WHAT DO PREGNANT WOMEN KNOW ABOUT ORAL HEALTH DURING PREGNANCY AND WHAT ARE THE BARRIERS THAT THEY EXPERIENCE TO MAINTAINING AND ACCESSING ORAL HEALTH?

by

K. Katina Garduno

Submitted in partial fulfillment of the requirements for the degree of Master of Arts

at

Dalhousie University Halifax, Nova Scotia March 2009

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Appendices • Copyright Releases (if applicable) Dedication

I would like to dedicate this thesis to my family. To my amazing husband and my wonderful parents, who have been so supportive and encouraging throughout the ups and downs of this journey. Without them I would have not been able to finish this work! But mostly, I'd like to dedicate it to my beautiful daughter, Madeleine. Being a premature baby herself, she inspired me to continue with this work as it's so important to do all we can to find out how to prevent premature births. I know there were times when she wanted to spend time with me, but I couldn't because I had to write. But I know that someday she'll understand that in more ways than one, it was worth it in the end!

IV Table of Contents

List of Tables viii

List of Figures ix

Abstract x

Acknowledgements xi

Chapter One: Introduction 1

Summary of Definitions 3

Chapter Two: Literature Review .5

Overview 5

Preterm Birth and Low Birth Weight 5

Periodontitis and Disease 8

Periodontitis and Pregnancy Outcomes 12

Animal studies 12

Microbiological studies 13

Clinical studies 14

Intervention studies 16

Maintenance of Oral Health Care During Pregnancy 17

Barriers Preventing Access to Oral Health Care 19

Research Framework: Population Health Model 21

Gaps in Current Knowledge 23

Summary and Rationale for the Current Study 25

Research Questions 28

Hypotheses 29

v Chapter Three: Methods 30

Participants 30

Measure 31

Questionnaire development 31

Construction of variables 34

Procedure 35

Ethical Considerations 37

Chapter Four: Results 40

Overview 40

Preliminary Analyses 40

Summaries of Women's Oral Health Care 40

Participant characteristics 41

Oral health care 41

Knowledge of general and pregnancy related oral health 43

Knowledge about risk of smoking and periodontitis on pregnancy 43

Predictors of Oral Health Knowledge 45

Participants' Barriers and Experiences Related to Oral Health Care 48

Participants' suggestions to overcome barriers 53

Post-hoc Analyses 54

Summary 57

Chapter Five: Discussion 58

Overview 58

General Oral Health Knowledge and Oral Health Maintenance 58

VI Oral Health Knowledge Specific to Pregnancy and Oral Health Maintenance.. ..59

Barriers that Prevent Good Oral Health Care During Pregnancy ..61

Finding Solutions: Health Promotion and Population Health 66

Future Research 72

Limitations 74

Conclusion 79

References 81

Appendix A: Questionnaire "Oral Health During Pregnancy" 93

Appendix B: Questionnaire Scoring Key 99

Appendix C: Consent Form 101

Appendix D: Oral Health Information Sheet 106

Appendix E: Correlation Matrix of Predictor and Dependent Variables 107

Appendix F: Information Booklet 108

VII List of Tables

Table 1: Demographic Characteristics of Participants 42

Table 2: Participants' responses on oral health care (general and pregnancy) and risk of adverse effects knowledge questions 44

Table 3: Variables that best predict general oral health knowledge 46

Table 4: Variables that best predict pregnancy oral health knowledge 47

Table 5: Variables that best predict risk of adverse pregnancy outcomes knowledge 47

Table 6: Variables that best predict total number of barriers ^48

Table 7: Number of barriers reported by participants 49

Table 8: Categories of barriers reported by participants 50

vm List of Figures

Figure 1: A cross-section of a healthy tooth and gum compared to a tooth and gum affected by periodontal disease 9

Figure 2: The framework for the Population Health Model 22

IX Abstract

Research linking periodontitis with adverse pregnancy outcomes is growing, but

little is known about pregnant women's knowledge about oral health and what barriers

they experience to accessing and maintaining oral health. A sample of 121 pregnant

women completed a questionnaire from January to August 2008 at the IWK Health

Centre Perinatal Centre in Halifax, Nova Scotia. Results showed that education, income,

dental check-up attendance, and having dental insurance best predicted oral health

knowledge. Women had adequate knowledge of general oral health practices, but their

knowledge about important aspects of oral health during pregnancy and the link between periodontitis and preterm birth was lacking. The main barriers to oral health access were

financial, lack of insurance, and lack of information from health care practitioners.

Women identified needing more information about oral health and assistance in accessing oral health care as ways to maintain better oral health.

x Acknowledgements

I would like to sincerely thank my supervisor, Dr. Lynne Robinson. Without her guidance and support throughout this journey I would not have been able to get to where

I am. I would also like to thank my committee members, Professor Lesley Barnes, Dr.

Lynne McLeod and Dr. Sathyasai Murty for their assistance and support. I surely could not have gotten through it all without all of their help! I would like to thank the staff at the IWK Health Centre, who helped out so much. I'd also like to thank Tracy Powell,

Graduate Administrative Secretary for the School of Health and Human Performance, for all her help with my never ending questions! Last, but certainly not least, I'd like to thank my husband and parents for their never ending support and encouragement, which was key to my completing this degree!

Thank You Everyone!

XI 1

Chapter One: Introduction

This thesis integrates two areas of concern: periodontitis and adverse pregnancy

outcomes (such as preterm birth and low birth weight). Periodontitis refers to the

infection of the gum and tooth supporting structures, which can lead to obvious problems

such as tooth decay and loss. However, periodontitis has also been linked to systemic health problems such as heart disease, diabetes, respiratory disease, osteoporosis, and adverse pregnancy outcomes such as preterm birth and low birth weight (Teng et al.,

2002; Xiong, Buekens, Fraser, Beck, & Offenbacher, 2006). Periodontitis is a relatively preventable condition, but if left untreated, can lead to more serious oral and systemic health problems (American Academy of Periodontology, 2008; Wener & Lavigne, 2004).

Preterm birth and low birth weight are major concerns for medical professionals, as well as for parents. The leading cause of death among infants is prematurity because preterm infants have low birth weight, breathing difficulties and other health concerns

(e.g. developmental and neurological health problems). Although medical advances have allowed for treatment and intervention to deal with the health consequences for infants of preterm birth and low birth weight, priority is placed on prevention and reduction of preterm birth rates by focusing on maternal health (Health Canada, 2000b, 2003). There are several factors that have been linked to preterm birth and low birth weight that can usually be treated to prevent any adverse outcomes. Some of these factors are smoking, drug use, domestic violence, strenuous exercise, low maternal weight, obesity, diabetes, high blood pressure, being pregnant with multiples, previous preterm birth, and some maternal infections (Health Canada). For example, research has linked bacterial 2

vaginosis, urinary tract infections (March of Dimes, 2008), and periodontitis (Xiong et

al., 2006) to preterm birth and low birth weight.

Although the research linking periodontitis to preterm birth and low birth weight

is fairly recent, it is beginning to point to a problem of concern. To date, research has

focused on establishing the relationship between periodontitis and adverse pregnancy

outcomes and the impact that periodontal treatment interventions have on reducing the risks (Xiong et al., 2006). Studies have included retrospective and prospective analyses of pregnancy outcomes in women with and without periodontitis, while other studies have

investigated the effectiveness of treating periodontitis and its effect on pregnancy outcomes (Xiong et al.). However, virtually no studies have investigated what knowledge pregnant women have about oral health and what barriers they experience to accessing proper oral health during pregnancy.

Based on a Population Health Model approach (Public Health Agency of Canada,

2005), it is important to not only understand what women know about oral health and the barriers that prevent them from maintaining good oral health, but also their personal experiences of barriers to oral health care. In doing so, strategies can be developed to provide women with the resources they need to effectively take charge of their oral health. The goal of the current thesis is to investigate this issue from this standpoint and attempt to add knowledge about oral health during pregnancy to the ongoing effort begun in some provinces to further understand the risk of preterm birth due to periodontitis. For example, the province of Ontario has started a review of this health concern and has suggested several strategies that may help reduce this risk, such as providing oral health kits (i.e. toothbrush, toothpaste, floss etc.) to at-risk women (McKeown, 2006). However, 3

because many women may not be aware of the risk periodontitis can have on pregnancy,

it may be difficult to expect adherence to good oral hygiene if it has not previously been a

priority to women. Thus, by conducting a study into what women know about oral health

practices and what they experience as barriers to maintaining good oral health, it is

envisioned that programs, strategies, and interventions can be designed effectively to help

women implement and maintain good oral hygiene and perhaps aid in reducing their risk

of developing periodontitis.

Summary of Definitions

To facilitate further reading, brief definitions of the different terms used

throughout are presented below.

Fetus. A term used to describe the developing infant during the gestational period.

This term was chosen for use for the current study as it is the preferred term used by the

Canadian Perinatal Surveillance System (CPSS) (Hack & Fanaroff, 1999; Health Canada,

2000b, 2003; Wener & Lavigne, 2004).

Infant. A term used to describe a child from the time of birth to age 2 years. This term was chosen for use for the current study as it is the preferred term used by the CPSS

(Hack & Fanaroff, 1999; Health Canada, 2000b, 2003; Wener & Lavigne, 2004).

Preterm birth. The definition of preterm birth is divided into three categories: extreme preterm birth (birth at 28 weeks gestation or less), very preterm birth (birth between 28-31 weeks gestation) and preterm birth (birth between 32-36 weeks gestation)

(Moutquin, 2003).

Low birth weight. Infant low birth weight is classified into two categories: very low birth weight which describes an infant born weighing 1500 grams or less (~3 lbs, 5 4

oz), and low birth weight which describes an infant weighing between 1500-2500 grams

(~ 5 lbs, 8 oz) (Leonard & Yeung, 2005).

Gingivitis. Gingivitis is the plaque build up on gums that cause them to swell,

become red and to easily bleed. This early stage of periodontal disease is often unnoticed

and if left untreated can lead to periodontitis, a more serious form of periodontal disease

(American Academy of Periodontology, 2008).

Periodontitis. Periodontitis is the chronic infection of the gum and tooth

supporting structures caused by plaque bacteria. If left untreated periodontitis can lead to serious oral problems, loss of bone, and other adverse health outcomes (American

Academy of Periodontology, 2008). 5

Chapter Two: Literature Review

Overview

This chapter will present the literature concerned with periodontitis and adverse pregnancy outcomes. First the risks and health implications associated with preterm birth and low birth weight will be discussed. Following this, the link between periodontitis and health problems, including adverse pregnancy outcomes will be explained. The gaps in the literature will be discussed and the rationale for this study will be presented.

Preterm Birth and Low Birth Weight

Preterm births are divided into three categories: extreme preterm birth (<28 weeks gestation), very preterm birth (28-31 weeks) and preterm birth (32-36 weeks) (Moutquin,

2003). Infant low birth weight has two classifications: very low birth weight (1500 grams or less) and low birth weight (1500-2500 grams) (Leonard & Yeung, 2005). Preterm birth and low birth weight, which often occur together, are risk factors for many life long health problems, such as blindness, deafness, developmental delay, heart disease, chronic lung disease, and neurological disorders. Therefore, prevention of preterm birth and low birth weight may be the most effective way in avoiding these lifelong health conditions

(Hack & Fanaroff, 1999; Health Canada, 2000b, 2003; Wener & Lavigne, 2004).

Due to the health risks of premature birth and low birth weight, the health of the mother and fetus during pregnancy is an important priority in our healthcare system.

Although some prenatal problems may not be preventable, others are preventable. For example, it is well established that a healthy maternal diet rich in folic acid can significantly reduce the rate of open neural tube birth defects in an infant (Health Canada,

2000b, 2003). Similarly, studies have shown that women may be able to reduce their 6

chances of preterm birth and low birth weight by fallowing a healthy diet and taking a

prenatal supplement (Glenville, 2006), not smoking (Ohmi, Hirooka, & Mochizuki,

2002) and not taking recreational drugs (Shankaran et al., 2007). Furthermore, some

studies suggest that attending prenatal care checkups (Gunter, Scharf, Hillemanns,

Wenzlaff, & Maul, 2007) and exercising moderately during pregnancy (Clarke & Gross,

2004) may help keep the mother healthy and perhaps reduce prenatal complications, such as preterm birth.

The rate of preterm births in Canada has usually been less than 10% of all live births (Health Canada, 2000b, 2003). Recently, preterm birth rates have been increasing slightly due to fact that many of the causes are non-modifiable factors such as a higher incidence of multiple births and advanced maternal age (Health Canada). Furthermore, other possible causes of preterm birth are obstetrical intervention, which in turn is reducing the rate of stillbirths, and changes in socio-demographic and behavioural factors, such as prenatal care, diet, and drug use during pregnancy (Health Canada).

About 80% of neonatal deaths in infants born without congenital anomalies happen in those who were born before 37 weeks gestation. Furthermore, the earlier an infant is born the higher the rate of mortality and morbidity. Compared to infants born at 36 weeks gestation, the mortality rate for preterm infants born at 24 weeks increases 180-fold, at 28 weeks increases by 40-fold and at 32 weeks increases by 7-fold (Health Canada).

Although today's medical knowledge and technology are advanced, "preterm birth is the most important determinant of perinatal and infant mortality, and preterm birth prevention is considered the most important perinatal challenge facing industrialized countries (Health Canada, 2000b, p. 51)." 7

In an effort to reduce preterm birth, research has aimed to identify the key

modifiable risk factors that may play a role in preterm birth. For example, in addition to

the factors mentioned above (adequate prenatal care, a healthy diet, moderate exercise,

and abstinence from smoking and use of recreational drugs), recent research has shown

that maternal infections and stress are also linked to increased risk of preterm birth

(Health Canada, 2000b, 2003). As well as these individual factors research has shown

that education and income are also important factors in determining pregnancy outcome.

Women with lower education and income are at higher risk of delivering preterm and of

having other pregnancy complications (Luo, Wilkins, Kramer, & Fetal and Infant Health

Study Group of the CPSS, 2006).

Other studies have also shown that a range of maternal demographics are related to poor prenatal care. For example, maternal age, having four or more children, lack of

support, and negative attitudes towards health care practitioners were all related to poor prenatal care and pregnancy complications (Delvaux & Buekens, 1999; Sword, 2003;

Tough, Siever & Johnston, 2007). However, some studies have shown that with appropriate prenatal monitoring and additional education during prenatal care, at-risk women may be able to reduce the likelihood of delivering preterm and of other pregnancy complications (Perry, 1996; Reynolds, 1998). Given the positive impact education may have on pregnancy outcomes, it is important to continue research that identifies the information pregnant women should know about improving their health and how to best deliver this information to them.

In addition to the obvious health benefits and improvement in quality of life preventing preterm birth and low birth weight can bring to the mother and the infant, "it 8

is imperative that clinical decision makers and budgetary and service planners recognize

the overall economic impact of the condition [preterm birth] (Petrou et al., 2003, p.

1295)." Up until the date of this writing, there have been no published studies assessing

the financial costs associated with preterm birth in Canada. Several studies have been

conducted in the United States and in the United Kingdom that report the health care

costs associated with preterm birth are substantial (Berkowitz & Papiernik, 1993). A

recent study in England investigated the costs per preterm infant during the first five

years of their life. The results showed that compared to infants born at term, infants born

before 28 weeks gestation cost the health care system an additional $22,000 USD and

infants born between 28-31 weeks gestation cost an additional $18,000 USD (Petrou et

al.). This research points to the fact that preterm birth has effects on infants' health but

also a cost to society.

Approximately 50% of preterm births occur without a known cause and about

30%-50% are estimated to be caused by maternal bacterial infections (Wener & Lavigne,

2004). Increasing research has sought to determine how and which bacterial infections

may lead to preterm birth (Wener & Lavigne). Recently, periodontitis (bacterial infection

of the gums and tooth supporting structures) has been strongly implicated as a risk factor

for preterm birth (Xiong et al., 2006).

Periodontitis and Disease

Periodontal disease is the broad term used to encompass several types of chronic infection that involve the gums and tooth supporting structures (American Academy of

Periodontology, 2008, see Figure 1, p. 9). The two main types of periodontal disease that are important to the current study are gingivitis and periodontitis. The early stage of 9 periodontal disease is called gingivitis and occurs when plaque builds up on the gums and causes them to swell, become red, and to easily bleed. This stage of periodontal disease is often unnoticed and if left untreated can lead to periodontitis, a more serious form of periodontal disease.

