Australian Dental Journal

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1 Australian Dental Journal The official journal of the Australian Dental Association SCIENTIFIC ARTICLE Australian Dental Journal 2013; 58: doi: /adj The oral health status, practices and knowledge of pregnant women in south-western Sydney A George,* M Johnson, A Blinkhorn, S Ajwani, S Bhole, AE Yeo,** S Ellis *Senior Research Fellow, Centre for Applied Nursing Research, The University of Western Sydney, Ingham Institute for Applied Medical Research/South Western Sydney Local Health District, New South Wales, Australia. Director, Centre for Applied Nursing Research, Professor of Nursing, School of Nursing and Midwifery, The University of Western Sydney, Ingham Institute for Applied Medical Research/South Western Sydney Local Health District, New South Wales, Australia. NSW Chair of Population Oral Health, Faculty of Dentistry, The University of Sydney, New South Wales, Australia. Head, Oral Health Research, South Western Sydney Local Health District Oral Health Services and Sydney Dental Hospital, Clinical Senior Lecturer, Faculty of Dentistry, The University of Sydney, New South Wales, Australia. Area Clinical Director, South Western Sydney Local Health District Oral Health Services and Sydney Dental Hospital, Clinical Associate Professor, Faculty of Dentistry, The University of Sydney, New South Wales, Australia. **Consultant Biostatistician, National Institutes of Health, USA. Antenatal Services Manager, Camden and Campbelltown Hospitals, South Western Sydney Local Health District, New South Wales, Australia. ABSTRACT Background: Current evidence highlights the importance of oral health during pregnancy. However, little is known about the oral health of pregnant women in Australia. The aim of this study was to report the oral health status, knowledge and practices of pregnant women in south-western Sydney. Methods: A cross-sectional survey of 241 pregnant women attending a large hospital in south-western Sydney. Results: More than half (59.3%) reported dental problems during pregnancy, less than a third (30.5%) saw a dentist in the last six months, only 10% had received any information about perinatal oral health and many (>50%) were unaware of the potential impact of poor maternal oral health on pregnancy and infant outcomes. Analysis revealed a significant difference (<0.05) in the uptake of dental services among pregnant women who had higher household incomes, private health insurance, received information about perinatal oral health and knowledge about maternal oral health. Conclusions: The participants reported significant barriers to obtaining dental care including limited access to affordable dental services and lack of awareness about the importance of maternal oral health. The findings suggest the need for preventive strategies involving dentists and antenatal providers to improve maternal oral health in Australia. Keywords: Oral health, pregnancy, antenatal care, dental service, Australia. Acronym: SWS = south-western Sydney. (Accepted for publication 13 June 2012.) INTRODUCTION Maintaining oral health during pregnancy has been recognized as an important public health issue worldwide. Research continues to show an association between gum disease (gingivitis and periodontitis) and adverse pregnancy outcomes such as low birth weight and premature births. 1,2 A recent Australian study found that women with prenatal loss due to extreme maturity were more than four times as likely to have periodontal disease, compared to women with full term, live born infant. 2 Mothers with untreated dental caries will also pass on cariogenic bacteria to their children through inappropriate feeding practices. 3 5 It is now recommended that all women should receive a comprehensive oral health evaluation and risk assessment during pregnancy. 6,7 Although there is debate over the efficacy of periodontal treatment in preventing adverse pregnancy outcomes, 8,9 it is clear that dental treatment during pregnancy is safe and will significantly improve the oral health of mothers and reduce the risk of infants developing early dental caries. 6,7,10 However, pregnant women often don t seek dental advice and treatment during pregnancy. 11 For example, less than half (44.7%) in the USA consult a dentist during pregnancy, even when an oral problem exists. 12 In Australia, the dental utilization rate among pregnant women appears to be even lower, ranging from 30% to 36%. 13,14 Various factors have been cited that deter women from seeking dental care during pregnancy, such as socio-economic and Australian Dental Association

