002;60(5):257-264.Murdoch Children's Research Institute. Maternal and child oral health systematic review and analysis. A report for the Ministry of Health. Wellington (NZ): Ministry of Health, 2008.Vergnes J. Studies suggest an association between maternal periodontal disease and pre-eclampsia. Evidence Based Dentistry 2008;9(1):46-47.Offenbacher S, Boggess K, Murtha A, et al. Progressive periodontal disease and risk of very preterm delivery. Obstetrics and Gynecology 2006;107(1):29-36.Jeffcoat MK, Geurs NC, Reddy MS, et al. Periodontal infection and preterm birth. Journal American Dental Association - JADA 2001;132(July):875-880.Lopez N, Smith PC, Gutierrez. Higher risk of preterm birth and low birth weight in women with periodontal disease. Journal Dent Res 2002;81(1):58-63.Highfield J. Diagnosis and classification of periodontal disease. Australian Dental Journal 2009;54(1):11-26.Offenbacher S, Beck DJ, Jared H, et al. Effects of Periodontal Therapy on Rate of Preterm Delivery, A Randomized Controlled Trial. Obstetrics and Gynecology 2009;114(3):551-559.Gunay H, Dmoch-Bockhorn, Gunay Y, Geurtsen W. Effect on caries experience of a long-term preventive program for mothers and children starting during pregnancy. Clin Oral Invest 1998;2:137-142.Brambilla E, Felloni A, Gagliani M, et al. Caries prevention during pregnancy: results of a 30-month study. Journal American Dental Association - JADA 1998;129:871-877.Zanata R, Navarro M, Pereira J, et al. Effect of caries preventive measures directed to expectant mothers on caries experience in their children. Brazil Dent Journal 2003;14(2):75-81.Ministry of Health. Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding women. Wellington: Ministry of Health, 2006a.Habashneh R, Guthmiller J, Levy S, et al. Factors related to utilization of dental services during pregnancy. Journal of Clinical Periodontology 2005;32:815-821.Honkala S, Al-Ansari. Self-reported oral health, oral hygiene habits, and dental attendance of pregnant women in Kuwait. Journal of Clinical Periodontology 2005;32:809-814.Hullah E, Turok Y, Nauta M, Yoong W. Self-reported oral hygiene habits, dental attendance and attitudes to dentistry during pregnancy in a sample of immigrant women in North London. Arch Gynecol Obstet 2007.Thomas N, Middleton P, Crowther C. Oral and dental health care practices in pregnant women in Australia: a postnatal survey. Biomed Central Pregnancy and Childbirth 2008;8(13):1-6.Cutress T, Hunter P, Davis P, et al. Adult Oral Health and Attitudes to Dentistry in New Zealand 1976. In: Unit. DR, ed. Wellington: Medical Research Council of New Zealand, 1979.Hunter P, Kirk R, Liefde B. The study of Oral Health Outcomes. The 1988 New Zealand section of the WHO second international collaborative study. Wellington: Health Research Services, 1992.Ministry of Health. A Portrait of Health - Key results of the 2006/2007 New Zealand Health Survey. Wellington: Ministry of Health, 2008.Makowharemahihi C. A community-based health needs assessment of the oral health needs of Maori mothers in Porirua. University of Otago, 2006.Ministry of Health. Good oral health for all, for life. The strategic vision for oral health in New Zealand. Wellington: Ministry of Health, 2006b.Ministry of Health. Report on maternity, Maternal and Newborn Information. Wellington: Ministry of Health, 2004.Capital and Coast, District Health Board. Maternity Services in Capital and Coast District Health Board - Working towards a Maternity Strategy. Wellington, 2004.Statistics New Zealand. 2001 Census of Populations and Dwellings; National Summary. Wellington (NZ): Statistics NZ, 2002.Gaffield M, Gilbert B, Malvitz D, Romaguera R. Oral Health during pregnancy, an analysis of information collected by the pregnancy risk assessment monitoring system. Journal American Dental Association - JADA 2001;132(7):1009-1016.Ressler-Maerlender J, Krishna R, Robosin V. Oral health during pregnancy: current research. Journal of women's health 2005;14(10):880-882.Stevens J, Lida H, Ingersoll G. Implementing and oral health program in a group prenatal practice. JOGNN 2007;36(6):581-591.Christensen L, Jeppe-Jensen D, Petersen P. Self-reported gingival conditions and self-care in the oral health of Danish women during pregnancy. Journal of Clinical Periodontology 2003;30:949-953.Thomson W. Use of dental services by 26-years-old New Zealanders. New Zealand Dental Journal 2001;97:44-48.Lydon-Rochelle M, Krakowiak P, Hujoel P, Peters R. Dental care use and self-reported dental problems in relation to pregnancy. American Journal of Public Health 2004;94(5):765-771.Nutbeam D. Health literacy as a public goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 2006;15(3):259-267.Berkowitz RJ. Causes, treatment and prevention of early childhood caries: a microbiological perspective. Journal of the Canadian Dental Association 2003b;69(5):304-307b.Murray E, Keirse M, Neilson J, et al. A guide to effective care in pregnancy and childbirth. Third Edition ed. New York: Oxford University Press, 2000.Abel S, Park J, Tipene-Leach D, et al. Infant care practices in New Zealand: a cross-cultural qualitative study Social Science & Medicine 2001;53(9):1135-1148.Thomson W, Poulton R, Milne B, et al. Socioeconomic inequalities in oral health in childhood and adulthood in a birth cohort. Community Dentistry and Oral Epidemiology 2004;32:345-353.Poulton R, Caspi A, Milne B, et al. Association between children's experience of socioeconomic disadvantage and adult health: a life-course study. The lancet 2002;360(November):1640-1645.

Contact diana@nzma.org.nz
for the PDF of this article

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