Figure 1. A cross-section of a healthy tooth and gum compared to a tooth and gum affected by periodontal disease (American Academy of Periodontology, 2006).

Periodontitis is a chronic infection caused by plaque bacteria that infect the gum and tooth supporting structures (American Academy of Periodontology, 2008). In response, the body triggers an inflammatory response to help fight off the infection. As the periodontal infection (periodontitis) progresses, the damage caused by the bacteria leads to the formation of pockets between the gum and teeth that allow the bacteria to grow and spread easily. This leads to a more severe infection and ultimately to damage of the bones and ligaments that hold teeth in place (American Academy of Periodontology;

Wener & Lavigne, 2004). The magnitude of advanced periodontitis has been compared to an infected wound the size of the forearm (Offenbacher et al., 1996). Treatment for a 10

superficial wound of that magnitude would not be delayed; however, the early stage of

periodontitis is often overlooked because the symptoms are mostly painless and

unnoticeable. Thus, in many cases, periodontitis is allowed to develop into a chronic

condition with adverse health outcomes (Wener & Lavigne, 2004). It is estimated that

about one-third of the population in North America is affected by some level of

periodontitis (Brown, Brunelle, & Kingman, 1996). The Canadian Dental Association has

stated that, "seven out of 10 Canadians will develop gum disease at some point in their

lives (Canadian Dental Association, 2005b, Gum disease FAQs section, para. 2)."

Research in the last few decades has found that several diseases may be linked to

periodontitis: diabetes, certain respiratory infections, heart disease, and several adverse

pregnancy outcomes (Anil & Al-Ghamdi, 2006; Li, Kolltveit, Tronstad, & Olsen, 2000;

Teng et al., 2002). Research investigating the relationship between diabetes mellitus and

periodontal disease in the general population has found that the link may be bi­

directional. Studies have found that patients with poor glycemic control also had a higher

incidence of periodontal disease. Intervention studies that treated the periodontitis found

an improvement in the patient's glycemic levels; but also found that when glycemic

levels were corrected, periodontitis was reduced (Teng et al.). The authors state that further work in this area is needed to determine this relationship more concretely.

Respiratory infections are another health problem that has been linked to periodontitis. Several clinical studies of Intensive Care Unit (ICU) patients and nursing home residents have found that only those patients who had an oral colonization of certain bacteria known to cause respiratory infections went on to develop pneumonia and other respiratory complications (Teng et al., 2002). Another detrimental health effect of 11

periodontitis is cardiovascular disease. Although cardiovascular disease has complex

determining factors (such as genetics and gender), research has shown that chronic

periodontal infection has a detrimental effect on the cardiovascular system (Li et al.,

2000; Teng et al., 2002). Several theories have been proposed to explain the pathway

between oral infection and cardiovascular complications (Teng et al.). One is that chronic

infection of the mouth may lead to thromboembolic disease (blood clotting) via bacterial

protein interfering with platelet aggregation (Schenkein et al., 2007). Another possibility

is that bacteria from the mouth enter the bloodstream and trigger the production of pro­

inflammatory cytokines, which are responsible for promoting inflammation and over time

lead to pathology of the cardiovascular system (Pussinen et al., 2007).

A more recent health concern arising from periodontitis is its effect on pregnancy outcomes. Numerous studies have concluded that after taking into account other risk factors for preterm birth, women with periodontitis may be seven times more likely to have a preterm delivery when compared to women who do not have periodontitis

(Moutsopoulos & Madianos, 2006; Xiong et al., 2006). There is a growing consensus that preterm birth and low birth weight may be influenced by chronic bacterial infections in areas of the body away from the fetus and placenta (Teng et al., 2002; Xiong et al.). This is supported by growing evidence showing that bacteria from the mouth enter the bloodstream and can affect the placenta and amniotic fluid. Once the bacteria reach the placenta and amniotic fluid an inflammatory response is triggered and may lead to the induction of preterm labour (or in early pregnancy, a miscarriage) via the release of prostaglandins. Furthermore, it is theorized that periodontitis, a low-grade chronic 12 infection, may also be the cause of growth restriction in the fetus, thus, leading to infant low birth weight (Bobetsis, Barros, & Offenbacher, 2006; Wener & Lavigne, 2004).

Periodontitis and Pregnancy Outcomes

The research linking periodontitis to preterm birth and low birth weight can be categorized into four main areas: animal studies, microbiological studies, clinical studies and intervention studies. Each of these areas will be discussed in more detail.

Animal studies. Several studies have been conducted using animal models to link periodontitis to adverse pregnancy outcomes (for a review see Bobetsis et al., 2006). The first published animal research study found that hamsters orally-injected with periodontal bacteria were more likely to give birth preterm and have pups who were of low birth weight (Collins, Windley, Arnold, & Offenbacher, 1994; Offenbacher et al., 1996).

Interestingly, oral bacteria were found in the cord samples of the preterm hamster pups, providing evidence that oral bacteria do in fact affect other organs (Han et al., 2004;

Offenbacher et al.).

The animal studies in this field have shown that the systemic spread of oral bacteria appears to have adverse effects on the growing fetus. It is postulated that when the bacteria reach the uterus they affect the structure of the placenta by interfering with the system responsible for supplying nutrients to the fetus, resulting in decreased growth and in some cases death (Bobetsis et al, 2006). In addition, studies have found that the effects of maternal periodontitis on a fetus may extend beyond the gestational period.

Several animal studies have found that mice pups affected by maternal periodontitis during gestation appear to have the effects of an inflammatory response in their brains, which may lead to brain damage and impaired function (Bobetsis et al.). Research has 13 shown that the underlying microbiological pathways of how bacteria spread from the mouth to other areas of the body and the ways in which it affects these areas, appear to be similar in animal models as in humans. This makes the evidence from animal model studies plausible when applied to human studies (Han et al., 2004; Han et al., 2006).

Microbiological studies. Another branch of research has attempted to investigate how periodontitis leads to preterm birth and low birth weight by examining how bacteria from the mouth lead to preterm labour. It is hypothesized that the bacteria from the oral cavity enter the bloodstream and are then spread to other areas of the body. These areas include maternal organs, including the uterus, resulting in the placenta and fetus possibly being infected by the bacteria. Further adverse effects to the fetus occur when in addition to a maternal immune response there is also a maternal inflammatory response. Part of this inflammatory response is mediated by prostaglandins which are released into the bloodstream (Klebanoff & Searle, 2006). This may be dangerous during pregnancy because prostaglandins are also responsible for the induction of labour. A normal induction of labour occurs when the fetus has reached complete gestation; however, if maternal periodontitis is present during pregnancy, prostaglandin release puts the mother at risk for going into preterm labour (Wener & Lavigne, 2004). There are three possible pathways by which preterm labour may be triggered via periodontitis: periodontitis alone leads to a release of prostaglandins into the bloodstream; lipopolysaccharides from the cell walls of bacteria induce the release of prostaglandins; and a direct translocation of oral bacteria to the uterus occurs, affecting the fetus and resulting in the release of prostaglandins (Wener & Lavigne). 14

A study conducted by Boggess et al. (2005) was the first to measure the

inflammatory and immune response of fetuses' exposure to oral pathogens. In this study a

dental examination was conducted on 1115 pregnant women. Upon delivery, 640

umbilical cord samples were tested for the presence of several markers of inflammation

and infection. The results showed that exposure of the fetus to oral pathogens during

gestation, which was determined by the presence of immunoglobulin M (IgM) in the cord

sample, was significantly associated with preterm birth. Furthermore, the risk for preterm

birth was greater in fetuses that also showed an inflammatory response. The authors state

that based on these results the treatment of periodontal disease either pre-pregnancy or in

the early stages of pregnancy would significantly reduce the number of preterm births

associated with periodontal disease (Boggess et al.). Another key study found that women

with periodontal disease, who delivered preterm, had a higher incidence of primary host

response (inflammatory response) in the amniotic fluid and umbilical cord (Dortbudak,

Eberhardt, Ulm, & Persson, 2005). Overall, microbiological studies have shown that

bacteria of oral origin can reach the fetal-placental unit and if the host, in this case the

mother does not have the protection of an immunoglobulin (IgG) antibody to these

bacteria, it can trigger an immune and inflammatory response that increases the risk of preterm birth by a ratio of seven to four (Bobetsis et al., 2006).

Clinical studies. The first known reference to a possible link between periodontitis and adverse pregnancy outcomes was made by Galloway in 1931. Galloway suggested that Gram-negative anaerobic bacteria might "provide sufficient infectious microbial challenge [to have] potentially harmful effects on the pregnant patient and developing fetus" (as cited in Radnai et al., 2004, p. 736). Since Offenbacher and 15 colleagues (Collins et al., 1994; Offenbacher et al, 1996) first officially researched the link between periodontitis and adverse pregnancy outcomes using an animal model, many studies have further investigated whether this would apply to humans.

Overall, the research has found a significant link between periodontitis and several adverse pregnancy outcomes such as preterm birth and low birth weight (for a review see Bobetsis et al., 2006; Xiong et al, 2006). The majority of these studies recruited a large sample of women, measured their periodontal status (usually during the mid first trimester) and followed them to time of delivery where the outcome was recorded (Dortbudak et al, 2005; Farrell, Ide, & Wilson, 2006; Moore et al., 2004;

Santos-Pereira et al., 2007). Other researchers recruited post-partum participants who had a preterm delivery and conducted an oral examination comparing them to a control group of women (Buduneli et al., 2005; Goepfert et al., 2004; Moliterno, Monteiro, Figueredo,

& Fischer, 2005; Radnai et al., 2004). There are also a handful of studies investigating the link between periodontitis and pre-eclampsia, which is characterized by high blood pressure and protein in the urine. Pre-eclampsia can often result in preterm birth as it can lead to the dangerous risks of eclampsia, i.e., maternal seizure, development of HELLP syndrome, and blood restriction to the fetus (Leonard & Yeung, 2005). A few of these studies found periodontitis to be a contributing factor to an increase in pre-eclampsia and preterm birth (Cota, Guimaraes, Costa, Lorentz, & Costa, 2006; Riche et al, 2002).

A few studies have reported not finding a significant link between maternal periodontitis and adverse pregnancy outcomes; however, many of these studies suffered from poor methodology and had confounding factors that were not controlled for (Xiong et al., 2006). In one study, women were interviewed and their oral health examined 16 within 11 months after delivery (Skuldbol, Johansen, Dahien, Stoltze, & Holmstrup,

2006). In this case, it is not possible to accurately state whether or not the preterm birth was related to the oral health status of the mother during the pregnancy, conducting an oral examination during pregnancy or right after the birth would be more effective. Other studies (Moore, Randhawa, & Ide, 2005; Noack, Klingenberg, Weigelt, & Hoffmann,

2005) did not exclude women who had taken antibiotics during their pregnancy, thereby introducing a confounding factor, because the antibiotics could affect the measurement of the women's oral health. Other studies used only a partial oral examination to make a diagnosis of periodontitis (Bassani, Olinto, & Kreiger, 2007; Holbrook et al., 2004). The rationale behind conducting a partial oral assessment in this study was that the length of time women had to participate in the study would be minimal to reduce potential discomfort; however, by doing so the authors may have jeopardized their ability to accurately diagnose periodontitis. As one team of researchers point out, the accurate diagnosis of periodontitis by a thorough oral examination is a crucial part of investigating this issue as well as determining whether or not treatment is effective (Xiong et al.,

2006).

Intervention studies. Research investigating whether dental treatment reduces the incidence of preterm birth and low birth weight has been limited and so far there have only been a handful of published studies that have found periodontal treatment is associated with a decrease in the preterm birth rate of the sample (Jeffcoat et al., 2003;

Lopez, Smith, & Gutierrez, 2002; Lopez, Da Silva, Ipinza, & Gutierrez, 2005; Mitchell-

Lewis, Engebretson, Chen, Lamster, & Papapanou, 2001; Tarannum, 2007). A recent study conducted in Brazil found that periodontal treatment in women with periodontal 17 disease significantly reduced the rate of preterm delivery and low birth weight. The authors of this study divided their participants into three groups: women without periodontitis, women with periodontitis receiving treatment, and women with periodontitis not receiving treatment. There was no significant difference in the rate of preterm delivery in the women without periodontitis group (preterm birth rate of 4.1 %) and the women with periodontitis who were treated (preterm birth rate of 7.4%).

However, in the group of women who had periodontitis and were untreated, 79% of women went on to deliver premature, low birth weight infants (Gazolla et al., 2007). This study shows that if left untreated, periodontitis can lead to a higher incidence of preterm birth. The results from these studies are valuable because they strengthen the link between periodontitis and preterm birth and low birth weight. Furthermore, the results of these studies are encouraging as they indicate that periodontal treatment may have an effect on reducing preterm birth and low birth weight and be one of the ways to help women modify a potential risk factor of preterm birth.

Maintenance of Oral Health Care During Pregnancy

Just as proper prenatal care is important to reduce pregnancy complications proper oral health care is also an important part of this process, given that periodontitis may play a role in adverse pregnancy outcomes. Understanding the modifiable risk factors of preterm birth is an important step to help in possibly reducing preterm births.

Thus, as the research appears to point to oral health as a potential modifiable risk factor of preterm birth, it is important to encourage women to maintain proper oral health to reduce the incidence of periodontitis. There is clinical support for the theory that general maintenance of oral health can reduce the incidence of periodontitis and other dental 18 problems from occurring (Wener & Lavigne, 2004). Daily brushing and flossing, not smoking, eating a healthy diet, and attending regular dental check-ups (twice a year) before and during pregnancy are the best ways to reduce the incidence of gingivitis and periodontitis (Wener & Lavigne). The increase in hormones during pregnancy makes the gums more sensitive and prone to infection. Increased brushing, with a soft bristled toothbrush, flossing, and maintaining regular dental check-ups are necessary to prevent oral infection and problems during pregnancy.

If any dental problems should arise during pregnancy, it is recommended that pregnant women receive treatment rather than postpone it because any problem, like a cavity or abscess, could lead to more serious oral health problems if left untreated. It is generally recognized that the safest and most comfortable time to receive dental treatment is during the second trimester (Russell, 2008). However, because oral health care is not a formal part of prenatal care guidelines and policies in Canada, many women may not know the importance of maintaining good oral health during their pregnancy (Health

Canada, 2000a).

In addition, women may not know the proper technique to floss and brush. For example, in Canada, it is recommended that flossing be done before brushing, this way any bacteria and/or food decay can be properly brushed away (Canadian Dental

Association, 2005b). To date there appears to be no published research in Canada studying the proportion of the population that does not use proper techniques to floss and brush. One study conducted in the United States found that patients surveyed in several dental clinics did not know the proper way to floss and brush (Segelnick, 2004). Due to the limited data on this issue, it is difficult to determine if improper use of oral health 19

technique is a factor in poor oral health and, in particular, poor oral health in pregnant

women.

Furthermore, a large proportion of pregnant women do not seek professional

dental treatment. One study (Gaffield, Gilbert, Malvitz, & Romaguera, 2001) found that

only 37.4 % of women went to a dentist during their pregnancy. What is even more

interesting is that among women who actually had an oral health problem that needed

attention, only half of them sought out treatment. Those most likely to seek treatment

were women of higher socioeconomic status (SES) and who had dental insurance

coverage. However, if women had a health care professional who identified the

importance of dental treatment and recommended it to them, they were more likely to

seek out dental treatment (Gaffield et al.). The results of this study point to the

importance of providing women with information on oral health care and of encouraging

women through their health care providers and community health programs to maintain

good oral health during pregnancy.

Barriers Preventing Access to Oral Health Care

Research from the United States has found that only about 60% of the population

receives the recommended level of oral health care (Danner, 2003). Studies have shown

that some of the barriers to accessing oral health care are: lack of financial resources (due

to poverty or lack of insurance), cultural issues (which may lead people to prioritize oral

health differently), fear and anxiety towards treatment, and lack of services and resources

in rural areas (Cohen & Manski, 2006; Danner). Many of these same barriers may also be applicable to the Canadian population. In Canada, the majority of oral health care services are not covered under regular provincial health care services. Many people live 20

in rural areas where access to oral health care services may be limited. Furthermore, fear

and anxiety related to oral treatment are possible in any population (Millar & Locker,

1999; Millar, 2004).