2 Oral health during pregnancy socio-cultural factors, lack of public awareness of the importance of oral health and concerns for foetal safety during dental treatment. 7,15 18 Many developed countries have implemented strategies to try to improve pregnant women s oral health which have included utilizing prenatal care providers to improve maternal oral health 19 (USA) and offering pregnant women free access to public dental services (UK and Greece). 13,20 However, in Australia there is a lack of emphasis on perinatal oral health with current initiatives focusing mainly on the postnatal period, particularly on early interventions for children. 11 This is of concern especially for women from socioeconomically disadvantaged backgrounds, who are more vulnerable to poor oral health due to the limited access to public dental services and the high cost of dental treatment in the private sector. 21 Little is known about the oral health of pregnant women in Australia but existing research suggests that they are poorly informed about the implications of poor oral health during pregnancy and experience barriers to accessing dental services during this period. 13,14,22 Before any oral health strategies can be planned for Australian women, the extent of the problem needs to be further explored. The aim of this study was to report the oral health status, knowledge and practices of pregnant women from south-western Sydney (SWS), a socio-economically disadvantaged area of Sydney. The research questions included: (1) How prevalent are dental problems among pregnant women in SWS? (2) How knowledgeable are pregnant women about perinatal oral health? (3) What are the oral hygiene habits and practices of pregnant women in SWS? (4) What are the experiences of pregnant women accessing dental services during pregnancy? (5) What are the factors that may influence the uptake of dental services among pregnant women? METHODS Sample and setting A cross-sectional survey of pregnant women attending the antenatal clinic in a large metropolitan hospital in south-western Sydney, New South Wales was undertaken. Ethical approval was obtained from the South Western Sydney Local Health District Human Research Ethics Committee and written consent was obtained from all participants. A convenience sample of 314 pregnant women was invited to participate by a dental assistant within the antenatal clinic. Surveys were administered by the dental assistant to all interested participants. Data items and procedure The survey administered was structured and contained items relating to oral health and care (including prevalence of dental problems), frequency of dental visits, barriers to seeking dental care, oral hygiene habits, perceptions of oral health, knowledge about oral health and access to dental care. Sociodemographic data including age, education, ethnicity, period of gestation, employment and household income were also collected. Many of the items used were selected from large national and international oral health surveys Two standardized items that have been found to be reliable in other studies 26,27 were also included, namely: (1) Do you have bleeding gums, toothache, cavities, loose teeth, sensitive teeth, teeth that do not look right or other problems in your mouth? (2) Have you had a dental visit in the last six months? A dental assistant attended the antenatal clinic two days a week for 20 weeks to recruit participants and provide the 15-minute self-complete questionnaire. All women in the antenatal clinic, whether or not they participated, received an education pack and oral hygiene products (n = 314). Data analysis The survey data were analysed using SPSS (Statistical Package for Social Sciences Version 17.0, 2008). Descriptive statistics such as mean and standard deviation for continuous variables and frequency and percentage for categorical variables were calculated and tabulated. Descriptive and inferential statistics such as the chi-square test was used to compare the profiles of pregnant women who had visited a dentist in the last six months with those who did not. The level of significance used was RESULTS Demographic characteristics Of the 314 pregnant women invited to participate, 241 completed the survey, giving a 77% response rate. The age of the participants ranged from 16 to 44 years with a mean age of 28.1 years (SD 5.6). The majority (85.9%) were in the age bracket of years (Table 1). Most women were born in Australia with 25.7% (95% CI ) born overseas which is similar with population data for the area (26.2% born overseas). 28 Most were married or in a de facto relationship (89.6%). More than half the participants (55.2%) were not engaged in employment and 46.1% (95% CI 2013 Australian Dental Association 27

