The adage goes that a woman loses a tooth for every child. But the outdated idea that poor oral health is the price women must pay for having babies may be putting children’s health at risk.
A Western Sydney research team led by dentist Ajesh George has introduced an oral health program for pregnant women that has been adopted across two states, significantly improving the health of women and children.
George became interested in oral health and pregnancy about ten years ago, following the publication of several studies linking gum disease with adverse pregnancy outcomes.
“At that time, Australia didn’t have any guidelines on oral health for pregnant women, there were no promotional resources and no-one really discussed it during antenatal care,” says George, now an associate professor at WSU’s School of Nursing and Midwifery.
Extracting truth from myth
Pregnancy is associated with poorer oral health for several reasons. “Many women think it’s normal to have bleeding gums during pregnancy, and there are a lot of other misconceptions, for example, that it’s not safe to see a dentist, or fear about potential x-rays that might harm the baby,” says George.
Another common misbelief is that the baby leaches calcium from the mother’s teeth to meet its own needs; while it’s true that calcium is mobilised from the mother’s skeleton and absorbed from the foods she eats, studies have revealed that the calcium in her teeth is unscathed.
The likelihood of enamel erosion and dental decay are instead increased due to sugar cravings and vomiting caused by morning sickness. Increased oestrogen and progesterone also boost blood flow to the gums, which can cause them to become more irritable and susceptible to damage or infection. Approximately 60 to 80 per cent of women suffer from bleeding gums during pregnancy and almost a third have more advanced gum disease, where the gums begin to recede, and bacteria start eating away at the bone that supports the teeth.
The evidence regarding an association between poor oral health and adverse pregnancy outcomes including preterm birth and low birth weight is less clear. “What we think happens, is that bacteria from the periodontal disease enter the bloodstream, travel down to the placental barrier and trigger an inflammatory reaction, which potentially results in preterm birth and low birth weight,” says George. Studies have found a two- to seven-fold increased risk of such outcomes associated with poor oral health, although there is a paucity of research to demonstrate that it is a direct cause, or that increased dental visits result in improved birth outcomes.
Despite being at greater risk of poor oral health, fewer than half of pregnant women in the US, for example, seek dental care. In Australia, these problems are compounded by a lack of oral health awareness among pregnant women, limited emphasis on oral health during antenatal care, the high cost of private dental treatment, and limited public dental services.
Sarah*, one of the participants in the team’s research commented, “I think it’s important when women get pregnant to know that oral hygiene plays a major role in having a healthy child. I don’t know if a lot of women know that your own oral hygiene plays a big role.”
Need to know
- Pregnancy is disproportionately associated with poor oral health
- A WSU program engaged midwives to educate on dental hygiene
- It led to an 87 per cent increase in dentist visits from participants
George and his colleagues decided to upskill midwives in oral health education, because they play a pivotal role in the provision of antenatal care in public health services in Australia. Midwifery services are provided to pregnant women from the very early stages of their pregnancy, so educating midwives enables greater opportunities for oral health intervention. Canvassing midwives revealed widespread ignorance about the importance of oral health, as well as a lack of practical skills for assessing or addressing it. So, George and colleagues teamed up with the Australian College of Midwives to develop a comprehensive training programme; evidence-based promotional resources; and a validated screening tool to identify pregnant women who might be at increased risk of poor oral health and need a referral to a dentist. Midwives are also trained to conduct a visual inspection of the mouth, which, although optional, reinforces the idea that oral health is important: “If a midwife says, ‘you’ve told me you have a problem, do you mind showing me where the problem is?’ it suggests to the woman she should address the issue,” George says.
An evaluation of 638 pregnant women recruited from three metropolitan hospitals in Sydney, suggests this midwife-led approach is effective. It showed that the programme can significantly improve the knowledge and confidence of midwives to promote oral health and can be easily integrated into midwifery practice. The intervention also improved the uptake of dental services, oral health knowledge, and quality of oral health among pregnant women, compared to current practice, with the greatest improvement in uptake (87 per cent) observed when the midwifery intervention was coupled with an affordable and accessible dental referral pathway.