A recent report by Statistics Canada concluded that poor dental check-up

attendance was influenced by three main factors: education, income, and dental

insurance. Only 47% of the people surveyed who had a level of education less than high

school attended regular dental check-ups. Those who were classified as having low

income had a 44% attendance rate and those who lacked insurance for dental care had a

48% attendance rate. Interestingly, only 57% of those who were in the low income

category and had dental insurance attended dental check-ups, indicating that there may be

other issues, besides finances, influencing those with low-income in attending dental

check-ups (Millar, 2004). In regards to dental coverage, only 53% of Canadians and 49%

of Nova Scotians in the year of 1996/1997 had insurance that covered dental care. Due to

dental care not being covered by provincial health care plans, financial reasons are one of

the main barriers experienced by Canadians to accessing oral health care (Millar &

Locker, 1999).

Another possible barrier to accessing oral health care may be that people do not

know the importance of maintaining good oral health and the effects poor oral health has

on systemic health. Thus far, no studies were found that have investigated lack of oral health knowledge as a barrier to accessing oral health care in Canada. Recently, there has been increased awareness in Canada about the health effects of poor oral health. Efforts to educate people on the importance of maintaining good oral health care are being implemented (Health Canada, 2008). Given the potential connection to adverse 21

pregnancy outcomes, a study investigating what pregnant women know about oral health

and their perceived need for oral health services is particularly timely as it may assist in

identifying specific oral health information and resources that may be useful to pregnant

women.

Research Framework: Population Health Model

In order to investigate what factors affect pregnant women's oral health care it is

useful to look at the Population Health Model (Public Health Agency of Canada, 2005),

which guides most health promotion in Canada. This model is based on an approach that

encompasses most of the factors that are known to affect health: income and social status;

social support networks; education and literacy; employment and working conditions;

social and physical environments; personal health practices and coping skills; healthy

child development; biology and genetics, health services; gender; and culture (Public

Health Agency of Canada, see Figure 2, p. 22). By incorporating all these factors, this

approach strives to improve the health of the entire population and to reduce health

inequities between particular population groups. This improvement in the population's

health is achieved by creating interventions and health promotion strategies based on

quantitative and qualitative evidence that may affect the population as a whole, or

specific sub-populations of interest (Public Health Agency of Canada).

Based on this model, the population of interest for the current study is that of pregnant women in Nova Scotia. The determinants of health that are of interest for the current study are: income, education, personal health practices, healthy child development, and health services. These determinants have been shown to affect overall 22 health, thus, it is likely that they may also play a role in oral health (Public Health

Agency of Canada, 2005).

Figure 2. The framework for the Population Health Model (Public Health Agency of Canada, 2007).

The information gained from the current study can, ideally, be used to equip women with the knowledge necessary to take charge of their oral health. Consequently, if women are aware of the importance of good oral health during pregnancy it may reduce preterm births related to periodontitis. Furthermore, there may be a significant cost savings to the health care system. Recent studies in the United States have estimated that if periodontal disease was eliminated as a risk factor for preterm birth, as many as 45,000 preterm births could be prevented, with a savings of $1 billion in Neonatal Intensive Care costs

(Offenbacher & Beck, 2001; Wener & Lavigne, 2004).

It is acknowledged that there are other health models that may have been considered, for example the Health Belief Model (Nutbeam & Harris, 2009). However, because the Health Belief Model focuses on individuals' behaviours, it is often not used in the health promotion field as it is thought it places too much responsibility and blame 23

on individuals. Furthermore, the Health Belief Model tends to de-emphasize the focus on

environmental factors that may play a role in the populations' health. Therefore, because

the main goals of the current study were to understand women's knowledge and the

barriers that prevent them from accessing oral health care, the Population Health Model

was thought to be an appropriate standpoint.

Gaps in Current Knowledge

Due to the growing consensus that periodontal disease is a risk factor for adverse

pregnancy outcomes, it is important that pregnant women receive the necessary education

about the health benefits of maintaining good oral health. In order to be able to create

interventions to educate women about oral health and possibly help reduce preterm births

in at-risk women, there are some important areas to consider. First, it is important to

understand what pregnant women know about oral health care practices and about the

possible adverse effects poor oral health can have on pregnancy. Secondly, it is important

to understand their dental check-up attendance behaviour to determine if women are

maintaining regular dental check-ups. Finally, it is important to understand women's oral

health care experiences and what they state would be most helpful for them to overcome

barriers to accessing oral health care. Basing interventions on what women themselves

think would be helpful to them to improve their oral health can, ideally, result in useful

and effective strategies. However, little research has investigated these issues.

Two recent studies have examined the relationship between education level,

income and number of pregnancies with pregnant women's oral health knowledge and their dental check-up behaviour. One study, conducted in Jordan (Alwaeli & Al-Jundi,

2005), investigated, via a self-administered questionnaire, what 275 pregnant women 24 knew about general oral health practices and specific oral health practices during pregnancy. Some examples of the questions women were asked were, "what is plaque?",

"what can plaque cause?", "how can you prevent gum disease?", "what causes inflamed gum disease in pregnant women?", and "do you think tooth brushing should increase during pregnancy?" Furthermore, the researchers specifically asked women if they believed that periodontitis could be linked to preterm birth. The results showed that women's education level was the only factor that was significantly related to oral health knowledge. Although it was found that women tended to have knowledge about most general oral health practices, they had poor knowledge about oral health practices specific during pregnancy. Only a minority of the participants thought that periodontal disease was a risk factor for preterm birth and that plaque could lead to periodontitis.

These results indicate the need to educate women in Jordan on important aspects of maintaining good oral health during pregnancy and that any interventions geared towards preventing the effects of periodontal disease on pregnancy should be created knowing that the majority of women are not aware of the risk.

Another study conducted in Australia with 388 post-partum women (Thomas,

Middleton, & Crowther, 2008) used a questionnaire to determine their oral health knowledge, their dental check-up attendance, and whether or not these were associated with education level and income. The results of this study indicated that women appeared to have a good overall knowledge of oral health, but that most of them were unaware of periodontal disease. Furthermore, their knowledge was positively associated with increasing education and income. The researchers also found that the participants were unlikely to have been informed by their health care practitioners to continue attending 25 dental check-ups during pregnancy and only 30% attended dental check-ups during pregnancy.

The results of these two studies point to some important issues: pregnant women appear to need more information about oral health care, especially underprivileged women, and pregnant women may need to be informed and encouraged to continue to attend regular dental check-ups during pregnancy.

Summary and Rationale for the Current Study

Preterm birth is a serious health issue that has adverse acute and chronic health outcomes for infants and a huge economic toll on health care systems. Prevention of premature birth is an important aspect of prenatal health care to reduce infant mortality and morbidity. However, over the last few years, the rate of preterm birth has been increasing. There are several factors that are associated with the incidence of premature birth. Higher rates of multiple births and obstetrical intervention are leading to more preterm deliveries (Health Canada, 2000b, 2003). In addition, poor maternal health habits

(such as smoking and drug use), poor prenatal care and maternal infections are also thought to be responsible for preterm births (Health Canada; Wener & Lavigne, 2004).

Recently, there has been an increased focus on maternal periodontitis and its link to preterm births. Animal and microbiological studies have shown that periodontitis can lead to preterm birth by the translocation of oral bacteria to maternal organs, including the uterus. This infection is then thought to lead to an immune and inflammatory response that can trigger the induction of labour via the release of prostaglandins

(Bobetsis et al., 2006; Wener & Lavigne, 2004). Clinical and intervention studies investigating the relationship between periodontitis and adverse pregnancy outcomes 26 have shown that pregnant women who have periodontitis are more likely to deliver preterm and that periodontal treatment may reduce the rate of preterm deliveries (Gazolla et al., 2007; Xiong et al, 2006).

Overall, the research has shown that preterm birth has been linked to periodontitis, which can result from poor oral health. Thus, women need to maintain proper oral health in order to possibly reduce and/or prevent premature births associated with periodontitis (Wener & Lavigne, 2004). In spite of the fact that the importance of oral health care has been gaining attention, there are still barriers that prevent women from accessing oral health care services. The main barriers are lack of financial resources, including lack of dental insurance, and not being informed about the importance of oral health care during pregnancy (Gaffield et al., 2001). Furthermore, those who have a lower educational attainment and lower income are at risk of poor oral health care maintenance (Alwaeli & Al-Jundi, 2005; Thomas et al., 2008). Because education has been shown to possibly improve some women's pregnancy outcomes when it comes to their prenatal care (Perry, 1996; Reynolds, 1998), it is important to determine if educating women about oral health can have similar positive effects on their oral health knowledge and maintenance. However, there has been limited research investigating this issue.

The aim of the current study was to investigate what variables are associated with the knowledge pregnant women in Nova Scotia have about general oral health, oral health practices specific to pregnancy, their dental check-up attendance habits, whether they were informed about the importance of continuing regular dental check-ups during 27 pregnancy, what barriers they experience in accessing oral health care, and their personal experiences with oral health care.

Given that education and income are important predictors of health and have been shown to be related to oral health knowledge and dental check-up attendance (Alwaeli &

Al-Jundi, 2005; Taani, Habashneh, Hammad, & Batieha, 2003; Thomas et al., 2008), it was important to determine how these relate to the oral health knowledge and dental check-up behaviour of women in Nova Scotia. Furthermore, it has been shown that women who are informed (or referred) to attend dental check-ups during pregnancy by a health care professional are more likely to see a dentist during pregnancy (Gaffield et al.,

2001) and attending regular dental check-ups is related to better knowledge of oral health

(Thomas et al., 2008). However, it is not known how this applies to pregnant women in

Nova Scotia. Therefore, the current study also investigated whether women are being informed about the importance of oral health care during pregnancy and how it might affect their oral health knowledge and dental check-up attendance.

Since previous researchers have investigated the number of pregnancies and how they might be related with oral health knowledge (Alwaeli & Al-Jundi, 2005; Thomas et al., 2008) it was important to see if this was a predictor of oral health knowledge for women in Nova Scotia. Although Alwaeli and Al-Jundi did not find a significant association, Thomas et al. found that a higher number of pregnancies were related to better knowledge of some aspects of oral health. The researchers do not discuss possible reasons for this finding (Thomas et al.), but it could be that mothers with more children are taking their children to doctor and dentists appointments more often and in turn are 28

gaining knowledge about health issues. Thus, for the current study it was postulated that

more pregnancies might be related to better oral health knowledge.

Another important aspect of the current study is that it included an opportunity to

gain a more in depth understanding about women's experiences with oral health care,

barriers in accessing oral health care, and their preferences for health promotion activities

in this area. As mentioned earlier, one of the main barriers experienced by Canadians is

lack of financial means to attend regular dental check-ups (Millar, 2004; Millar &

Locker, 1999). Thus, it was important to also consider if pregnant women in Nova Scotia

are experiencing similar difficulties in oral health care maintenance.

Research Questions

In order to address the above issues it was important to answer the following questions:

1) How much do pregnant women know about recommended oral health

practices in pregnancy, including the risk of periodontal disease leading

to preterm labour?

2) What do pregnant women know about oral health practices that prevent

periodontal disease?

3) What are the barriers that prevent women from maintaining good oral

health and accessing information on oral health?

4) What do women perceive is needed to raise awareness of periodontitis

and help them to maintain good oral health? 29

Hypotheses

Several hypotheses were formulated to answer the above questions [see Appendix

B, p. 99, to see how each of the following variables was defined and scored]:

1) Women of lower income and education will have a lower score on

general oral health care knowledge, pregnancy oral health care

knowledge, and risk of adverse pregnancy outcomes knowledge.

2) Women of lower income and education will have more barriers to oral

health care.

3) Women whose physician or dentist has recommended dental care

during pregnancy will have a higher score on general oral health care

knowledge, pregnancy oral health care knowledge, and risk of adverse

pregnancy outcomes knowledge.

4) Women with lower dental check-up attendance will have a lower score

on general oral health care knowledge, pregnancy oral health care

knowledge, and risk of adverse pregnancy outcomes knowledge.

5) Women with lower number of previous pregnancies will have a lower

score on general oral health care knowledge, pregnancy oral health

care knowledge, and risk of adverse pregnancy outcomes knowledge. 30

Chapter Three: Methods

Participants

One hundred and twenty one pregnant women, who were attending a regular prenatal appointment at the Perinatal Centre in IWK Health Centre, were recruited. Most women recruited were from Nova Scotia and living in the Halifax Regional Municipality

(HPvM). Participants had to be able to understand English and give their informed consent. Initially, only women over the age of 18 years would be eligible to participate to avoid any potential issues surrounding informed consent. However, as per advice from the IWK Research Ethics Board, age was not used as an exclusion criterion. Women attending the high risk pregnancy clinics were not eligible to participate because the presence of medical co-morbidities would perhaps make them substantially different from the general population and beyond the scope of this research study. The women attending the IWK Health Centre's Perinatal Clinic range in demographic background so it was highly possible to recruit a diverse sample from this location.

The 'rule of thumb' for calculating sample size is to have 10 participants per dependent variable. In this study there are 6 independent variables (income, education, insurance, referral to oral health care, dental check up attendance, and number of pregnancies), so a minimum of 60 participants was needed for a multiple regression analysis. Due to the nature of the study, a convenience sample was used. Although this approach did not allow for using sampling techniques that would ensure a representative sample, by having a relatively large sample it was hoped to approximate representativeness sufficiently to estimate how significant this issue is in Nova Scotia.

Therefore, the goal was to recruit 200 participants. 31

Measure

Questionnaire Development. The measure used in this study was a self-

administered questionnaire, which can be seen in Appendix A (p. 93). The questionnaire

for the current study was constructed based on the one utilized in a recent study by

Alwaeli and Al-Jundi (2005). The authors developed their questionnaire in collaboration

with members of the dental professional community to ensure its content validity and that

all the questions reflected current practices of dental health and care during pregnancy.

Also, the authors collected useful psychometric information by conducting a pilot study

with 50 pregnant women to test the questionnaire's reliability. This resulted in a

Cronbach's a coefficient of 0.83, which is quite satisfactory (Alwaeli & Al-Jundi). This

questionnaire used by Alwaeli and Al-Jundi was chosen for the current study because, up

until the time the current study was started, it was the only one available. Although

another study had investigated women's knowledge of oral health, it was published after

the current study was in progress (Thomas et al., 2008). Furthermore, information on the

questions used and the questionnaire's reliability were not reported by the authors

(Thomas et al.). Thus, the Alwaeli and Al-Jundi questionnaire was a useful tool for the current study. However, a few minimal changes were necessary to make it more appropriate for the goals of the current study. The final version of the questionnaire was reviewed by the IWK Research Ethics Board and after a few suggested editions was deemed appropriate for the current provincial standard literacy level (Grade 6).

The questionnaire for the current study consisted of four sections: 1) demographics, 2) knowledge of general oral health and oral health during pregnancy, 3) dental check up attendance and barriers to dental care, and 4) pregnant women's 32

experiences and barriers related to their oral health. All the questions were in multiple-

choice format, except for section four, which consisted of three questions in open-ended

format.

Questionnaire section one (p. 93) was loosely based on Alwaeli and Al-Jundi's

(2005) questionnaire. The authors asked questions on the age, education level and

number of pregnancies of participants. For the current study several questions were added

to this demographics section. In addition to age, education level and number of

pregnancies, questions were added on participants' household income, place of residence

and whether or not participants had dental insurance. The answer options for education

level and number of pregnancies were changed from the Alwaeli and Al-Jundi version to

reflect more user-friendly language. The answer options for the questions on age and

income were categorized to match Statistics Canada's categories for these two

demographic variables. Statistics Canada reported pregnancy rates by age for 2003 using

the following categories: 18-19 years, 20-24 years, 25-29 years, 30-34 years, 35-39 years

and 40 years and over (Statistics Canada, 2007b). These same age ranges were used for the current study. The answer options for income were based on Statistics Canada report on the average income per family from 2001-2005 (Statistics Canada, 2007a). The lowest average income per year in a single parent family without a wage earner in 2005 was

$17,800. The lowest average income per year in a two-parent household with no wage earner was $21,500. The average income per year in a two-parent, two income family in

2005 was $90,900. In light of these statistics, the income range chosen for the questionnaire was designed to categorize those with a total household income lower than 33

$25,000 as on the low end of the income continuum while those over $100,000 on the

high end of the continuum.

All the items from Alwaeli and Al-Jundi's (2005) section on general oral health

knowledge and knowledge about specific oral health practices during pregnancy were

included in the current study (see section two, p. 94). The wording for questions 1, 2, 3,

4, 6, 10, 11, 12, 13, and 14 was modified to incorporate more user-friendly language and

the answer options were edited to reflect current practices in Canada. In addition

questions 5, 7, 8 and 9 were added to gather a more comprehensive understanding of

participants' knowledge about tooth brushing and flossing, and about women's

susceptibility to periodontal disease during pregnancy.