3 A George et al. Table 1. Socio-demographics and obstetric characteristics of participants (n = 241) Characteristics Frequency (%) 95% CI Age (years) (85.9) (11.2) Country of Birth Australia 179 (74.3) Overseas 62 (25.7) Highest qualification achieved No qualifications 111 (46.1) Vocational college 74 (30.7) University 53 (22) Employment status at recruitment Working full-time 58 (24.1) Working part-time 43 (17.8) Not working 133 (55.2) Average annual household income <$ (20.3) $ to less than $ (32) $ to less than $ (20.7) >$ (5.4) Don t know 36 (14.9) Refused 13 (5.4) Health Care Card Yes 84 (34.9) No 153 (63.5) Private Health Insurance Yes 47 (19.5) No 191 (79.3) Parity Primipara 68 (28.2) Multipara 171 (71) Period of gestation 1 st trimester 7 (2.9) nd trimester 80 (33.2) rd trimester 151 (62.7) Missing data (range 3 7). Excludes schooling up to year ) had no formal qualifications. Over half the participants (52.3%) were from low to middle income families (<$ and $ <$80 000) and just over a third (34.9%, 95% CI ) had health care cards (health care cards are provided to Australian residents who are low income earners, i.e. annual household income <$ or weekly <$872, which entitles them to cheaper prescription medicines and public hospital expenses). 29,30 These figures are fairly consistent with population data from the area which show that 53.1% have no formal qualification and 33.2% have annual household incomes of less than $ (<800/week). 28 The majority of women surveyed (62.7%) were in their third trimester and had other children (71%). Oral health status The majority of women claimed that their oral health status was average to good (75.5%) with just over half [53.9% (n = 130)] reporting at least one oral health problem during their current pregnancy (Table 2). The most common oral health problems Table 2. Perceived oral health status of pregnant women (n = 241) Variables Frequency (%) 95% CI Oral health status Excellent 26 (10.8) Good 71 (29.5) Average 111 (46.0) Fair 21 (8.7) Poor 12 (5.0) Self-reported oral health problems None 111 (46.1) One problem 70 (29.0) Two or more problems 60 (24.9) Type of oral health problems (n = 130) Bleeding gums 78 (60.0) Toothache 22 (16.9) Cavities 54 (41.5) Loose teeth 4 (3.1) Sensitivity 27 (20.1) Teeth that don t look right 19 (14.6) Dental problems affected what to eat and overall health in general (n = 130) Never 65 (50.0) Sometimes 54 (41.5) Often 11 (8.5) Importance of dental health compared to overall health Not important 5 (2.0) Neutral 44 (18.3) Important 80 (33.2) Extremely important 112 (46.5) Multiple responses. reported by the 130 participants who gave information were bleedings gums [60%, 95% CI (n = 78)], cavities [41.5%, 95% CI (n = 54)], sensitivity [20.1%, 95% CI (n = 27)] and 50% (n = 65) reported that dental problems had sometimes/often affected both what they could eat and overall health in general. These figures are higher than population data for New South Wales where 25.3% of women between 15 to 34 years reported cavities (coronal decay) and 21.3% reported bleeding gums (gingival inflammation). 31 Nearly 80% noted that their dental health was important/extremely important compared to their overall health, but only 10% had received any information about oral health care during pregnancy, the main source of information being oral health promotion material such as pamphlets and brochures (87.5%). Other information sources included antenatal care providers (29.2%) and dentists (12.5%). Oral health practices Less than a third (30.5%) of the women surveyed had seen a dentist in the last six months. Further, only 45.6% had seen a dentist in the last 12 months which is lower than the 62.1% reported in the population data for similar aged women (15 34 years) (Table 3). The main reported dental services accessed by pregnant women were private practitioners [74.7% Australian Dental Association

4 Oral health during pregnancy Table 3. Dental care of pregnant women (n = 241) Variables Frequency (%) 95% CI When was the last time you saw a dentist? <6 months 73 (30.5) to <12 months 36 (15.1) yrto <2 yrs 59 (24.7) yrs to <5 yrs 41 (17.2) >5 yrs 24 (10.0) Never visited 6 (2.5) Barriers in seeking dental treatment (n = 72) Safety concerns regarding 23 (31.9) treatment during pregnancy Dental costs 21 (29.2) Time constraints 21 (29.2) Oral health not seen as a priority 15 (20.8) Advised by antenatal care 3 (4.2) providers not to seek treatment How often do you brush? A few times a week 3 (1.2) Less than once a week 3 (1.2) Once a day 65 (27.0) Twice a day 162 (67.2) More than twice a day 8 (3.4) Oral hygiene products used Flouride toothpaste 237 (98.3) Mouthwash 98 (40.7) Dental floss 103 (42.7) Sugar free gum 86 (35.7) Missing data (n = 2). Multiple responses. (n = 180)] while the remaining