Trends in maternal oral health services at primary healthcare centers in Saudi Arabia: a cross-sectional study | BMC Oral Health

Our study described trends in the utilization of dental services by women before, during, and after pregnancy. Our study found that despite the elevated number of dental problems exhibited by women during pregnancy, the prevalence of dental visits during pregnancy was significantly lower than that reported before and after pregnancy. We also found that despite the remarkable increase in dental check-up visits during pregnancy, all other dental services significantly declined.

Most studies have examined only the prevalence of dental visits during pregnancy. A cross-sectional study of Canadian women who visited a community health center for well-child visits reported that 93%, 80.5%, and 28.8% of these women received a dental check-up, preventive dental care, and dental or periodontal treatment, respectively, during pregnancy. Among those who reported receiving dental or periodontal treatment, fillings (32.5%) and extractions (10.0%) were the most frequent services [31]. Our study, however, reported the prevalence of dental services received during pregnancy relative to the need for such services. For example, about 27% of women reported having periodontal problems but only 21% and 6% received dental cleaning or periodontal treatment during pregnancy, respectively. Furthermore, at least 50% of women reported having toothache or tooth decay but only 26% received dental restorations during pregnancy. Therefore, there is a need to increase the rate of preventive and restorative dental services for our population of expectant mothers. Preventive dental visits should include dental evaluation, plaque removal, scaling and root planing, in addition to oral hygiene instructions.

Among the one-third of women who visited a dentist during pregnancy, most (71%) underwent dental checkups. This high percentage can be attributed to the successful implementation of a dental referral policy in PHCs. Prenatal health providers referred these women to the dental clinic for consultation, as per the PHC referral policy. However, the rate of all other dental services decreased significantly during pregnancy compared to that before pregnancy, while their dental problems remained the same as before pregnancy. Dental prophylaxis, a preventive dental service associated with a lower risk of preterm delivery [32], decreased significantly by 40% during pregnancy relative to the rate before pregnancy. Increasing the number of preventive dental visits during pregnancy is among the best practice criteria recommended by the Association of State and Territorial Dental Directors (ASTDD), which shows improved access to oral health care and/or improved oral health status of pregnant women [33]. Dental visits during pregnancy provide an opportunity for dentists to educate and perform dental treatment on expectant mothers who might otherwise be completely occupied after delivery with the care of their newborn and may find scheduling and attending dental appointments difficult [7].

Our findings also highlight the lack of attention paid to women’s periodontal health. Women with periodontal disease were not treated by the general dentists at the PHCs, nor were they referred to periodontists at the specialized dental centers. Further research is needed to explore the reasons for not referring these patients to the specialty centers to receive periodontal treatment. Successful treatment of periodontal disease early in the first trimester of pregnancy or even before becoming pregnant is safe for pregnant women and their unborn children; prevents adverse consequences of periodontitis for the mother, such as toothache and tooth loss; and may improve perinatal outcomes [34, 35].

Another alarming finding of this study was the pregnant women’s report of being prescribed pain medications and antibiotics when they presented to the dental clinic for toothache and/or dental infection, rather than being provided with the necessary dental care. Others were told to come after delivery to prevent potential harm to the fetus from X-rays, local anesthesia, filling material, and extractions. The American Academy of Periodontology has confirmed that the presence of an acute infection, abscess, or other potential sources of septicemia may necessitate prompt intervention, irrespective of the stage of pregnancy [36]. In addition, the interprofessional practice guidelines endorsed by the American College of Obstetricians and Gynecologists (ACOG) and the American Dental Association (ADA), recommend that pregnant women be reassured that oral health care, including the use of radiographs and local anesthesia, is safe throughout pregnancy [37, 38]. The harm of leaving active dental infections in pregnant patients may outweigh the benefits of not providing immediate dental care. Prompt treatment of dental disease before conception and during pregnancy not only benefits the expectant mother but can also prevent infant dental caries by reducing the maternal cariogenic bacterial load, and hence, the transmission of oral bacteria from mothers to children [39].

Our study also reiterates the importance of Andersen’s predisposing (education) and enabling factors such as access to free governmental health care, income, and dental health insurance in pregnant women’s access to dental care [40]. Women with lower educational attainment had a higher prevalence of toothache before pregnancy and a greater need for dental extraction before and during pregnancy. Therefore, increasing women’s awareness of the importance and safety of oral healthcare during pregnancy and integrating it with general healthcare can enhance their oral health practices and increase their access to dental care [41]. The Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) mandates the administration of well-structured preventive dental education for pregnant women in PHCs (Dental and Oral Health Standard 5.3). Although our current health system provides free dental care for Saudi citizens, our results showed that most (80%) women who went for dental care went to private dental clinics because they were unable to receive the necessary dental services at the PHCs. However, the cost of dental care and the lack of dental insurance caused others to forgo dental care. The fact that patients forgo dental care and are exposed to significant costs when they seek care underlines the need for action. Having dental insurance increases the percentage of services delivered to pregnant women. An analysis of the 2017 Medicaid (a public health insurance program for people with low income) dental claims data of pregnant women in Virginia, USA, reported 77.5% treatment, 50.4% preventive, and 93.6% diagnostic dental services among pregnant women [42]. The National Health Insurance Center (NHIC] in Saudi Arabia, an upcoming health reform, will provide free insurance coverage to all Saudi citizens [43]. Hopefully, this coverage will enable women of childbearing age to access dental care during pregnancy and to continue their dental care after delivery. Difficulties in setting up dental appointments, a lack of case management services, unavailability of dentists, and malfunctioning dental units are other barriers that hinder the utilization of dental services in PHCs that need to be resolved [44].

Limitations of our study include the fundamental characteristics of cross-sectional studies. Recall bias among respondents is another limitation; however, women are unlikely to forget a visit to a dentist during pregnancy. Although under-coverage bias is a possible limitation, we do not feel that this limitation had a significant weight on the validity of our study findings. Our study’s relatively large sample size, high response (75%) and low exclusion rates (7%), and coverage of all PHCs in the city make our findings robust and credible. Although our results may not be generalizable to pregnant women who attend private prenatal clinics in Jeddah, they can be generalized to most women attending prenatal health clinics in PHCs in the country. Furthermore, we believe that our study findings are extremely useful to the international dental and obstetric community and to primary healthcare physicians.

The engagement and support of key stakeholders in the healthcare system in Saudi Arabia, whether internal or external to the Ministry of Health, are fundamental to improving oral health care for women during pregnancy and throughout their lifespan. Current health reforms in Saudi Arabia have created an opportunity to enable women of childbearing age to access and utilize basic preventive and treatment dental services in primary healthcare settings. Based on the findings of this descriptive study, several recommendations are proposed to improve the oral health and access of pregnant women to dental care. First and foremost, the education and training of oral health providers on the importance of good oral health to the well-being of expectant mothers. The inclusion of an instructional module in the curriculum of dental schools on the care and management of pregnant women is important for educating future dentists about the importance and safety of providing dental services to women during pregnancy. Another proposed recommendation is to couple every dental examination and oral health education of referred pregnant women with dental prophylaxis. Finally, key performance indicators should be used to monitor dental referrals, dental treatment plans, and dental prophylaxis for pregnant women. The contribution and collaboration of every stakeholder in the provision of oral healthcare for women of childbearing age are crucial for improving the general well-being and oral health of women and their children.