The questions in section three (p. 96) were created specifically for the current

study to gather information about women's dental check up attendance before and during

pregnancy, and the barriers that prevent them from accessing oral health care. The

Canadian Dental Association recommends that, on average, dental check-ups be every six

months, in other words, twice a year. In an article titled "Visiting the Dentist: The Check­

up" by the Canadian Dental Association, a regular dental check-up is defined as an

examination by a dentist, complete cleaning, and in some cases x-rays and fluoride treatment (Canadian Dental Association, 2005b). These recommendations were taken

into account when creating these questions.

The three open ended questions in section four (p. 97) were designed specifically

for the current study. These questions were included to allow participants to provide

information on their personal experience regarding their oral health during pregnancy and 34

their perceived needs to improve their oral health, specifically, how the believed they

could overcome the barriers to accessing oral health care.

In order to determine content validity prior to the commencement of the current

study a practicing dentist and obstetrician in Nova Scotia reviewed the questionnaire.

This review ensured that the questions were clear and that they reflected current and valid

dental and prenatal health practices in Canada. After a few formatting adjustments, a

small test-run was completed by a group of prenatal and obstetrics nurses at the IWK

Health Centre to ensure the clarity of the questions and determine the approximate time

to complete the questionnaire. The average time determined to complete the

questionnaire was eight minutes.

Construction of variables. The independent variables in this study were: income,

education, insurance, referral to oral health care, dental check up attendance and number

of pregnancies. The dependent variables 'general oral health care knowledge',

'pregnancy oral health care knowledge', and 'risk of adverse pregnancy outcomes

knowledge' were created by adding up each participant's total number of correct

questionnaire responses to each of the three types of knowledge. The dependent variable

'total number of barriers' was created by adding up the barriers expressed by each participant in sections three and four of the questionnaire. Care was taken to ensure that

responses that were the same in each section were not counted twice. For example, if a participant answered that financial reasons was her main barrier to accessing dental care

in section three, and then in section four she also expressed financial difficulties as part of her personal experience, this was tallied as one barrier and added to the financial category only once. The total tally of barriers was verified four times by the principal researcher 35

and twice by a second individual to check for accuracy, and there were no discrepancies

found. Participants' responses clearly fell into nine categories of barriers. Similar ideas

expressed by participants were placed in one common category to simplify results as

some ideas were only expressed by one or two participants. For example, fear of the

dentist, anxiety and fear of harming the fetus were all placed into one category labeled

Fear/Anxiety (see Appendix B for more details, p. 99).

Data collected from the three open-ended questions (section four, p. 97) were

carefully reviewed by the principal researcher and organized into categories according to

what emerged from participants' responses. These categories were created from any word, sentence or phrase that expressed a certain idea. For example, responses could be 'I have no time', 'having a dental plan would help', 'I have no concerns with my dental care'. Thus, in this example, the data would be categorized into "Time Constraints",

"Lack of Dental Plan" and "No Barriers". The number of participants who fit into a certain category was summed to create the proportion of the sample that experienced these barriers. Participants' answers to the open-ended questions which clearly and strongly expressed a particular category were used as quotations to add depth to the categorical results.

Procedure

The procedure took place at the IWK Health Centre's Perinatal Centre. The registration staff at the Perinatal Centre agreed to distribute the questionnaire packages to women at the time of registration. The questionnaire packages consisted of a study information sheet, the questionnaire and an oral health information handout (see

Appendices C, A and D; p. 101, 93, and 106 respectively). The registration staff handed 36

out questionnaires to only the women attending the regular obstetrics and family doctor

obstetrics clinics. The registration staff were instructed to say, "This is a questionnaire

study being conducted for pregnant women attending an appointment." At this point a

questionnaire was provided to them; however, each woman decided if she wanted to

participate.

It was anticipated that women would complete the questionnaire in the waiting

room. To further enhance confidentiality while completing the questionnaire, there was a

designated area in the waiting room with more privacy where participants could complete the questionnaire away from other people in the waiting room. However, it was the choice of each participant where she chose to complete the questionnaire.

Participants were first asked to read an information sheet on the purpose and procedure of the study. Participants were given detailed written instructions about completing the questionnaire, including inclusion criteria, and were provided with contact information for the researchers should they have any questions or concerns. In addition, participants were instructed to not read the oral health information handout until after they had completed the questionnaire, as doing so could affect participants' responses. In order to further encourage this, the handout was provided to participants in a sealed envelope. This handout contained information on proper oral health care practices during pregnancy and additional resources about oral health. This handout was included as an education tool for participants and to reassure them if they had any questions or concerns

(see Appendix D, p. 106).

A secure drop-off box was placed at the main registration desk where completed questionnaires were placed. The front of the box contained a storage slot where stamped 37

return envelopes were available to women who did not have enough time to complete the

questionnaire before leaving the Perinatal Centre, but it was anticipated that the majority

of women would be able to place their completed questionnaire in the box. Overall, only

three questionnaires were returned via mail.

Data collection was scheduled to run from January 2008 to April 2008. However,

the sample size goal had not been met by April. Thus, the data collection phase was

extended to mid-August 2008 to recruit more participants. For most of the third trimester, pregnant women attend bi-weekly and then weekly appointments, thus, many of the women attending the clinics had already participated in the study earlier on. Thus, in late

April 2008, it was decided to take a break from data collection for a few weeks, to allow time for patient turn-over (for these patients to deliver and new patients to begin attending appointments). Recruitment was re-commenced in late June 2008 and was completed in mid-August 2008.

Another issue that affected recruitment was that registration staff sometimes forgot to ask patients about the study when they were being registered (this tended to occur during very busy times). In order to prevent missed participants, it was decided to have some small incentives for registration staff. These two strategies helped and a total of 220 questionnaires were distributed. Of these, 121 completed questionnaires were returned giving a response rate of 55%, this was fewer than the target number of 200.

Ethical Considerations

Before commencement of this study, ethical approval was obtained from the IWK

Health Centre's Research Ethics Board. According to current policy, the Dalhousie

Research Ethics Board did not require further ethical approval if a study was conducted 38

only at the IWK Health Centre. Instead, a copy of the ethical approval letter from the

IWK Health Centre was required, and this was provided.

Due to the nature of the study and the participant group required, there were a few

ethical issues of specific concern. Only women capable of providing consent were

included in the study. Before completing the questionnaire, women were required to read the study information sheet. As this was a questionnaire study the Research Ethics Board indicated that a signed consent form was not required. Instead, participants were informed in the information letter that by participating and filling out the questionnaire they were giving their consent. This was a volunteer study and it was made clear to participants that they could stop their participation at any time for any reason. Every effort was made to ensure that the questionnaire was as respectful as possible in addressing those questions of sensitive content such as education level, income, and other demographic variables. Participants were assured of the strict privacy attached to this study.

This research involved information about a potentially harmful risk factor for participants' pregnancy (i.e., periodontitis). It was anticipated that the majority of the women would have access to a practicing dentist either through a private health plan or through social assistance. However, Dr. Sathyasai Murty, a practicing dentist in Halifax, agreed to be available to consult with any participants who had dental concerns after taking part in the study. If dental treatment was deemed necessary after consulting with

Dr. Murty, she was to discuss treatment options and refer women to the Dalhousie

Dentistry Clinic if cost was a concern. This clinic provides professional level dental check-ups and procedures at a lower cost than other dental clinics. One drawback to the 39

Dalhousie Dentistry Clinic is that there is a long waiting period. However, if Dr. Murty referred patients directly, it reduced the waiting time. Participants were required to contact the researcher to make an appointment to see Dr. Murty. In addition, this study was conducted in a setting where women were waiting to be seen by their physician, therefore, should any concerns arise from completing the questionnaire they were encouraged to discuss them with their physician. During the duration of the study no participants contacted the principal researcher with questions or concerns, thus, no consultation with Dr. Murty was required.

To provide further information on oral health to participants, a published patient guide that addressed oral health was given to all participants along with the questionnaire

(Association of Women's Health Obstetrics and Neonatal Nurses [AWHONN], 2004; see

Appendix D, p. 106). It was anticipated that this handout would help provide information, to participants and direct participants to resources on oral health. Participants were reassured that their well-being was of highest priority, thus, contact information for all researchers involved in this study was provided for those with questions or concerns regarding the research or if they wanted to be directed to further resources. 40

Chapter Four: Results

Overview

Data from all the completed questionnaires were entered into an SPSS database

(version 15.0) for analysis. The results will be presented in the following order:

preliminary analyses, summaries of women's oral health care, predictors of oral health

knowledge, participants' barriers and experiences related to oral health care, what

participants' perceived would help them overcome barriers, and post-hoc analyses.

Preliminary Analyses

Prior to beginning the analysis, the entered data were examined for any data entry

errors or outlying values and none were found. In order to test the reliability of the

questionnaire a series of inter-item reliability tests were conducted with the items that

made up each of the three types of knowledge (general oral health knowledge, pregnancy

oral health knowledge, and risk of adverse effects knowledge) which resulted in

Cronbach's a coefficients of 0.171, 0.369 and 0.217 respectively. Ideally, Cronbach's a values of 0.7 or higher are considered acceptable (Brace, Kemp, & Snelgar, 2003), thus, the items for the questionnaire appeared to have poor reliability.

Summaries of Women's Oral Health Care

Creating descriptive summaries of women's oral health care during pregnancy was a key goal of this study. These summaries describe the participants and the proportion of participants that knew about: good oral health care maintenance, good general health care practices, the increased risk of preterm birth due to periodontitis, and appropriate oral health care during pregnancy. 41

Participant characteristics. The demographic characteristics of the participants

can be seen in Table 1 (p. 42). A total of 121 pregnant women returned questionnaires.

The majority of participants (68.6%) were in the age range of 25-34 years, had achieved

at least a university degree (44.6%) and reported an income in the 71-100K range

(31.4%o). The next highest reported income bracket was in the 'over 100K' category

(23.1%o). The majority of participants reported having a dental care insurance plan

(80.2%o). The majority of participants reported living in Halifax and the surrounding areas

(80.4%>), while only 7.4% reported living outside of the Halifax Regional Municipality

(HRM). The majority of participants reported being in their third trimester (71.9%), about

half reported that this was their first pregnancy (53.7%), and about one third reported

having at least one delivery (32.2%).

Oral health care. The results showed that the majority of participants had good

oral health care maintenance prior to becoming pregnant, with 47.9 % reporting they

attended dental check-ups twice a year. Another 29.8% reported they attended dental

check-ups at least once a year. Only 5% of participants reported they did not attend

regular dental check-ups before pregnancy, and the main reason for not attending was due

to financial reasons, including lack of a dental insurance plan. During pregnancy 34.7%

of participants reported they attended at least twice a year and 26.4% reported they

attended once a year. However, 17.4% of participants reported that they did not attend or

were not planning to attend a dental check-up during pregnancy. Interestingly, 14%> of

these participants were women who reported regular dental check-ups before pregnancy.

It is important to note that there was a reduction of about 13% in women attending dental check-ups "twice a year" from before pregnancy to during pregnancy. 42

Table 1.

Demographic Characteristics of Participants (n-121) # Participants (% of sample) Age (in years) Under 18 1 (0.8) 18-24 10(8.3) 25-29 46 (38) 30-34 37 (30.6) 35-39 23 (19) Over 40 4(3.3) Education No high school 7(5.8) High school 16(13.2) Some university 11(9.1) Diploma 18(14.9) BSc or higher 54 (44.6) Other 15(12.4) Income Under 25K 7(5.8) 25-50K 22(18.2) 51-70K 22(18.2) 71-100K 38(31.4) Over 100K 28(23.1) Not given 4 (3.3) Insurance Do have insurance 97 (80.2) Do not have insurance 24(19.8) City Halifax 54 (44.6) HRM 53 (43.8) Outside HRM 9 (7.4) City not given 5(4.13) Trimester First 6(5) Second 28 (23.1) Third 87(71.9) Number of deliveries None 65 (53.7) One 39(32.2) Two 12(9.9) Three 3 (2.5) Four or more 1 (0.8) Not given 1 (0.8) 43

The majority of participants reported that no one recommended they have regular

dental check-ups during pregnancy (62.8%). Of those who did receive a recommendation

to continue with regular dental check-ups during pregnancy, 12.4% reported being told

by their dentist, 3.3% reported being told by their obstetrician, 5.8% reported being told

by a family member or friend, and 11.6% reported reading about it in a pregnancy book,

magazine or on the internet.

Knowledge of general and pregnancy related oral health care. Examination of

participants' responses to the questionnaire items on oral health care showed that the

correct answers were chosen by the majority of the participants (see Table 2, p. 44).

There were several questions which less than 50% of participants answered correctly.

Questionnaire responses indicated that the majority of participants did not seem to know what plaque was, when the best time to floss is, that tooth brushing and flossing should increase during pregnancy, and that the best time to receive dental treatment during pregnancy is in the second trimester. Although 57% of participants agreed that pregnant women were more susceptible to gum disease, this could be considered a marginal majority.

Knowledge about risk of smoking and periodontitis on pregnancy. Almost all of the participants reported that they thought smoking during pregnancy had a negative effect on the fetus (92.6%). Surprisingly, there was a minority of participants who reported that they did not think smoking during pregnancy was harmful to the fetus

(1.7%) and some reported that it was possibly harmful (3.3%). Only a minority of participants thought that periodontitis was linked to preterm birth (17.4%). The remaining 44

Table 2.

Participants' responses on oral health care (general and pregnancy) and risk of adverse effects knowledge questions General Oral Health Questions Participants who answered correctly (%) (Correct answer) What is plaque? 45 (37.2) (Soft bacterial deposit build-up on gums) What could plaque cause? 95 (78.5) (Gum disease) What do bleeding gums indicate? 109 (90.1) (Inflamed gums) How can gum disease be prevented 118 (97.5) (By brushing and flossing) How important do you think brushing is? 121 (100) (Very important) When is the best time for brushing? 107 (88.4) (More than once a day) How important do you think flossing is? 114 (94.2) (Very important) When is the best time to floss? 49 (40.5) (Before brushing) Pregnancy Oral Health Questions (Correct answer) Do you think pregnant women are more 69 (57) likely to get gum disease? (Yes) What causes inflamed gum disease in 83 (68.6) pregnant women? (Hormonal changes) Regarding tooth brushing and flossing 51(42.1) during pregnancy, which of the following is true? (Tooth brushing and flossing should increase) When do you think is the best time to 17(14) receive dental treatment during pregnancy? (Second Trimester) Risk of Adverse Effects Questions (Correct Answer) Do you think gum disease is linked to 21 (17.4) preterm labour? (Yes) Do you think smoking during pregnancy 112 (92.6) has a negative effect on the baby? (Yes) 45 participants reported that they thought it was not linked (21.5%), possibly could be linked

(21.5%), or that they were unsure (37.2%). Participants who did not know about the link between periodontitis and preterm birth ranged in education and income.

Predictors of Oral Health Knowledge

A linear stepwise regression analysis was chosen to analyze the data, as this method is "parsimonious and ensures that you end up with the smallest possible set of predictor variables (Brace et al., 2003, p. 214)." In this regression model the predictors were: income, education, insurance, referral to oral health care, dental check-up attendance and number of pregnancies. The dependent variables were 'general oral health care knowledge, 'pregnancy oral health care knowledge', 'risk of adverse pregnancy outcomes knowledge', and 'total number of barriers'. A collinearity diagnosis was performed on all regressions and these resulted in acceptable tolerance values (even though there were significant correlations between some of the variables, none were high enough to cause problems in the regression calculations, as regression can tolerate some degree of multicollinearity [Brace et al., p. 213]).

A stepwise multiple regression analysis was performed to determine which variables best predicted 'general oral health care knowledge'. This resulted in a significant model (Adjusted R square = 0.070. F2jn8 = 5.488, p <0.01). This model showed that the predictor variables education (Beta = 0.201, p <0.05) and dental checkups during pregnancy (Beta = 0.185, p <0.05) were significantly related to general oral health care knowledge (see Table 3, p. 46). This showed partial support for

Hypothesis 1 (women of lower income and education will have a lower score on general oral health care knowledge) and Hypothesis 4 (women with low dental check-up 46

attendance will have a lower score on general oral health care knowledge), confirming

that, as education and regular dental check-ups increased, so did general oral health care

knowledge. The variables 'referral' and 'number of pregnancies' were not found to be

significant predictors of general oral health knowledge. Thus, Hypothesis 3 (women

whose physician or dentist has recommended dental care during pregnancy will have a

higher score on general oral health care knowledge, pregnancy oral health care

knowledge, and risk of adverse pregnancy outcomes knowledge) and Hypothesis 5

(women with lower number of previous pregnancies will have a lower score on general

oral health care knowledge, pregnancy oral health care knowledge, and risk of adverse

pregnancy outcomes knowledge) were not supported.