consulted the public dental service [21.2% (n = 51)]. Of the 130 women who reported dental problems, 55.4% (n = 72) did not consult a dentist. The main barriers to seeking dental care for these women (Table 3) were safety concerns regarding dental treatment during pregnancy (31.9%), dental costs (29.2%) and time constraints (29.2%). In terms of oral hygiene habits, more than two-thirds of women [67.5% (n = 162)] reported brushing twice a day with a fluoride toothpaste [98.3% (n = 237)]. Other oral hygiene products used included mouthwash (40.7%), dental floss (42.7%) and sugar-free gums (35.7%). Oral health knowledge The mean percentage of total correct responses for the 10 knowledge items was 79.1% (SD = 14.2) which indicated that the pregnant women had good knowledge about maternal and infant oral health, especially relating to good oral hygiene habits during the perinatal period (Table 4). However, analysis of the individual knowledge items showed that pregnant women had inadequate knowledge about the potential impact of poor maternal oral health. Less than half the women were aware that dental decay could spread from the mother to the baby s mouth (47.5%) and that a mother s poor oral health may contribute to low birth weight (47.5%). It is also evident that some confusion exists among pregnant women regarding Table 4. Percentage of correct participant responses by individual survey item (n = 241) Item content Flossing should be done daily to clean in between teeth (True) Routine dental visits help keep teeth and gums healthy (True) Pregnant women should avoid dental treatment unless it is an emergency (False) Dental decay or cavities can spread from the mother to the baby s mouth (True) A mother s poor oral health may contribute to low birth weight (LBW) baby (True) The first tooth usually appears at around 6 months of age (True) Sleeping with a bottle containing formula could cause holes on a baby s teeth (True) Cavities on baby teeth are OK because they will fall out anyway (False) When is the best time for a baby to have the first dental visit? (Between 2 and 3 years of age) A baby drops a pacifier on the floor. The mother puts it in her mouth to clean it and then puts it in her baby s mouth. Is this ok or not ok to do? (Not ok) Correct responses% Note: All questions marked were presented in a multiple choice format. All other questions required an answer of True or False. the appropriateness of accessing dental care both during pregnancy and early childhood. Nearly a third of pregnant women (32.5%) were unsure about the best time for a baby to have the first dental visit and 26.1% felt that dental treatment should be avoided during pregnancy unless it is an emergency (Table 4). A comparison of dental attenders and non-attenders in the last six months was undertaken using the variables shown in Table 5. As there were limited responses in some categories, variables marked with were regrouped to satisfy the chi-square assumptions that no expected frequency should be less than 1 and no more than 20% of the frequencies should be less than The results showed a significant difference in the uptake of dental services among pregnant women who had higher household income, private health insurance, received information about oral health during pregnancy and knowledge about the impact of poor maternal oral health. The influence of other socio-demographic indicators such as education and employment on dental visits was not evident. Likewise, perceived oral health status, self-reported oral health problems and accessibility to dental care were not significantly different between the groups. DISCUSSION This study sought to provide further insight into the oral health of pregnant women in Australia by reporting the perceived oral health status, practices and Australian Dental Association 29

5 A George et al. Table 5. Comparison of profiles of pregnant women who visited a dentist in the last 6 months (n = 73) with those who did not (n = 166) Variables Dental visit last 6 months Yes (%) n = 73 No (%) n = 166 v 2 value (df) P value Highest educational level Secondary 14 (19.4) 25 (15.2) (3) 0.08 High school 13 (18.1) 57 (34.8) Vocational college 27 (37.5) 47 (28.7) University 18 (25.0) 35 (21.3) Employment status Working 32 (44.4) 70 (43.2) (1) 0.86 Not working 40 (55.6) 92 (56.8) Health Care Card Yes 23 (31.9) 60 (36.8) (1) 0.47 No 49 (68.1) 103 (63.2) Average annual household income <$ (23.6) 30 (18.3) (5) 0.015* $ to 18 (25.0) 59 (36.0) <$ $ to 24 (33.3) 26 (15.9) <$ >$ (1.4) 12 (7.3) Don t know 8 (11.1) 28 (17.1) Refused 4 (5.6) 9 (5.5) Private Health Insurance Yes 23 (31.9) 24 (14.6) 9.4 (1) 0.002* No 49 (68.1) 140 (85.4) Oral health status Excellent 9 (12.3) 17 (10.2) (4) 0.42 Good 