Poor oral health during pregnancy has been linked to
- Increased risk of preterm birth
- Low birth weight
- Increased risk of stillbirth
- Childhood dental decay
The research indicated that simply telling women to go and visit a dentist wouldn’t be enough; they needed access to affordable services. George and the team worked with public health providers in Victoria to roll out the programme across the state and provide low-income pregnant women with referral pathways. The programme has become state policy and put in place across 55 maternity services. Meanwhile, the screening tool is being used by 75 per cent of hospitals in Victoria. In certain regions, the number of pregnant women being referred to and accessing dental services has risen by more than 50 per cent.
George and his colleagues are now investigating the possible longer-term benefits of the programme for women and the oral health of their children, some of whom are now four. Babies acquire most of the microbes living upon and within them from their mothers — including bacteria associated with dental decay.
“Usually, if women have poor oral health during pregnancy, this continues after birth, and if they engage in certain feeding practices, such as tasting the baby’s food with their mouth, or sharing
the same spoon, then their bacteria will be transferred to the baby’s mouth causing early cavities, which is the most common chronic childhood disease world-wide,” George says.
*Name has been changed for privacy reasons
A study which followed the health of 2,798 Danish twins into old age, found that women with lower socio-economic status lost one tooth per pregnancy, on average, while those from higher socio-economic groups lost a tooth for every two children they had. For men, the correlation was negligible.
Meet the Academic | Associate Professor Ajesh George
Dr Ajesh George (BDS, MPH, PhD) is an Associate Professor at the School of Nursing and Midwifery, Western Sydney University (WSU) and Honorary Associate Professor in the Faculty of Dentistry at University of Sydney. He is a Dentist with extensive experience in interdisciplinary oral health care and is a leading expert in Australia in providing oral health training to nurses/midwives and translating oral health guidelines into their practice. Dr George is also the Director and Co-founder of the "Centre for Oral Health Outcomes & Research Translation" (COHORT) which is an innovative partnership between WSU and South Western Sydney Local Health District (SWSLHD) Oral Health Services bringing together Dentists and non-dental professionals for the first time in Australia.
Since his PhD Dr George has been initiating and leading multidisciplinary teams in developing and implementing innovative models of oral health care in the areas of maternity, paediatrics, aboriginal health, cardiovascular disease, diabetes, stroke, intellectual disability and palliative care. His work has led to the development of Australia’s first midwifery initiated oral health (MIOH) program which has been recognised nationally and internationally. He has also been instrumental in providing oral health training to nursing and midwifery students at WSU- another first in Australia.
A/Prof George has 35 grants ($4.1M) including NHMRC grants (26 as CIA), 65 publications (32 first authored, 25 last authored), 78 conference presentations (19 international) and a H-index of 15 with 751 citations. He also currently supervises 6 HDR students (PhD and MRes) most of whom have received scholarships. Dr George has also secured numerous awards including the 2008 SWSLHD Research Showcase Best Poster Award, SWSLHD Quality Awards for 2011/2013/2015/2018, NSW Health Awards Finalist for 2011/2013/2018, 2013 Ingham Institute Early Career Researcher (ECR) Award and the 2014 UWS Vice Chancellor’s Excellence Award as an ECR.
A/Prof George also has a significant track record of translating research into policy and practice. The MIOH program has been successfully implemented in various hospitals in NSW/Victoria and included in Victoria’s Oral Health Promotion Strategic Plan and Obstetric Monitoring system. In addition, the MIOH training package is endorsed by Australian College of Midwives as a professional development program nationally, the MIOH oral health promotional resources are being distributed state-wide by NSW Ministry of Health and oral health has been successfully implemented in the nursing and midwifery curriculum at Western Sydney University- another first in Australia. The MIOH program has received attention through media and television including ministerial media releases, newspapers and Channel 10 news.
Higher Degree Research at Western
This research was partially funded by the Australian Government through the National Health and Medical Research Council.
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Future-Makers is published for Western Sydney University by Nature Research Custom Media, part of Springer Nature.