Table 3.

Variables that best predict general oral health knowledge Predictor Beta p Adjusted R Tolerance Variables Square

Education 0201 p <0.05 0981

Dental check- 0.185 p <0.05 0.07 0.981 ups during pregnancy

A second stepwise multiple regression analysis was performed to determine which variables best predicted 'pregnancy oral health care knowledge' and this resulted in a significant model (Adjusted R square = 0.036. Fijig = 5.458, p <0.05). This analysis indicated that income (Beta = 0.209, p <0.05) was the only predictor significantly related to pregnancy oral health care knowledge (see Table 4, p. 47). This showed partial support for Hypothesis 1, as the higher the income the more knowledge participants had about 47

oral health care practices during pregnancy. In this analysis, Hypotheses 3 and 5 were not

supported.

Table 4.

Variables that best predict pregnancy oral health knowledge Predictor Beta P Adjusted R Tolerance Variables Square

Income 0.209 p<0.05 0.036 1.0

A third stepwise multiple regression analysis was performed to determine which variables best predicted 'risk of adverse pregnancy outcomes knowledge' and this resulted in a significant model (Adjusted R square = 0.087. Fi,n9 = 12.417, p <0.005).

This model indicates that dental check-ups before pregnancy (Beta = 0.307, p <0.005) was the only predictor related to risk of adverse pregnancy outcomes knowledge (see

Table 5, p. 47). This result partially supports Hypothesis 4, as it shows that the more regular the dental check-up attendance before pregnancy, the more knowledge participants had about the risk of adverse pregnancy outcomes due to periodontitis and smoking. Hypotheses 3 and 5 were not supported in this analysis.

Table 5.

Variables that best predict risk of adverse pregnancy outcomes knowledge Predictor Beta p Adjusted R Tolerance Variables Square

Dental check- 0.307 p <0.005 0.087 L0 ups before pregnancy 48

The final regression was performed to determine which variables best predicted

'total number of barriers' and resulted in a significant model (Adjusted R Square = 0.18.

F 2,ii8 = 14.148, p <0.0005). This model showed that the predictor variables dental check­

ups before pregnancy (Beta = -0.360, p O.0005) and dental insurance (Beta = -0.182, p

<0.05) were significantly related to the total number of barriers (see Table 6, p. 48). This

result does not directly support Hypothesis 2 (women of lower income and education will

have more barriers to oral health care) as income and education were not significantly

related to the number of barriers experienced by participants. However, the result does

add insight, as it shows that low dental check-up attendance before pregnancy and not

having dental insurance appeared to lead to more barriers experienced by participants.

Hypotheses 3 and 5 were not supported in this analysis.

Table 6.

Variables that best predict total number of barriers Predictor Beta p Adjusted R Tolerance Variables Square

Dental check- - 0.360 p <0.0005 0.945 ups before pregnancy 0.18

Insurance -0.182 p <0.05 0.945

Participants' Barriers and Experiences Related to Oral Health

As well as including a checklist of potential barriers to attending dental check ups, participants were asked three open-ended questions about barriers: 1) Is there anything you would like to tell us about your experience of "going to the dentist" during your 49

pregnancy? 2) What prevents you from having positive and informative dental health

care? and 3) What would help you get regular dental health care?

Of all 121 participants, 72 (59.5%) responded to these open-ended questions. Of

these 72 participants there were many who reported more than one barrier to accessing

oral health care in their responses, although no participants reported more than four barriers, out of a possible total of nine (see Table 7, p. 49). The majority of participants who did not report having any barriers also had insurance and were in the upper income category (34.7%). However, 16.5% of participants who reported having one or more barriers were also in the upper income category and had dental insurance coverage. Given this finding it was pertinent to present the results to clearly depict that even participants in the upper income category where reporting financial barriers to accessing oral health care. Thus, financial barriers to accessing oral health care due to lack of money and barriers to accessing oral health care because of lack of dental insurance coverage were presented separately.

Table 7.

Number of barriers to accessing oral health care reported by participants Number of participants ; (%}

No barriers reported 71(58.7)

One barrier 30 (24.8)

Two barriers 16 (13.2)

Three barriers 3 (2.5)

Four barriers 1(0.8)

More than four barriers 0 (0.0) 50

The barriers reported by participants were organized into nine categories by the

researcher (see Table 8, p. 50). The results show that among the women who answered

these questions, 29.16% (n=21) reported they did have regular dental care. Of those

women who indicated they had some form of barrier to accessing dental care, the most

common barriers were due to financial reasons (21%, n=15) and the lack of dental

insurance plan or not having enough coverage through their existing dental plan (16.7%,

n=12). Not getting enough information was reported by 12.5% (n=9) of participants.

Table 8.

Categories of barriers reported by participants Barriers reported by Number of participants participants (%)

No barriers reported/ 21 (29.16) I get regular care

Financial 15 (20.83)

Lack of 12(16.67) insurance/Better Coverage

Time/Procrastination 9(12.5)

Lack of info from 9(12.5) health care practitioners

Inaccessible Dentist 6(8.33)

Fear/Anxiety 4(5.55)

Lack of support 3(4.16)

Sickness/Nausea 2 (2.77)

Question not 12(16.66) answered 51

The following quotations are from participants who indicated that their dental care was lacking due to financial reasons and lack of insurance coverage. One participant expressed that, "Even though I have dental care I still have work that needs to be done that is still not covered. If there is one reason why [I don't get regular dental care], it would only be because of the expense (Mother of two, in her third trimester)."

Another mother stated that she could not get regular dental care because of:

Financial reasons. I am a single working mom of almost 3 children. I have

medical at work, but no dental. I fear my son turning 10 years old soon will lose

out on proper care, I already do. [A] dental plan, [and] cheaper rates for single

working moms [would help me get regular dental care]. We get no help, that is

why single moms depend on welfare or go on welfare to help their children,

because of dead-beat-dads. [There is] [n]o support for single working moms

(Mother of two, in her third trimester)."

One participant commented on the expense of certain treatments, "I need to have my teeth cleaned by a specialist (I have periodontal disease) and due to the cost of getting the cleaning done it is not affordable at this time. [If] the cost of a cleaning [could] be reduced to an affordable amount (not $700), [that would help me get regular dental care] (Mother of one, in second trimester)."

The next most common barrier, reported by 12.5% (n=9) of participants, was lack of time and/or procrastination to attend dental check-up appointments. The following quotation illustrates one participant's view about not having enough time to attend dental check-up appointments, "Unfortunately lack of time [prevents me from having regular 52 dental care]. Recommendation from doctor [would help me get regular dental care]

(Mother of one, in her third trimester)."

Not getting enough information or recommendations on dental health from health care practitioners was reported by 12.5% (n=9) of participants. The following quote depicts a participant's feelings about not having enough information from her health care practitioners:

There is not much info available about oral hygiene and pregnancy. Not like

smoking, nutrition or even domestic violence, where there is more info available.

This should be up in Dr. 's offices or given to women by Dr. 's. Even here at the

hospital in the room I am in now, there are handouts on everything from exercise

to [the] chicken pox vaccine to fibre in diet. All are important but no info on oral

hygiene (Mother of one, in her second trimester).

Another 8.3% (n=6) of participants indicated that they needed a more accessible dentist with flexible appointment times and the option to attend on a weekend day. One participant expressed that, "Evening/weekend appointments [and] better cost/rates

[would help me get regular dental care] (Mother of one, in her first trimester)."

Fear and anxiety were reported as barriers by 5.5% (n=4) of participants. A few of these participants indicated that they were extremely fearful of the dentist, but that they were planning to attend during their pregnancy in spite of their fear. One participant stated, "When I go to the dentist in 2 months from now I am concerned that there could be exposure to things that could harm the baby. I do plan to go for a cleaning but would not feel comfortable having any other procedure done while pregnant (Mother of one, in her second trimester)." 53

About 4% (n=3) of participants specified they needed more support in order to

attend dental appointments. In this category, issues with childcare were included, but it

was categorized as 'more support' because of participants' wording in their answers. One

participant's response was that it was "Too difficult to get to appointments, husband is

away and I have two preschool aged children. Transportation and childcare [issues

prevent me from having regular dental care] (Mother of two, in her third trimester)."

Only about 3% (n=2) of participants said that feeling sick and nauseous during

their pregnancy prevented them from seeing their dentist: "If I felt a lot better I would

definitely go to the dentist during my pregnancy. Besides that, I have a great Dentist and

a good dental plan, I just can't stop getting sick. Even when I brush and floss it can be a

challenge to not vomit (Mother of one, in her third trimester)."

Participants' suggestions to overcome barriers. In response to the question "What

would help you get regular dental care?" participants made some suggestions about what

they perceived would help them maintain better oral health. Overall, participants focused

on suggestions to improve financial issues and lack of information on oral health. These

are some of the quotes that depict participants' suggestions. The majority of participants

who expressed that their main barrier was due to financial issues, also reported that lower

dental fees and having coverage through a dental insurance plan would help them get

regular dental care. One participant's statement seems to capture this well, "Lowered

costs or better insurance coverage. It would be great if there was some type of special

lowered cost program for pregnant women-a funded or partially funded part of prenatal care (First pregnancy, in her third trimester)." 54

Many participants suggested that improvements could be made to better inform

women about oral health during pregnancy. One participant suggested that "Doctors and

Dentists collaborate so [regular oral care] was more encouraged (Mother of one, in her

second trimester)." Another participant stated that "Physicians could be mentioning the

importance of it at first visit, as a reminder (First time mother, in her third trimester)."

Post-hoc Analyses

A series of Pearson correlations among all the variables was performed to

examine which variables were significantly related and to further understand the

regression analysis (the entire correlation matrix can be seen in Appendix E, p. 107). In particular, it was important to examine the relationship between education (M= 4.16, SD

= 1.44) and income (M= 3.38, SD = 1.35). These two variables are usually closely related and with one, can predict the other fairly well. A Pearson correlation of 0.444 with a significance level of p <0.001 was found between education and income, indicating that these variables are positively related, as expected.

Several other significant correlations were found. The relationship between income and total number of barriers resulted in a significant negative correlation

(r = -0.291, p O.001). The relationship between insurance (M= 0.8, SD = 0.4) and total number of barriers also resulted in a significant negative correlation (r = -0.251, p

O.001). This indicates that those participants at the lower income level and who had no insurance experienced more barriers to accessing oral health care. Dental check-ups before pregnancy (M= 3.28, SD = 0.97) and dental check-ups during pregnancy (M=

3.12, SD = 1.29) were each significantly related to the total number of barriers experienced by participants, resulting in correlation values of r = -0.5, p <0.001 and r = - 55

0.422, p <0.001 respectively. This indicates that the more barriers experienced by

participants, the lower was their dental check-up attendance. Moreover, education and

income were significantly correlated to dental check-up attendance. A marginally

significant correlation was found between education and dental check-ups before

pregnancy (r = 0.198, p <0.05). Significant relationships were also found between income

and dental check-ups before pregnancy (r = 0.329, p O.001) and dental check-ups during

pregnancy (r = 0.209, p <0.05) indicating that the higher the income, the greater the

dental check-up attendance. The variables dental check-ups before pregnancy and dental

check-ups during pregnancy were significantly related (r = 0.58, p <0.001), indicating that regular dental check-up attendance before pregnancy seemed to predict dental check­ up attendance during pregnancy.

In summary, the correlations showed that having lower income and not having insurance were related to having more barriers to oral health care. Having more barriers to dental care was in turn related to lower dental check-up attendance. Higher income and education were also directly related to more regular dental check-up attendance. Finally, dental check-up attendance before pregnancy was related to attendance during pregnancy.

Due to the significant correlation between education and income it was important to conduct some additional analyses to determine if and how these two variables affected the significance of the results if they were removed as predictors from the regression analyses. Education and income were found to be significant predictors in two of the above analyses. In the first one, education significantly predicted part of the variance of general oral health knowledge (the other significant predictor variable was dental check­ ups during pregnancy). A post-hoc stepwise multiple regression analysis was performed 56

to determine if, by removing education as a predictor, the result of the analysis would

change. This resulted in a significant model (Adjusted R square = 0.045. F^m - 5.649, p

<0.05) with dental check-ups during pregnancy still being the only predictor variable

related to general oral health knowledge. In this case, removing education as a predictor

did not change the variables that best predicted general oral health knowledge, indicating

that education and income were not interchangeable for this analysis.

In the second relevant analysis, income was found to be a significant predictor of

pregnancy oral health knowledge. A second post-hoc stepwise multiple regression

analysis was performed to determine if, by removing income as a predictor, the result of

this analysis would change. This resulted in a marginally significant model (Adjusted R

square = 0.033. Fijig = 4.057, p <0.05), with education now predicting pregnancy oral

health knowledge. In this case, education and income did replace each other. This is

somewhat to be expected, as these two variables are related and it appears that at least in

one of the regressions, education seemed to be as good a predictor as income.

Another part of the post-hoc analysis was to look more closely at the Cronbach's

a coefficients. In the original analysis, the questionnaire items that corresponded to each

of the three dependent variables were used for each calculation of the Cronbach's a coefficients. It was thought that if all the items were combined and only one Cronbach's a calculated, it might improve the reliability. This analysis resulted in a Cronbach's a coefficient of 0.45. Additionally, another analysis was done using only the questionnaire

items that had to do specifically with oral health practices. Items 13 and 14 (the items having to do with smoking during pregnancy and the risk of periodontitis associated with preterm birth) were removed from the analysis because it was thought they might be quite 57

different from the rest of the items, and perhaps this might be contributing to the low

reliability. This resulted in a Cronbach's a coefficient of 0.337. Thus, the only

improvement in reliability was observed by including all 14 items in the calculation, but

this still did not result in a Cronbach's a coefficient in the acceptable range.

Summary

The results indicate that the majority of participants were young, well-educated,

middle-to-upper class women, who had dental insurance and were currently pregnant for

the first time. Most of the participants had adequate knowledge of oral health, but they

were not knowledgeable about certain aspects of oral health during pregnancy. The

results of the regression analysis suggest partial support for the hypotheses, indicating

that education, income and dental check-up attendance do appear to significantly predict

oral health knowledge. Overall, participants' experiences with oral health tend to be

positive; however, many participants reported that they have barriers that prevent them

from accessing oral health care. The main barriers reported were: financial reasons, lack of insurance, and lack of information from health care practitioners on oral health. 58

Chapter Five: Discussion

Overview

The recognition that oral health may play an important role in overall health is

increasing in our health care system and efforts are being made to improve the

population's awareness of and access to oral health by providing information to the

public (Health Canada, 2008). Having the appropriate knowledge about good oral health

practices is an important factor that can potentially result in an improvement in oral

health practices. Thus, it is important for women to be aware of this knowledge and these

practices so they can improve their oral health care habits and possibly prevent the

adverse pregnancy outcomes associated with poor oral health care. Furthermore, it has

long been understood that education and income may play a significant role in people's

health, where inequities in health and poor health are related to lower SES (Public Health

Agency of Canada, 2005). The current study has resulted in several important findings

that emphasize that these inequities also affect pregnant women's oral health knowledge

and access to proper oral health care and information. This chapter will discuss these

findings and explore several possible solutions to these issues.

General Oral Health Knowledge and Oral Health Maintenance

For the most part, the majority of the women had adequate knowledge of general oral health care practices. Overall, when it came to basic oral health care practices, such as knowing that brushing and flossing are important, and that bleeding gums can indicate periodontal disease, women appear to be properly informed. This finding has been supported by previous research, indicating that women are at least meeting minimum conditions for good oral health (Alwaeli & Al-Jundi, 2005; Thomas et al., 2008). This 59

finding closely ties in with women's regular dental check-up attendance because it was

found that dental check-up attendance was in part associated with better oral health

knowledge. However, there were a few questions on basic oral health that women missed.

For example, the majority of women did not know what plaque was and that the best time

to floss is before brushing. This indicates that women were not aware of certain oral

health practices that may help reduce periodontal disease, a finding that is also supported

by previous studies (Alwaeli & Al-Jundi; Thomas et al.). This shows that in three

different populations, women's oral health knowledge, although adequate in most areas,

can use some improvement. This is important information that dentists should know as it

may have implications on the information they give women. Furthermore, these women

will soon be mothers, who will influence their children's oral health. Although this study

was not focused on children's oral health, this issue is one that future research can further explore.