27 (37.0) 43 (25.9) Average 28 (38.4) 82 (49.4) Fair 6 (8.2) 15 (9.0) Poor 3 (4.1) 9 (5.4) Self-reported oral health problems None 33 (45.2) 76 (45.8) (2) 0.11 One problem 27 (37.0) 43 (25.9) Two or more problems 13 (7.8) 47 (28.3) Oral health information received during pregnancy Yes 14 (19.2) 10 (6.0) (1) 0.002* No 59 (80.8) 156 (94.0) Aware of association between poor maternal oral health and LBW Yes 42 (57.5) 72 (43.4) (1) 0.044* No 31 (42.5) 94 (56.6) Aware that dental decay can spread from mothers mouth to baby s mouth Yes 45 (61.6) 68 (41.0) (1) 0.003* No 28 (38.4) 98 (59.0) Aware that dental treatment is safe during pregnancy Yes 60 (82.2) 118 (71.1) (4) 0.07 No 13 (17.8) 48 (28.9) Accessibility to dental care Very easy 23 (31.9) 40 (24.8) (4) 0.30 Easy 16 (22.2) 36 (22.4) Average 15 (20.8) 55 (34.2) Difficult 13 (18.1) 22 (13.7) Very difficult 5 (6.9) 8 (5.0) Variable regrouped as explained on previous page. *Statistically significant (<0.05). knowledge of pregnant women from SWS. The findings from this study confirm other research 22 that pregnant women in this area of Sydney have a high reported prevalence [53.9% (n = 130)] of dental problems. This rate is consistent with earlier studies in Australia (range 49.8% 13 to 60% 14 ) and confirms that poor maternal oral health is a serious issue. One of the main reasons for poor maternal oral health is the hormonal variations and dietary changes that occur during this period which puts pregnant women at a higher risk of suffering various dental problems. 11 This is reflected in the findings with a higher prevalence of dental problems seen in the pregnant women than the general population. Exacerbating the situation is the limited number of women that actually seek dental advice during pregnancy even when a dental problem exists. 7 The low uptake of dental services among pregnant women is well documented worldwide and is evident in Australia as well. 11,12,15 18 The findings from this study show that only around 30% of pregnant women are utilizing dental services in Australia which is fairly consistent with previous reports of 30% to 36% from prenatal and postnatal surveys of women living in another city in Australia (Adelaide). 13,14 The low utilization of dental services is of serious concern especially considering a number of pregnant women here reported that their dental problems had affected their diet and overall health in general. Having an inadequate diet and poor oral health during pregnancy can be detrimental to the health and well-being of the baby. 33 According to this study the low uptake of dental services during pregnancy can be attributed to a number of factors, one being the cost of dental services. The issue of cost was highlighted by close to 30% of study participants and comparison analysis showed that pregnant women with higher household incomes were more likely to seek dental treatment than those on lower incomes. This is an expected finding as SWS, where this study was conducted, contains a large proportion of socio-economically disadvantaged families that are either unemployed or have low incomes and rely on welfare benefits from the government. 34 Further, it is well documented that high dental costs are a significant barrier for pregnant women seeking dental care both internationally 7,35 and in Australia. 13,14,22 A survey of 649 pregnant women attending antenatal care in South Australia found that more than half the women (59.3%) had delayed their dental appointments due to dental costs. 13 This disincentive was reiterated in a qualitative study of pregnant women in SWS. 22 Although dental costs are a frequently cited barrier for pregnant women, it seems to be more of an issue in Australia than other developed countries. In the USA, affordable dental treatment is available to pregnant women from low income families through the Medi-Cal programme 36 while in both Greece and the UK pregnant women have access to free dental treatment during the perinatal period. 13,20 Unfortunately, in Australia, pregnant women have limited Australian Dental Association