Oral Health Knowledge Specific to Pregnancy and Oral Health Maintenance

Women's knowledge was lacking in certain important areas of oral health care practices specific to pregnancy. For example, most women did not know that pregnancy may make women more susceptible to gum disease and that increased brushing could help to possibly prevent this from occurring. An important issue found by the current study was that the majority of women were not aware that periodontitis may lead to preterm birth. Previous studies have also found that women are generally unaware of oral health practices during pregnancy and the effects that poor oral health may have on pregnancy outcomes (Alwaeli & Al-Jundi, 2005; Thomas et al, 2008). Some women also decreased or stopped their dental check-up attendance during pregnancy and this may be 60

a reason of why women were not aware of these pregnancy-specific oral health practices.

By not attending dental check-ups, they may be missing out on receiving pertinent

information from their dentists. Previous studies have also found that women tend to

decrease or stop attending dental check-ups during their pregnancy (Gaffield et al., 2001;

Thomas et al.). Thus, it is important for dentists and health care practitioners to recognize

that even women with dental insurance and regular dental check-up attendance before

pregnancy may still need to be encouraged to continue during pregnancy.

Overall, women were not aware of the susceptibility to periodontal disease during pregnancy, of the link between periodontitis and preterm birth, and many women

decreased their dental check-up attendance during pregnancy, possibly putting these women at risk for poor oral health and possible adverse pregnancy outcomes. This information is new to this field, as research in Canadian populations has been lacking thus far. Health care practitioners and dentists should be aware that these are issues occurring in women's oral health, as they point to a need for increased oral health education for their patients. The hypothesized association between periodontal disease and preterm birth is still being investigated and therefore it may be too soon to begin sharing information on this link with pregnant women. However, health promoters may want to consider when it might be appropriate to share information about this potential risk with women.

The fact that, for some women, attending regular dental check-ups prior to becoming pregnant was associated with better attendance during pregnancy, means that a possible solution to increase dental check-up attendance during pregnancy would be to not only encourage pregnant women, but also women who may become pregnant, to 61

attend regular dental check-ups. This emphasizes the importance of health promotion in

this area, as by encouraging proper preconception oral health care for all women, possible

adverse outcomes during their pregnancy may also be prevented.

Barriers that Prevent Good Oral Health Care During Pregnancy

Although women of high education and income were the majority in this study,

there was a sub-sample of women who had low education and income and no dental

insurance plan. Lack of oral health knowledge and poor dental check-up attendance was

most visible in these women, indicating that these factors play a role in their oral health knowledge and maintenance. This finding is supported by the hypotheses and previous research that has linked low SES with poor oral health knowledge and maintenance

(Alwaeli & Al-Jundi, 2005; Gaffield et al., 2001; Thomas et al., 2008). The effect that poor oral health knowledge and maintenance has on these women is increases their risk of developing oral health problems, such as periodontitis, and possibly adverse pregnancy outcomes. Furthermore, the size of the correlation between SES and barriers to oral health care in this study of relatively well-off women and the fact that even women with dental insurance reported financial barriers to such care, suggests that financial issues may be a factor in oral care for many women, not just those of low SES. It is therefore important to consider each of these factors separately in new studies. Since this sample was so homogenous, it is also important to ensure a wider range of SES in future work to further explore the connections between income, education, dental insurance and other financial considerations. The women in this study generally reported that one of the best ways to help them maintain good oral health and learn about the effects of periodontitis, would be to help them to be able to afford dental check-ups, thus allowing them to 62 maintain regular oral health care. In other words, they understood that oral health is an important issue, but many of them just did not have the financial ability to take care of their oral health. For these women being informed about the importance of maintaining oral health care during pregnancy is not enough, they also need a way to access oral health care services.

Given that Canada has a public health care system means that no woman should have to miss out on proper prenatal care. There will of course be women who do not maintain proper prenatal care, for reasons such as poor maternal health habits, substance and domestic abuse, mental health issues, lack of support, and number of pregnancies

(Delvaux & Buekens, 1999; Health Canada, 2000b, 2003; Sword, 2003; Tough et al.,

2007). Many of these barriers to accessing prenatal care may or may not be the same when it comes to accessing oral health care. For example, it had been postulated that the number of pregnancies might have an impact on women's oral health knowledge and maintenance, but this was not found for women and their oral health care in the current study. This was likely due to the fact that this was the first pregnancy for almost all the women in this study.

Furthermore, even though prenatal care is provided free of cost to all women, there are some women of low SES who are at risk of having pregnancy complications and poor infant outcomes (Joseph, Liston, Dodds, Dahlgren & Allen, 2007). However, it is likely that in addition to low SES, these poor pregnancy outcomes are due to other concurrent maternal health issues, such very young or advanced maternal age, poor nutrition, and smoking (Joseph et al.). This further supports the fact that SES has far reaching effects beyond simply not being able to afford health treatment. Still, at least all 63

women are given the opportunity to have access to funded prenatal care, but this is not

the case when it comes to oral health care. As the current study has indicated, the main

barrier for women, including some women who reported middle to upper class income,

was due to the inability to afford dental care. This means that, theoretically, if oral health

care became publicly funded, more women would be given the opportunity to be able to

maintain proper oral health.

To date, oral health care in Canada is not publicly funded, despite many efforts by

advocacy groups (Canadian Association of Public Health Dentistry, 2007). Thus, only part of the population who is able to afford dental care fees, either by a dental insurance plan or by sufficient income, is able to maintain proper oral health care. Even though

some provinces and territories provide coverage to certain groups of the population (e.g., children, the elderly and those on social assistance), these assistance programs are limited and most people without dental insurance plans are responsible for payment (Health

Canada, 2006). This lack of resources makes it very difficult for these at-risk women to be able to maintain proper oral health. In addition, even women who reported having dental insurance still experienced some financial barriers to accessing oral health care.

Thus, as found by the current study, access to oral health care can be affected by many factors not related to SES.

Even though many of the women reported they had good oral health care maintenance, more than half reported one or more barriers to accessing oral health care.

In fact, regardless of education and income women reported several common factors that prevented them from accessing oral health care. For example, lack of information on oral health, lack of time, and fear about dental treatments were all reported as barriers by 64

women. So why is this occurring when most of the women had good oral health

maintenance? As highlighted by women's responses, even women who did attend dental check-ups regularly before becoming pregnant may still need to be encouraged to continue to have dental check-ups during pregnancy. Furthermore, some women who had regular dental check-ups before pregnancy stated that they did not plan to attend during pregnancy. The issue of not going to the dentist while pregnant has been raised by previous research, indicating that lack of oral health care during pregnancy is an ongoing issue for women (Gaffield et al, 2001; Thomas et al., 2008). Perhaps the reason why women do not attend dental check-ups during pregnancy is related to the fact that women also reported they perceived a lack of information from their health care practitioners about oral health and this affected their oral health care maintenance. Related to this issue was the fact that only a minority of women were informed that they should continue with regular dental check-ups during pregnancy. In fact, women themselves suggested that it would raise their awareness of oral health issues during pregnancy if health care practitioners informed them of these issues.

Previous research has shown that if women are told about the importance of oral health care during pregnancy by their health care practitioner, it can have a positive impact on their dental check-up attendance (Gaffield et al., 2001). This finding was supported by the current study, as the women who reported being referred to continue regular oral health care when they became pregnant, did in fact have more regular dental check-up attendance during pregnancy. This goes along with the finding that increased education and information may also improve prenatal care and pregnancy outcomes

(Perry, 1996; Reynolds, 1998). The findings of the current study imply that key figures in 65

women's health care are not informing their patients about oral health care and not

encouraging them to continue dental check-ups during pregnancy. This is particularly

worrisome, as it indicates that women are not being informed about a potentially serious

health issue that may have adverse pregnancy outcomes. If women are not properly

informed on oral health care and the important impact it may have on their pregnancy

outcomes they may not make it a priority to attend dental check-ups during pregnancy.

This is perhaps complication further by the fact that there are many

misconceptions surrounding the safety of oral health treatments during pregnancy, even

though most oral health care treatments are safe (Ressler-Maerlender, Krishna &

Robison, 2005; Russell, 2008). Although it was not one of the specific research questions

in the current study, fear of potentially harming the fetus may be a factor of why women

are not attending dental check-ups regularly during pregnancy. However, the results of this study appear to show that this was not one of the main concerns for women, as only a

few women reported that this was the reason for not attending dental check-ups during pregnancy. Furthermore, there is limited research investigating what role fear of harming the fetus plays on women's oral health care behaviour. Thus, future studies should consider investigating this issue further.

Understanding why women are not being informed by health care practitioners about the importance of oral health is difficult. However, a few studies have shown that many physicians are not aware of the adverse pregnancy outcomes linked to periodontitis

(Al-Habashneh, Al-Jundi & Alwaeli, 2008; Silk, Douglass, Douglass & Silk, 2008), which could help explain why women are not being informed about this issue. This was 66

not explored in the current study, but would be an important step in future research to

further understand where the information gap is occurring.

Furthermore, as several studies have shown, including the current one, many

women are themselves not aware about the possible adverse pregnancy effects caused by

periodontitis (Alwaeli & Al-Jundi, 2005; Thomas et al, 2008). Therefore, they may not

be taking the initiative to seek out oral health care during their pregnancies. If women

were aware that poor oral health, especially during pregnancy, may have adverse effects

on their pregnancy, it is possible that they might make every effort to ensure their oral

health was taken care of. This is an important finding, as it shows that dentists and other

health care practitioners need to provide information to women so any misconceptions on

the safety of dental check-ups during pregnancy can be addressed and to educate women

on the serious pregnancy outcomes that may arise from poor oral health. In doing so,

perhaps more women may be inclined to attend dental check-ups during pregnancy.

The issues raised by the current study on women's oral health knowledge and

barriers to accessing oral health care have pointed to the fact that many women do not

have the financial ability to access oral health care, that women have indicated they need

more information on oral health, and that health care practitioners need to provide

information and encouragement to women on maintaining proper oral health. These findings have important implications for health care practitioners and dentists.

Finding Solutions: Health Promotion and Population Health

The Population Health Model postulates that there are certain factors that affect a population's health (a full list of these factors can be found in Chapter One). The model indicates that lower SES (which is influenced by education and income) and poor 67

personal health practices can result in poor health outcomes. A cornerstone of the

Population Health approach and of health promotion is to empower members of the population by giving them the necessary tools to improve their health (Hamilton &

Bhatti, 2001; Public Health Agency of Canada, 2005). It is from this standpoint that possible solutions to the issues raised by the current study will be presented.

Prior to discussing these solutions, it is important to mention that, because the research on periodontitis and adverse pregnancy outcomes is fairly recent (Xiong et al.,

2006), there may still be hesitation and caution from some health care providers about acknowledging the role of oral health in adverse pregnancy outcomes. For example, in

Nova Scotia a history of the patient's oral health is not one of the standard checklist items on the prenatal record, which includes other public health items such as nutrition, exercise, and risk factors for abuse (Health Canada, 2000a). Furthermore, only recently has Health Canada acknowledged that oral health may play a role in adverse pregnancy outcomes. The official statement on Health Canada's website is that "cavities and gum disease can be painful and lead to serious infections. They may also contribute to many serious conditions, such as diabetes, respiratory diseases and perhaps heart disease and preterm low birth weight (PLBW) babies (Health Canada, 2008, The issue section, para.

1)." Furthermore, Health Canada recommends that "even though this research is ongoing, it is still important for pregnant women to take care of their gums and teeth (Health

Canada, 2008, Health risks of poor oral health section, para. 4)." Furthermore, the

Canadian Dental Association's official position on the relationship between periodontitis and systemic health is that, "further emphasis should be placed on research and educating dentists, physicians, students, residents, other healthcare professionals and most 68

importantly, patients regarding the importance of these possible relationships (Canadian

Dental Association, 2005a, para. 5)." Thus, even if the relationship between periodontitis and preterm birth continues to be investigated, there is a growing consensus that it is a health issue that requires our attention.

There are several recommendations that can possibly lead to improving women's oral health knowledge and oral health care maintenance. These solutions are based on the approach of providing women with the tools they need to improve their oral health. For example, providing information directly to women and to their health care practitioners

(Public Health Agency of Canada, 2005), and by making sure all women of child-bearing age have access to adequate dental care. It is important to focus on encouraging women to attend dental check-ups before they become pregnant, so that the knowledge they gain at this time will benefit them when they do become pregnant. Furthermore, many women develop oral health problems during pregnancy (Russell, 2008), thus, continuing proper care by a dentist during pregnancy is important. However, as the current study indicated, some of the main barriers experienced by women that prevent them from maintaining regular oral health care were the inability to afford oral health care and lack of information on oral health.

Difficulty in accessing dental care due to financial issues is a barrier for many women and solving this problem may be more complicated as it would require monetary health policy changes. However, there may be some solutions that could help women who are experiencing financial difficulty to attend regular dental check-ups. A useful solution, specific to prenatal care, would be to have a dentist join the hospital prenatal care team (similar to physiotherapists, nutritionists, social workers, etc) that works to 69

provide pregnant women with services they may need. In doing so, any dental issues that

may arise during a women's pregnancy could be dealt with by a dentist focused on

pregnancy dental care and the cost of the care would be covered under the provincial

health plan. The research in this type of collaboration is limited. However, efforts have

been implemented to bridge the gap between dentists and prenatal health care providers.

For example, in New York, a report was released indicating that oral health care during

pregnancy is important and that pregnant women should receive regular dental check-ups

(Russell, 2008). In addition, a referral program has been initiated which allows prenatal

care providers to refer women to dentists in the area and maintain communication between the two care providers (Russell). Although this does not effectively take care of those women who cannot afford dental care fees, it is a step in the right direction.

Another possible solution for women experiencing financial difficulty would be to open a clinic solely dedicated to prenatal dental care. This clinic could be opened as part of the Dalhousie's School of Dentistry student clinics. The Dentistry School holds these supervised student clinics for the public to give dental students clinical practice at a reduced cost. Although it would take effort and planning, it may be possible that an additional clinic for pregnant women could be created. In the meantime, making prenatal health care practitioners aware of the general clinics might be a helpful way to give women more options regarding their oral health until better solutions can be found.

In order to fully deal with the financial gap in oral health care pregnant women are experiencing, it is necessary to address current health care polices. As mentioned earlier, most Canadians are responsible for any of their oral health care costs. This means that unless coverage is provided by a dental plan through work or otherwise, each person 70

is paying out of pocket. As this study found, this is a problem for some pregnant women.

In light of the fact that research has shown prenatal oral health is important for many reasons, it is important to consider implementing oral health care during pregnancy as part of the overall health care system (Breedlove, 2004).

Lack of information about oral health was found to be an issue in this study's population. Pregnancy is for many women, a time when they become more aware of their health habits and are more likely to implement healthy lifestyle changes (Russell, 2008;

Strafford, 2008). Thus, it is an important time when health promotion efforts may be most beneficial. By providing information on oral health to women, health care practitioners can have a positive effect on women's choices about oral health (Gaffield et al., 2001). Aside from the benefits to pregnant women and, potentially, to their fetuses, providing oral health information and care to pregnant women may have other benefits. If women adopt healthy oral health habits during their pregnancy, then perhaps these may continue afterwards and women can teach their children about the benefits of proper oral health (Public Health Agency of Canada, 2005). Childhood oral health is an important health issue, which unfortunately was beyond the scope of the current study. However, it is hoped that if mothers are informed about proper oral health they may establish the basis for their children to have healthy oral health habits, which may lead to a lifetime of improved overall health (Association of Women's Health Obstetrics and Neonatal Nurses

[AWHONN], 2004).

It is important that researchers develop guidelines to facilitate the transfer of information on oral health between dentists and physicians, so that women can benefit from this information (Strafford, 2008). A short-term solution to this issue could be for 71

health care professionals involved in prenatal care to hold interdisciplinary education

seminars on oral health during pregnancy. This would ensure that all those involved in

prenatal care are aware of the importance and potential risks related to oral health care.

More long term solutions would be to review the training that prenatal health care

practitioners (physicians, nurses, midwives) and dentists receive, and incorporate

required changes to address pregnancy oral health issues (Al-Habashneh et al., 2008).

Some other fairly straightforward ideas to provide pregnant women with information on

oral health would be to have dental information sessions for women, to provide

information brochures on oral health available at prenatal check-ups (Russell, 2008) and

to include a section on oral health in women's prenatal records. Information sessions

could be held by dentists or dental hygienists and might be useful for women to learn the ways they can improve and maintain proper oral health before and during pregnancy.

Another aspect of these information sessions would be to provide a dental health kit to women in need, similar to the initiative suggested in Ontario (McKeown, 2006). In addition, if women are asked about their oral health during their prenatal check-up, it would give them another opportunity to ask questions about oral health and obstetricians can inform them about the importance of oral health care maintenance during pregnancy

(Dasanayake, 2008).

Ideally, information brochures on oral health should also be handed out in dental and doctor's offices so that women may become aware of the importance of oral health either before becoming pregnant or early in their pregnancy. The fact that this is not already being done is somewhat surprising. This may be due to the fact that the research in this area is considered to be "in progress" and health care practitioners and policy 72

makers may be hesitant to accept and share information on this potential health risk factor

with the public. However, with the growing literature and awareness indicating that oral

health is an important part of overall health, not only adverse pregnancy outcomes, now

is the time to consider beginning to focus on implementing changes that will benefit pregnant women. As part of the outcomes of the current study, an information brochure

for patients on oral health during pregnancy was created as an example of a possible brochure that could be provided to patients (see Appendix F, p. 108). This information brochure includes important information about overall oral health during pregnancy, without causing alarm to pregnant women. In addition, appropriate and reliable websites are provided to women for further information. An important aspect of Health Promotion research is to continue to learn more about oral health and the ways to provide adequate information and access to oral health care. In doing so, research in this area will ideally be able to lead to healthier pregnancies and infants.

Future Research

Even though there have been many studies that have found a reduction in adverse pregnancy outcomes when periodontitis was treated (Lopez et al., 2002; Lopez et al.,

2005; Tarannum, 2007), there have been very limited prospective studies examining whether treatment prior to pregnancy leads to a reduction in the rate of preterm births.

Thus, further research investigating this issue is needed to better understand how periodontitis and adverse pregnancy outcomes are related and how they can be prevented.

Understanding women's experiences and what they know about oral health is important if any further research or program initiatives are to be taken. That way, any health promotion initiatives can be based on the population's needs to increase their 73 success. However, up until the time of this writing, there had been no Canadian studies of pregnant women's knowledge and experiences with dental health. The research so far, has shown that pregnant women are more likely to not attend regular dental check-ups compared to non-pregnant women (Breedlove, 2004; Gaffield et al., 2001; Ressler-

Maerlender et al., 2005; Thomas et al., 2008), a finding that was supported by the current study. Not attending regular dental check-ups during pregnancy could potentially put women at a higher risk of developing oral health problems (Russell, 2008). Thus, more research investigating why women are not as likely to attend dental check-ups during pregnancy and how to help them maintain their oral health is important. Furthermore, as the current study showed that women appear to report they are lacking information on oral health, futures studies should investigate whether providing women with pertinent information on oral health results in women maintaining regular dental check-ups during pregnancy. Perhaps the literature in the "risk perception health model" would be a useful standpoint in future research to further understand why women tend to not maintain regular dental check-ups during pregnancy, as this model states that often information is not enough to evoke behaviour changes when it comes to people's health (Floyd,

Prentice-Dunn & Rogers, 2000).

Moreover, many researchers in this field think it is crucial to implement a dental health care program for pregnant women as part of prenatal care (Breedlove, 2004; Mills

& Moses, 2002; Russell, 2008). However, it is not clear what effects this could have on women who are not pregnant, on the rest of the population, or if it would be effective in actually increasing and maintaining proper oral health care. Therefore, exploring this 74

issue further could identify the most effective ways to undertake any change in dental health care programs.

Investigating further what women know about oral health would add important insight about the areas of oral health knowledge that women require more information.

The current study has added to this knowledge, showing that women did have knowledge about oral health, but were lacking knowledge about pregnancy specific oral health.

However, a multi-centre study could help ensure that women of variable education and income backgrounds be included. For example, having data collection take place at physicians' offices, walk-in clinics, and other hospital centres could ensure that more women be given the opportunity to participate. In doing so, the knowledge and barriers of not just one part of the pregnant women population could be further addressed.

Furthermore, investigating health care practitioners' beliefs about oral health care might help identify ways to better understand the underlying issues surrounding women's oral health care during pregnancy. Finally, conducting a larger scale, quantitative survey with possibly a more in depth qualitative piece, might add important insight into other issues in prenatal care and oral health care during pregnancy.

Limitations

There are limitations in this study that need to be discussed: low statistical power, poor generalizability, use of a self-administered measure, and poor reliability of the questionnaire. Usually, studies collecting data by a questionnaire have large sample sizes to allow for statistical power, and this increases the likelihood that any significant relationship between variables that exists will be identified (Brace et al., 2003). However, recruitment of participants reached a plateau due to only one central recruiting location 75

and the goal for the total number of participants was not obtained. Thus, it is important to

acknowledge that the results of this study were based on a somewhat smaller sample size

than desired. Another limitation is that the results are most likely not generalizable to

those not represented in the sample. An important assumption of conducting regression

analyses is that the population should approach, or nearly approach, normalcy. This

implies that there should be an equal amount of variance on either side of the average

outcome measure (Moore & McCabe, 2003). However, the results revealed that the

sample was fairly homogenous. The majority of the participant population was made up

of young, middle-to-upper-class women, who were well educated, had a dental health

insurance plan, and were experiencing their first pregnancy. Thus, the majority of

participants answered similarly on the oral health knowledge questions and, because they

were in similar education and income brackets, there was very little variability within the

sample. However, in spite of this homogeneity there were important significant

associations between the variables. Thus, the results of this study are still important and

future studies can further improve generalizability.

One possible reason to account for the low variability is that certain groups of the

pregnant women population may not have completed the questionnaire. Women with

children may not have had the time to complete a questionnaire as they may have brought

their child(ren) with them to their appointment and not have been able to participate in the study. Also, more women of low education and income may not have been interested

in participating. Moreover, perhaps some women of low education and income may not have been attending prenatal appointments at the recruiting location. Thus, these women would not have been included in the study and their knowledge and experiences not 76

accounted for. Also, women who were considered to have a high risk pregnancy were not

intended to be a part of the sample. Perhaps this exclusion prevented women of lower

income, lower education, and women who had poor health habits from completing the questionnaire and this hinders the ability to generalize the results beyond the population represented in the study. However, perhaps efforts to exclude high risk women were not enough to ensure that these women did not complete the questionnaire. These women's health experiences could certainly have had an impact on the results. However, it is likely that this was not the case, as the women who were part of this study, overall, did not report any issues that would indicate this. However, future studies should consider recruiting women considered to be "high risk", as this group of women may have important risk factors that can have an impact on oral health that should be considered.

Furthermore, in order to increase the sample size and variability of any future studies, there should be multiple recruitment locations in various neighbourhoods. This strategy could increase the likelihood that women not represented in the current study would be included.

Another limitation is that data were collected using a self-administered questionnaire. Thus, data provided by participants may not have been completed honestly and may have been influenced by people accompanying the participant. Furthermore, participants' answers regarding oral health knowledge may have been influenced by the information provided in the patient handout if it was read before completing the questionnaire. However, only the questions on oral care during pregnancy and whether or not periodontitis is linked to preterm birth could have been affected. Given that the majority of participants' did not know the correct answer to these questions, it is unlikely 77

that reading the handout prior to answering the questions affected their answers.

Furthermore, the answers provided to the questions about barriers and participants'

experiences, were by design, less affected by outside knowledge. Thus, one of the major

aims of this study (to gain an understanding of the barriers women experience and what

they perceive is needed to help them achieve good oral health) was not jeopardized.

However, it might be prudent for future studies to provide any information handouts

separately after completion of the questionnaire and/or provide participants with a web

page address where they can later check the information. In doing so, any chance that

participants' knowledge was affected by outside information could be reduced.

Another limitation is that the questionnaire used in this study did not appear to

have good reliability, i.e. the Cronbach's a coefficients were below acceptable values.

This finding came as a surprise because it was based on a questionnaire that had reported

a high Cronbach's a coefficient (Alwaeli & Al-Jundi, 2005). Even though a few items

were added for the current study, these were not expected to have any major alteration of the overall reliability of the measure as similar structure and wording was maintained. In

addition, there were some similarities in populations between the two studies. For example, both studies recruited pregnant women of similar ages and education level.

However, income and access to oral health care was not measured by the researchers of the Jordanian study (Alwaeli & Al-Jundi). In addition to income and access to oral health care, other differences between populations could have been level of literacy, cultural and religious factors, and differences in health care. All of these differences may have affected participants' responses, which could also have an effect on the questionnaire's reliability. 78

Even though the questionnaire for the current study did not aim to address a specific construct which is typically the case when using Cronbach's alpha coefficients to test for reliability, it was still an important psychometric property to obtain as it provided an overall assessment of the questionnaire. Thus, certain improvements in the reliability could be made in future studies. Due to time constraints and access to the population of interest, conducting a pilot study for the current study was not possible. Therefore, to develop the current study's questionnaire into a more reliable measure it is necessary to conduct a pilot test using a more heterogeneous population. The low reliability for the current study might have been caused by having relatively few questionnaire items and little variability in the responses. Depending on the results of the pilot study, it might be necessary to make further modifications to improve the reliability. One modification might be to add more questions on oral health practices. For example, "What dental treatments are safe to have during pregnancy?", "Are dental x-rays safe during pregnancy?", "What are some of the oral health issues that pregnant women could experience?" Also, adding a degree of difficulty to all the multiple choice answer options might help to better capture participants' knowledge. Furthermore, it is important to take a closer look at the wording of the questionnaire items to ensure they are not confusing, as despite efforts to prevent misinterpretation, this may still have occurred and affected participants' responses.

Other improvements to the questionnaire could be made to the sections on barriers and oral health experiences. Adding a few questions to determine participant's state of oral health might add some insight into some of the issues they may be dealing with. For example, "Did have you any oral health issues prior to becoming pregnant?" and "Do you 79

have any oral health issues that have developed since becoming pregnant?" Although the

questionnaire for the current study can be improved, it is still a useful tool that can be

used to further investigate women's oral health knowledge and their personal oral health

experiences.

Conclusion

The current study has added important information to the area of oral health and pregnancy. Women were generally well-educated and were of higher SES. Overall, women had adequate knowledge of oral health practices, but their knowledge was lacking when it came to certain oral health practices, especially those regarding oral health care during pregnancy. Overall, women were not aware of the increased risk pregnant women have of developing oral health issues and the ways to prevent these problems.

Furthermore, the majority of women did not know about the link between periodontitis and preterm birth. Participants' knowledge was affected by education, income and their dental check-up attendance. Thus, there was also a gap in knowledge between those participants who were able to afford and maintain regular dental check-ups and those who could not. Although the majority of women reported having regular dental check-up attendance before pregnancy, many women indicated that they would not attend a dental check-up during pregnancy. This shows that, in spite of having the financial means to afford oral health care, many women are still not attending dental check-ups during pregnancy.

Many participants experienced barriers to accessing oral health care and information. Although the main barrier reported was the inability to pay for dental care, there were other barriers that were common across education and income background. 80

Many women reported that they did not receive enough information from their health

care practitioners on oral health during pregnancy, but that they wanted to know more

about this topic. Only a minority of women reported being specifically told by their

health care practitioners to continue with regular dental check-ups during pregnancy.

These findings indicate that low education, income, and not having dental insurance are

not the only barriers that are affecting women's access to oral health care.

Women should be receiving information on oral health from key sources (i.e.,

health care practitioners, dentists, information brochures) before and during pregnancy so

they can improve their oral health knowledge and their oral health care maintenance. In

doing so, perhaps some adverse pregnancy outcomes may be prevented. Health promotion initiatives should focus on finding the most appropriate ways to provide access

to oral health care to women as well as relevant information to health care practitioners,

dentists, and women. Future research should focus on further investigating what oral health information women need and how to effectively provide this information to women. Also, investigating the beliefs of health care practitioners in Canada about oral health and pregnancy could also provide useful information. Future studies should also investigate what, if any, changes in prenatal care guidelines and/or health policies can be made to provide solutions to these issues, so that women may be well informed on and have adequate access to oral health care during pregnancy. 81

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Appendix A: Questionnaire "Oral Health During Pregnancy"

SECTION ONE We would like to know a little more about you... 1. How would you best describe your age? a. I am under 18 b. I am between 18-24 c. I am between 25-29 d. I am between 30-34 e. I am between 35-39 f. I am over 40

2. What is your level of education? a. Didn't graduate from high school b. Graduated from high school c. Some university education d. Diploma e. Bachelor's degree or higher f. Other (Please explain)

3. What is your average household income per year? a. Under $25,000 b. $25,000-$50,000 c. $51,000-$70,000 d. $71,000-$100,000 e. Over $100,000

4. Where do you currently live? City Province

5. Do you currently have a dental care insurance plan? a. Yes b. No c. Other (Please explain)

6. What stage of pregnancy are you in presently? a. First trimester (first three months) b. Second trimester (three to six months) c. Third trimester (last three months)

7. How many deliveries have you had (including delivery by caesarian section)? a. One b. Two c. Three d. Four or more e. None 94

SECTION TWO (To facilitate reading of this thesis, the correct answers for the oral health knowledge questions of the questionnaire have been denoted by an asterisk (*), but questionnaires given to participants were not marked in this way.)

Please answer the following questions about dental health knowledge by circling your answer.

1. What is plaque? a. Soft bacterial deposit buildup on gums * b. Hard deposit buildup on gums c. Staining on teeth d. Not sure

2. What could plaque cause? a. Discoloration of teeth b. Malformation of teeth c. Gum disease * d. Not sure

3. What do bleeding gums indicate? a. Inflamed gums * b. Healthy gums c. Gum recession d. Not sure

4. How can gum disease be prevented? a. By eating a soft diet b. By brushing and flossing * c. By taking vitamin C d. Not sure

5. How important do you think brushing is? a. Very important * b. Somewhat important c. Not important d. Not sure

6. When is the most appropriate time for brushing? a. In the morning b. Midday c. Before going to bed d. More than once * e. No need for brushing f. Not sure 95

7. How important do you think flossing is? a. Very important * b. Somewhat important c. Not important d. Not sure

8. When is the most important time for flossing? a. Before brushing * b. After brushing c. It doesn't matter d. Not sure

9. Do you think pregnant women more susceptible to gum disease? a. Yes * b. No c. Depends on each woman d. Not sure

10. What causes inflamed gum disease in pregnant women? a. Dental plaque b. Hormonal changes * c. Neglecting to floss and brush teeth d. Plaque and neglecting to floss and brush e. Not sure

11. Regarding tooth brushing and flossing during pregnancy, which of the following is true? a. Tooth brushing and flossing should increase during pregnancy * b. Tooth brushing and flossing should decrease during pregnancy c. Tooth brushing and flossing should not change d. Not sure

12. When do you think is the best time to receive dental treatment during pregnancy? a. First trimester b. Second Trimester * c. Third Trimester d. All of the above e. Never during pregnancy f. Not sure

13. Do you think smoking during pregnancy has a negative effect on the unborn newborn? a. Yes * b. No c. Possibly 96

d. Not sure

14. Do you think gum disease is linked with preterm labour? a. Yes * b. No c. Possibly d. Not sure

SECTION THREE

Please tell us about your dental care experience... *Please note: A dental check-up is defined as an examination by a dentist and cleaning. 1. How often did you attend dental check-ups BEFORE this pregnancy? a. I do not attend dental check-ups b. At least twice a year c. Once a year d. Less than once a year e. Other (Please explain)

2. If you answered "A" to the previous question (#1), what is the main reason for you NOT attending regular dental visits BEFORE this pregnancy? a. Fear b. Anxiety c. It's not apriority d. I have no time e. It's not important f. Financial g. Other

3. How often are you attending dental check-ups DURING this pregnancy? a. I do not attend dental check-ups b. At least twice a year c. Once a year d. Less than once a year e. Other (Please explain)

4. If you answered "A" to the previous question (#3), what is the biggest reason for you NOT attending regular dental checkups DURING pregnancy? a. Fear b. Anxiety c. It's not a priority d. I have no time e. It's not important 97

f. Financial g. Other

5. Has anyone recommended you have regular dental checkups during pregnancy? a. Yes b. No c. Not Sure

6. If you answered "Yes" to the previous question (#5), who recommended it? a. Dentist b. Obstetrician c. Spouse d. Family member e. Friend f. Other (Please explain)

SECTION FOUR 1. Is there anything you would like to tell us about your experience of "going to the dentist" during your pregnancy? (If you need more space please use the back of this sheet). 98

2. What prevents you from having positive and informative dental health care? (If you need more space please use the back of this sheet).