6 Oral health during pregnancy access to affordable dental services. Reports indicate that due to the long waiting list to access public dental services, less than 10% of low income families who are eligible for such services are able to access them. 21 Further, the average cost of consulting a private dentist in Australia is about $296 per hour which is unaffordable for most families, especially those without private health insurance. 21 It is thus no surprise that this study found that pregnant women who had private health insurance were more likely to see a dentist than those who did not. Clearly more effective strategies need to be put in place to offer Australian women, especially those who are socio-economically disadvantaged, affordable and accessible dental services. Another contributing factor to the low uptake of dental services is the lack of awareness among pregnant women about the importance of maternal oral health. Less than half the women surveyed were aware about the potential ill-effects of poor oral health during pregnancy, which could explain why 20% of the women did not view oral health as a priority (Table 3). However, most participants did have good knowledge about oral hygiene habits which was reflected in their practices with more than two-thirds brushing twice a day and using fluoride toothpaste. The results of this study also revealed that pregnant women who consulted a dentist were more likely to be those who had received information about perinatal oral health and were aware of the association between poor maternal oral health and adverse pregnancy and infant outcomes. This is consistent with earlier studies 12,13,17,22 which show that pregnant women are unaware of the importance of maternal oral health and consequently avoid seeking regular dental care. This study also shows that this lack of awareness among pregnant women, especially in Australia, can be attributed to the limited information on perinatal oral health that is provided to them by antenatal care providers. Only 10% of women in the study had received any information about oral health care during their pregnancy, with the main source of information being oral health promotional material rather than antenatal care providers. This finding is strongly supported by other research in SWS which showed that antenatal care providers in Australia, especially midwives, do not routinely include oral health as part of antenatal care. 11,37 A particularly worrying finding was that nearly a third of the women avoided consulting a dentist because of safety concerns regarding dental treatment. This is a commonly cited barrier for pregnant women seeking dental care 7,11 even though it is well established that dental treatment during pregnancy is extremely safe and will not result in adverse pregnancy outcomes. 12 There also appears to be some confusion among women regarding the appropriate time to seek dental treatment during pregnancy and early childhood. Although not evident in this study, other researchers have reported that mothers believe that poor oral health is normal during pregnancy and a tooth may be lost with each child. 7,13 This problem of misinformation may be attributed to the lack of information being provided to pregnant women on oral health care by antenatal care providers. However, it is also possible that antenatal care providers may be contributing to the problem by providing conflicting advice on perinatal oral health. For example, a few women in this study were advised by antenatal care providers not to seek dental treatment. Although this issue was not prominent in our study, other papers 35,38,39 report that there is no real consensus among dentists and prenatal care providers regarding oral health care during pregnancy. For example, gynaecologists are supportive of dental treatment during pregnancy 39 but some dentists and doctors remain confused about the safety of dental procedures. 11,35 Receiving such conflicting messages from health professionals could deter pregnant women from seeking dental treatment. Clearly there is a need for clinical practice guidelines on perinatal oral health. Time constraints appear to be another limiting factor for pregnant women with some women reporting that they did not have sufficient time to seek dental treatment during pregnancy. This may be due to the fact that the majority of women had other children to care for and many were engaged in active employment. Studies show that getting time off work is a frequently cited barrier for low income families seeking dental appointments as many will not have leave entitlements. 7 Due to such time constraints, pregnant women may need to have access to flexible dental care such as private dentists. An antenatal survey of expectant mothers in Malaysia 18 found that private dental services were a more convenient option for pregnant women than public dental services as they are more accessible after hours and on weekends. Therefore, private dental practitioners should be included in any strategies to improve maternal oral health. This is especially important in Australia where the majority of dental services are provided by the private sector. It is evident from the findings that current policies and systems in Australia are not meeting the oral health needs of pregnant women. This view is strongly supported by a recent review which found that unlike other developed countries, Australia does not offer pregnant women regular oral assessments and prompt dental treatment during the antenatal period. 11 In order to address this issue, it is clear from this study that a multidimensional approach needs to be adopted. First, the affordability of dental care for pregnant women in Australia must be addressed and 2013 Australian Dental Association 31