3. What would help you get regular dental care? 99

Appendix B: Questionnaire Scoring Key

Section One: Demographics

Questionnaire items 1 through 7 resulted in descriptive statistics for each participant. The answers to items 1-5 resulted in a description of participants' education, income, dental plan insurance coverage status and current place of residence. Answers to items 6-7 were used to describe the stage of pregnancy and number of deliveries for participants.

Section Two: Knowledge of Oral Health and General Health During Pregnancy

For questionnaire items 1 though 14 there was one correct answer. Answers were coded as 1 = correct answer and 0 = incorrect/unknown/unanswered answer. In order to know exactly what each participant's responses were to each item, the SPSS database was created so that an answer would have to be inputted for each answer option of each item. For example, a participant answered option "a" for item number one. In the database it was entered as follows: la = 1, lb = 0, lc = 0, Id = 0. This way, the data of participants' exact responses would not be lost by only coding it as a correct or incorrect answer. For each participant, the number of correct answers were added up for a total score and defined into the following variables. Questionnaire items 1 though 8 were used to calculate the variable 'general oral health care knowledge'. Questionnaire items 9 through 12 were used to calculate the variable 'pregnancy oral health care knowledge'.

Questionnaire items 13 and 14 were used to calculate the variable 'risk of adverse pregnancy outcomes knowledge'. Answering questionnaire items correctly gave a high score and an incorrect answer or answering "Not sure" gave a low score. 100

Section Three: Barriers and Access to Oral Health

Questionnaire items 1 and 3 were used to calculate the variables 'dental check up attendance before pregnancy' and 'dental check up attendance during pregnancy'. Items 1 and 3 had a choice of responses to indicate how often participants' attend dental check ups and answers were coded as follows: 4= Twice a year; 3= Once a year; 2= Less than once a year; 1= I do not attend. Questionnaire items 2 and 4 were scored to determine the variable barriers to oral health care. All the participants' responses were added up and the variable "total number of barriers" was created.

Section Four: Women's Experiences About their Oral Health

This section consisted of three open-ended questions where participants were given the opportunity to share their experiences on oral health and any barriers that they experienced in accessing oral health. The answers to these questions were categorized as described in Chapter Three (p. 33). In addition if participants' listed or included within their answer barriers to oral health that were not included in Section Three (above) they were added to each of their "total number of barriers" score. 101

Appendix C: Consent Form

INFORMATION LETTER FOR STUDY Participant Information

IWKTfeftb Centre Research Title

"What do pregnant women know about oral health during pregnancy and what are the barriers they experience to maintaining oral health?"

Dear Participant,

You are being invited to take part in the research study named above. This torm provides information about the study. Before you decide if you want to take part, it is important that you understand the purpose of the study, the risks and benefits and what you will be asked to do. You do not have to take part in this study. Taking part is entirely voluntary (your choice). Informed consent starts with the initial contact about the study and continues until the end of the study. Because this study is a questionnaire study, you are not required to sign a consent form. By completing the questionnaire you will be giving your consent to take part in the study. If you have any questions please contact a member of the research team (contact information is provided below). You may decide not to take part or you may withdraw from the study at any time. This will not affect the care you or your family members will receive from the IWK Health Centre in any way.

Researcher(s)

Katina Garduno - Master's student in Health Promotion at Dalhousie University o Supervisor: Dr. Lynne Robinson, Dalhousie University, (902) 494-1157 - • Dr. Lynne McLeod, IWK Health Centre, (902) 470-8888

Funding

This research is being conducted without specific funding from any agency. 102

Why are the researchers doing the study?

This study is being done to find out what pregnant women know about oral health care during pregnancy and to find out what pregnant women find to be the main barriers to accessing oral health care. Learning this, may help physicians, dentists, nurses and health promotion specialists come up with effective ways to provide information to women about good oral health during pregnancy.

How will the researchers do the study?

This research study is a questionnaire study being conducted in the Perinatal Centre at the iWK Health Care Centre. Pregnant women who are attending an appointment with their Obstetrician or Family Doctor will be invited to participate. We expect to have a total of about 200 women fill out the questionnaire. There are no risks involved in participating and your safety is not being jeopardized in any way.

What will I be asked to do?

First you will be asked to read this study information letter. Then you will be asked to fill out a questionnaire with 29 questions. Questions 1 through 26 are multiple choice and the other three questions require a written answer. Filling out the questionnaire should take you about 5-10 minutes. You may fill out the questionnaire while you are in the waiting room, but may also finish it later before leaving the Perinatal Centre. Stamped returned envelopes are available should you need to complete it later and send it back to us via mail (envelopes are located in a slot on the secure drop off box located at the main registration desk). Attached to the back of the questionnaire there is an information handout inside an envelope that is for you to take home with you. We ask that you wait to open the envelope until after you have completed all the questions. This sheet has information about oral health that you may find helpful. You should also keep this study information letter. We ask that you please put your completed questionnaire inside the secure box located at the main registration desk. This will help us maintain confidentiality.

What are the burdens, harms, and potential harms?

The only potential inconvenience of participating is the time it will take you to complete the questionnaire. You may have some questions or concerns about your oral health after completing the questionnaire. If you have any questions or concerns you are encouraged to contact one of the researchers so we may assist you and/or direct you to further 103 resources. You are encouraged to seek advice from your Dentist if you are concerned. If you do not have access to a dentist through a dental health care plan, a dentist from our research team Is available to consult with you. If you wish to see her you need to contact Katina Garduno first to book an appointment. In addition, I have information about oral health practices and other resources if you would like to learn more (my contact information is provided below).

What are the possible benefits?

Taking part in this study may be of no help to you personally, however, it may be informative to you. It is hoped that what is learned from the results will be of future benefit to pregnant women by helping us find better ways to provide education about oral health during pregnancy.

What alternatives to participation do I have?

This study is a volunteer study and you are not required to participate unless you want to. Your care will not be affected in any way.

Can I withdraw from the study?

Even if you decide to participate you may still withdraw from the study at any time.

Will the study cost me anything and, if so, how will I be reimbursed?

There is no cost to participating in this study. If you are not able to complete the questionnaire before you leave the Perinatal Centre there are stamped return envelopes available at the main desk so you may complete the questionnaire later and send it to the researcher without any cost to you.

Are there any conflicts of interest?

There are no conflicts of interest in this study.

What about possible profit from commercialization of the study results?

There are no possible profits to be made from the results of this study. 104

How will I be informed of study results?

The results of this study will be available in early 2008. Due to the nature of the study individual results will not be available because identifying information is not attached to each questionnaire. However, if you would like a copy of the final results please contact me via phone or email so it can be arranged (contact information is provided below). You may also wish to visit our website to see updates on the study and to see the final results. The website address is: http://pregnancyandoralhealthknowledge.blogspot.com

How will my privacy be protected?

The protection of your information is of highest priority to us. We will do everything to keep the answers you provide strictly confidential. You are not required to sign a consent form so you do not need to reveal any personal identifying information to us. If you would like more privacy while completing the questionnaire there is a designated area in the waiting room that will allow you to complete the questionnaire more privately. Look for the poster "Oral Health During Pregnancy Study". In order for us to maintain confidentiality once you complete the questionnaire we ask that you please place your questionnaires inside the secure box located at the main registration desk in the Perinatal Centre. We can only protect the questionnaires once they are in the box so please do not leave them anywhere other than inside the secure box. Also, do not write your name anywhere on the actual questionnaire so we may protect your anonymity. Once the study is complete, only the researchers will have access to the questionnaires. All the information you provide will never be identifiable back to you. The information collected will be kept in a locked filing cabinet for a maximum of 5 years after publication. Secure storage of the results is required should there be any future inquiries as to how the study was conducted. Also, there is a possibility that the IWK Ethics Committee may do an audit of this research study. If this happens, members of the committee will have access to the collected data, however, it will be treated with strict confidentiality and used only for the purpose of the audit. After 5 years from when this study is published, all information will be shredded and destroyed. 105

What if I have study questions or problems?

If you have any questions or concerns you may contact the researchers:

*Katina Garduno *Dr. Lynne McLeod Email: [email protected] Email: [email protected] Phone number: (902) 446-2849 Phone number: 470-8888

What are my Research Rights? "By completing the questionnaire you are indicating that you have understood to your satisfaction the information regarding your participation in the study and agree to participate as a subject. In no way does this waive your legal rights nor release the investigator, the research doctor, the study sponsor or involved institutions from their legal and professional responsibilities".

If you have any questions at any time during or after the study about research in general you may contact the Research Office of the IWK Health Centre at (902) 470-8765, Monday to Friday between 9a.m. and 5p.m 106

Appendix D: Oral Health Information Sheet

(Association of Women's Health Obstetrics and Neonatal Nurses (AWHONN) Lifelines Patient Page, 2004) C

Patient Page How Oral Care Affects Your Baby's Health

When you're pregnant, your gums may look red or three to four months pregnant, makes your gums extra- swollen and bleed when you brush or floss your teeth, sensitive to bacteria in dental plaque. If these bacteria This is because your body's hormones are busy working are not thoroughly removed every day. this can lead lo Where can I go for more to make your body baby-friendly. Progesterone, a female gum infections like gingivitis and periodontitis. information? hormone found in your gum tissue by the time you are • Association of Women's Health, Gum Disease & Prematura Babies Obstetric and Neonatal Nurses: More & more research is linking gum disease during times the risk! Dental cleanings during pregnancy have www.awhonn.oif> pregnancy with an increased risk of having an been shown to reduce the risk of early delivery. underweight, premature baby; in fact, three to eight • March of Dimes: (888)M0DIMESor VA'AV. mod i mes.org FACT; YOU Share Your Cavities With Your Baby

Moms with untreated tooth de:ay can put theit babies decay can cause children to have trouble eating and at risk for getting cavities. Bacteria are shared through sleeping. Untreated, children can weigh less and not saliva, for example, when food is tested before baby eats grew as tall as other kids their age. Help save your or pacifiers are cleaned in Mom's mouth. Painful tooth baby's teeth & health—eel all your cavities filled!

What Can I Do to Promote Oral Health?

See your dentist & dental hygienist early to get your Avoid sugary snacks—if you crave sweets, have your mouth in shape and plan needed treatment. A sweet treat right after a meal, when there is more checkup & routine dental hygiene care can be done saliva to help wash away the sugars. at any time. Avoid dental x-rays. Infections need If you vomit, rinse with 'A t. baking soda in 1 cup of treatment right away. warm water to neutralize the acid. Wait for 30 Clean your mouth carefully every day. Brush two minutes before brushing with toothpaste containing times a day for two minutes, especially before bed. fluoride to strengthen damaged enamel. Fluoride Brushing at the gum line and cleaning between your rinses can also help strengthen weakened teeth. teeth with dental floss every day will help keep your Can't brush right after eating? Chew sugar-free gums healthy. Ask your dentist or hygienist about gum for 10 minutes or eat some cheese, both which brushing and flossing techniques work best for reduce your chances of getting tooth decay. your mouth and gums. And when baby arrives . . . Learn how to clean your Eat healthy foods, especially those high in Vitamin A, baby's mouth and teeth when they come in. Take your C, D, calcium S phosphorus. Baby teeth start forming baby for a dental visit by his or her first birthday to by the time you are 6 weeks pregnant. A healthy check for early siens of tooth decay and learn haw to pregnancy helps your baby to have smooth, strong keep your baby's teeth and gums healthy. A teeth that are less likely to decay. Correlation matrix of predictor and dependent variables Education Income Insurance Deliveries Referral DCKUPBEF DCKUPDUR GOHK PGOHK RAVEFK Total Barriers

Education 0.444** 0.115 -0.141 0.082 0.198* 0.137 0.227* 0.182* 0.201* -0.091

Income 0.444** 0.387** 0.011 0.115 0.329** 0.209* 0.160 0.209* 0.132 -0.291**

Insurance 0.115 0.387** -0.028 0.214* 0.235** 0.190* 0.107 0.109 0.059 -0.251**

Deliveries -0.141 0.011 -0.028 -0.132 -0.130 -0.067 0.059 0.015 -0.110 0.061

Referral 0.082 0.115 0.214* -0.132 0.198* 0.189* 0.159 0.152 0.157 -0.104

DCKUPBEF 0.198* 0.329** 0.235** -0.130 0.198* 0.578** 0.138 0.179* 0.307** -0.502**

DCKUPDUR 0.137 0.209* 0.190* -0.067 0.189* 0.578** 0.213* 0.166 0.298** -0.422**

GOHK 0.227* 0.160 0.107 0.059 0.159 0.138 0.213* 0.133 0.243** -0.096

PGOHK 0.182* 0.209* 0.109 0.015 0.152 0.179* 0.166 0.133 0.336** -0.041

RAVEFK 0.201* 0.132 0.059 -0.110 0.157 0.307** 0.298** 0.243** 0.336** -0.156

Total Barriers -0.091 -0.291** -0.251** 0.061 -0.104 -0.502** -0.422** -0.096 -0.041 -0.156

** Correlation is significant at the 0.001 level (2 tailed) * Correlation is significant at the 0.05 level (2 tailed) DCKUPBEF = Dental Check-Ups Before Pregnancy DCKUPDUR = Dental Check-Ups During Pregnancy GOHK = General Oral Health Knowledge PGOHK = Pregnancy Oral Health Knowledge RAVEFK = Risk of Adverse Effects Knowledge Where can !! get more information? I 1 !i III II Some helpful websites: - Canadian Dental Association I '' "I Mil 11 III II III I! ' www.cda.ca - American Academy of Periodontology Information Booklet > www.perio.org •aa a - March of Dimes 3 9* www.marchofdimes.com ><" - Health Canada www.hc-sc.gc.ca Some local resources: *—*- o' - Nova Scotia Public Health / 3 A CO o www.gov.ns.ca/health IWK Health Centre o - Nova Scotia Dental Association www.nsdental.org - Nova Scotia Community Services IWK Health Centre (Information on assistance to cover 5850/5980 University Avenue medical costs) P.O. Box 9700 www.gov.ns.ca/coms/employment/inc Halifax, Nova Scotia ome_assistance/index.html B3K 6R8 www.iwk.nshealth.ca - Dalhousie School of Dentistry (902) 470-8888 (Supervised student clinics) www.dentistry.dal.ca/patient/index.html ORAL HEALTH IS IMPORTAN"! COMMON QUESTIONS DURING PREGNANCY (continued)

Going to regular dental check-ups is an Q. How can I keep my gums and teeth healthy during important part of your overall health. pregnancy?

When you become pregnant, it is still A. Eating a healthy diet, not smoking and taking care of very important to continue with your Healthy Gums-, your teeth are the best ways to keep your mouth regular dental care. healthy. It is important to floss and brush your teeth HeailfiyBonef regularly. During pregnancy, it is recommended that During pregnancy, hormone changes can women brush more often, but make sure you do it make women's gums more sensitive. gently and with a soft bristled toothbrush. It's also a Pregnant women are also more likely to good idea to floss at least once a day before you brush. get "pregnancy gingivitis" and other oral Also, go to regular dental check-ups and ask your health problems. That's why it is dentist about any concerns you might have. important to continue to see your Q. Are dental check-ups safe during pregnancy? dentist, so any problems can be prevented. This picture shows that periodontal disease A. Yes, most regular dental care is absolutely safe, it is (gum disease) can damage the gum, tooth important that your dentist is aware you are pregnant. Studies have also found that women and the bone that holds the tooth in place. Your dentist will discuss any treatment options with you who have periodontitis (gum disease) before anything is done. are 4 to 7 times more likely to have a COMMON QUESTIONS Q. What if I don't have a dentist or I can't afford to go preterm baby (a baby born before 37 to the dentist? weeks). Dental treatments have been You might have some concerns about your oral found to help reduce the risk of having a health or about going to the dentist while A. If you don't have a dentist we recommend you ask preterm baby. That's why it is very pregnant. Here are the answers to some your doctor, friends or family for recommendations. important for women to make sure they common questions women have. You can also check in the phone directory because have good oral health before and during many dentists take new patients. If you can't afford pregnancy. Q. How often should I have a check-up? regular dental check-up it is important that you talk to A. It is recommended people have check-ups your doctor about this. They may be able to give you Make sure you discuss any questions or every 6 months. But check with your dentist information on low-cost options. concerns with your doctor or dentist. to make sure your treatment is specific to your needs. Pregnant women may need to go o more often if they have any problems come *0 up during their pregnancy.