7 A George et al. one way of achieving this could be by allowing pregnant women who are eligible (have a health care card) priority access to the public dental services. Such efforts have been implemented in the state of Victoria 40 where pregnant women are offered the next available appointment in the public dental service without being put on the waiting list. However, other states have, as yet, to implement similar measures. Other options could include providing targeted dental plans for pregnant women similar to the Medicare Teen Dental Plan and the new Child Dental Benefits Schedule that reimburses (up to a certain amount) private dental practitioners providing the treatment. 41 Additionally, pregnancy could be included in the current Oral Health for Fee Service Scheme 42 which can provide pregnant women (via vouchers) the option of consulting a participating private dental practitioner. Another aspect that needs to be addressed is the role of antenatal care providers in promoting maternal oral health in Australia. Clearly more emphasis needs to be placed in this area as it is a strategy that is strongly recommended internationally 7 to deliver best practice during antenatal care. Doctors and midwives are the first point of health care contact and can play a vital role in educating pregnant women and improving their awareness about oral health care during pregnancy. Such efforts can help address many of the concerns and misconceptions pregnant women have on this issue, which in turn could influence their oral health practice and potentially improve the uptake of dental services. Current initiatives in Australia such as the midwifery-initiated oral health programme 22 which involves educating midwives about perinatal oral health and incorporating oral health guidelines into their practice is a step in the right direction. However, it is important that such efforts should also extend to other antenatal care providers such as doctors and nurse practitioners. One way of driving this forward is to develop perinatal oral health guidelines for dentists and antenatal care providers in Australia. Having such guidelines will help ensure that all relevant health professionals are agreed on the importance of oral health care during pregnancy and have evidence based information to reduce the conflicting messages that may be offered to pregnant women. CONCLUSIONS This study has provided valuable insight into the oral health of pregnant women in SWS. The prevalence of poor oral health was substantial with more than half the women having poor oral health and the majority not consulting a dentist for their problems. Although the study sample mostly reflects a socioeconomically disadvantaged population which may not be representative of all pregnant women in the country, the results confirm that poor maternal oral health is a significant issue in Australia with most pregnant women not seeking treatment for their dental problems. Expectant mothers have limited access to affordable and accessible dental services. Further, they are not receiving adequate information about oral health care through their antenatal care providers and hence are unaware of its importance. There is an urgent need for researchers, clinicians and policymakers to develop effective strategies to address this important yet neglected aspect of dental care in Australia. ACKNOWLEDGEMENTS Funding for this study is gratefully acknowledged from the NSW Centre for Oral Health Strategy and the Australian Dental Association (NSW Branch). REFERENCES 1. George A, Shamin S, Johnson M, et al. Periodontal treatment during pregnancy and birth outcomes: a meta-analysis of randomised trials. Int J Evid Based Healthc 2011;9: Shub A, Wong C, Jennings B, Swain JR, Newnham JP. Maternal periodontal disease and perinatal mortality. Aust N Z J Obstet Gynaecol 2009;49: American Academy of Pediatric Dentistry. Policy on Early Childhood Caries (ECC). Unique Challenges and Treatment Options. Chicago: AAPD, URL: guidelines/p_eccuniquechallenges.pdf. Accessed October Yost J, Li Y. Promoting oral health from birth through childhood: prevention of early childhood caries. Am J Matern Child Nurs 2008;33: Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. J Paediatr Child Health 2006;42: American Academy of Pediatric Dentistry. Guideline on Perinatal Oral Health Care. Chicago: AAPD, URL: aapd.org/media/policies_guidelines/g_perinataloralhealthcare. pdf. Accessed October California Dental Association. 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8 Oral health during pregnancy 13. Keirse MJNC, Plutzer K. Women s attitude to and perceptions of oral health and dental care during pregnancy. J Perinat Med 2010;38: Thomas NJ, Middleton PF, Crowther CA. Oral and health care practice in pregnant women in Australia: a postnatal survey. BMC Pregnancy Child Birth 2008;8: Dinas K, Achyropoulos V, Hatzipantells E, et al. Pregnancy and oral health: utilisation of dental services during pregnancy in northern Greece. Acta Obstet Gynecol Scand 2007;86: Machuca G, Khoshfeiz O, Lacalle JR, Machuca C, Bullon P. The influence of general health and socio-cultural variables on the periodontal condition of pregnant women. J Periodontol 1999;70: Al-Habashneh R, Guthmiller JM, Levy S, et al. Factors related to utilization of dental services during pregnancy. J Clin Periodontol 2005;32: Saddki N, Yusoff A, Hwang YL. Factors associated with dental visit and barriers to utilisation of oral health care services in a sample of antenatal mothers in Hospitak University Sains Malaysia. BMC Public Health 2010;10: Stevens J, Iida H, Ingersoll G. Implementing an oral health program in a group prenatal practice. J Obstet Gynecol Neonatal Nurs 2007;36: National Health Service. What are my rights during pregnancy? URL: SubCategoryID= Accessed April New South Wales Parliament. Dental services in NSW. Report by Standing Committee on Social Issues, URL: 11E86CA256FE4000BE787. Accessed September George A, Johnson M, Duff M, Ajwani S, Bhole S, Blinkhorn A, Ellis S. Midwives and oral health care during pregnancy: perceptions of pregnant women in South-Western Sydney, Australia. J Clin Nurs 2012;21: Carter KD, Stewart JF. National Dental Telephone Interview Survey AIHW cat. no. DEN 109. Adelaide: AIHW Dental Statistics and Research Unit, California Department of Public Health. Maternal and Infant Health Assessment (MIHA) survey, URL: cdph.ca.gov/data/surveys/pages/maternalandinfanthealthassessment(miha)survey.aspx. Accessed 12 October Department of Health. The NHS Oral Health Assessment Final Report URL: Accessed October New York State Department of Health. Oral health care during pregnancy and early childhood: practice guidelines (No. 0824). Albany, NY: New York State Department of Health, Jeganathan S, Purnomo J, Houtzager L, Batterham M, Begley K. Development and validation of a three-item questionnaire for dietitians to screen for poor oral health in people living with human immunodeficiency virus and facilitate dental referral. Nutrition & Dietetics 2010;67: Campbelltown City Council. Community Profile, URL: type=enum. Accessed October Department of Families, Housing, Community Services and Indigenous Affairs. Health Care Card, URL: facs.gov.au/about/benefits/concessions/pages/healthcarecard.aspx. Accessed October Department of Human Services. Low Income Health Care Cards. URL: payments/conc_cards_iat.htm. Accessed April Australian Institute of Health and Welfare. The National Survey of Adult Oral Health : New South Wales, URL id= Accessed November Yates D, Moore D, McCabe G. The Practice of Statistics. New York: WH Freeman, Fitzsimons D, Dwyer JT, Palmer C, Boyd LD. Nutrition and oral health guidelines for pregnant women, infants, and children. J Am Diet Assoc 1998;98: Sydney South West Area Health Service. Year in Review 2006/ URL: Accessed August Strafford K, Shellhaas C, Hade E. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal Med 2008;21: Department of Health Care Services. Dent-Cal URL: Accessed April George A, Johnson M, Duff M, et al. Maintaining oral health during pregnancy: Perceptions of midwives in Southwest Sydney. Collegian 2011;18: George A, Shamim S, Johnson M, et al. Perceptions of dental and prenatal care practitioners towards dental care during pregnancy: current evidence and implications. Birth (in press). 39. Morgan MA, Crall J, Goldenberg RL, Schulkin J. Oral health during pregnancy. J Matern Fetal Neonatal Med 2009;22: Dental Health Services Victoria. Public Dental Services who is eligible URL: Accessed November Department of Human Services. Medicare Teen Dental Plan and Medicare Chronic Disease Dental Scheme, URL: teen-dental.jsp. Accessed 1 November NSW Health. Oral Health Fee for Service Scheme, URL: pdf. Accessed November Address for correspondence: Dr Ajesh George Centre for Applied Nursing Research The University of Western Sydney Ingham Institute for Applied Medical Research South Western Sydney Local Health District Liverpool BC Locked Bag 7103 NSW ajesh.george@sswahs.nsw.gov.au 2013 Australian Dental Association 33