Oral Health Status and Dental Services Utilisation Among a Vulnerable Sample of Pregnant Women

Abstract

Introduction and aims

Oral health conditions during pregnancy can negatively impact both mother and fetus, highlighting the importance of maintaining dental care. In Canada, significant disparities exist between general and dental healthcare access, with limited evidence on oral health status and dental care utilisation among pregnant women. This study aimed to provide initial insights into self-perceived oral health status and dental utilisation patterns among a vulnerable sample of pregnant women in southwestern Ontario.

Methods

This cross-sectional study recruited a convenient sample of pregnant women referred to the Family Medicine and Obstetrics Clinic, serving those without a family physician. Data were collected using a self-administered questionnaire adapted from the Canadian Health Measure Survey, the Canadian Community Health Survey, and the Survey of Maternal Health. Andersen and Newman's framework for health service utilisation was used as the theoretical framework. Descriptive and univariable analyses were conducted, followed by a forward stepwise selection of variables with p-values < 0.1 from the univariable analyses.

Results

One-hundred-fifty patients were approached and 130 (86.7%) completed the questionnaire. Of these, 96 (73.9%) reported their oral health as good/excellent while 34 (26.2%) reported having poor/fair oral health. Education level and quality of life were the strongest predictors of oral health status. While 101 (77.7%) visited a dentist within the last 2 years, only 35 (26.9%) had a dental visit during pregnancy. Toothbrushing frequency was the main predictor of time since last dental visit, with no other predictive factors once toothbrushing was considered.

Conclusion

The study sample showed relatively positive self-perceived oral health and dental visit patterns. However, the low rate of dental visits during pregnancy highlights the need for better integration of dental care into prenatal care. To ensure maternal and child health, pregnant women should be a high priority in policies aimed at improving access to dental care.

Introduction

During pregnancy, hormonal fluctuations, changes in eating and snacking patterns and changes in oral hygiene practices can increase women's vulnerability to oral conditions such as gingival inflammation, periodontal diseases, and dental caries.¹ Periodontal diseases are prevalent in 40% of pregnant women globally² and are often correlated with adverse pregnancy outcomes such as preterm birth and low birth weight.³ Moreover, the pain and discomfort resulting from oral health conditions can compromise pregnant women's overall health and quality of life.⁴ Therefore, good oral health maintenance and prevention of oral diseases such as periodontal disease and dental decay during pregnancy are crucial for the general health of both pregnant women and their fetuses.⁵

Understanding how pregnant women perceive their oral health is crucial as it can influence their healthcare-seeking behaviors during pregnancy and thereafter.⁶ It is recommended that self-perceived oral health treatment needs should be considered for clinical examination and treatment, as this indicator exhibits good sensitivity in revealing actual oral health problems.⁷ Several studies have employed self-perceived data to evaluate the oral health status of pregnant women.^6,8, 9, 10 While certain oral conditions, such as periodontal problems, may be challenging for patients to perceive accurately, previous research has shown the acceptable validity of self-reported periodontal diseases,¹¹ as well as other conditions like dental caries and missing teeth.¹²

Existing literature has identified factors such as education level,^8,13, 14, 15 race/ethnicity,¹⁴ and income⁸ as predictors of oral health status during pregnancy. In addition to sociodemographic influences, health behaviors like dental hygiene practices¹⁵ and dental services utilisation^10,15 also play crucial roles in determining oral health outcomes during this period. Dental visit avoidance can potentially exacerbate oral health issues during this period which underscores the importance of integrating preventative care and comprehensive oral examination into prenatal care.¹⁶

However, there is a worldwide tendency among pregnant women to avoid visiting a dentist.^17,18 Evidence shows that globally, the prevalence of dental visit avoidance typically falls below 50%¹⁸ and can be as low as 10% in certain regions.¹⁹ Several factors contribute to pregnant women underutilising oral health care services.²⁰ Socioeconomic disparities present barriers to dental visits, where lower education levels often lead to poorer oral health knowledge and therefore behaviors.²¹ Ethnic minorities encounter challenges due to cultural beliefs and discrimination, exacerbated by language barriers, particularly among immigrant communities.^21,22 Literature also showed that unfavorable beliefs, such as concerns about fetal harm from dental treatments, deter dental visits during pregnancy.²³ Cost and lack of dental insurance are also significant barriers to dental visits in most parts of the world, with higher income levels often mitigating these obstacles.^18,20

In examining barriers to dental care services utilisation, previous studies have applied the Andersen and Newman (A&N) framework for health service utilisation.²⁴ This framework highlights individual factors affecting healthcare access, including predisposing (sociocultural characteristics that exist before a health condition emerges), enabling (factors that facilitate access to care at individual and community levels), and need factors (individuals’ perception of their health status and/or healthcare providers’ assessment of their health).²⁵ In addition to the comprehensive view of the multifaceted reasons behind the underutilisation of dental care, this framework is beneficial in understanding the source of individual and environmental disparities which can be due to social factors, financial limitations, or lack of awareness of oral health issues. This can lead policymakers to plan for targeted interventions in future. Despite its potential utility, this theoretical framework has seldom been applied to this demographic.¹⁰

Furthermore, the body of research focusing on oral health status and the patterns of dental care utilisation among pregnant women, especially in Canada, is notably limited.^10,26 In Canada, significant disparities exist between healthcare and dental care access for the general population. While healthcare is universally provided through the publicly funded system, dental care often remains accessible only to those who can afford private insurance or out-of-pocket expenses.²⁷ This gap disproportionately affects vulnerable populations, including pregnant women, who are prone to oral health conditions and may face unique challenges in accessing dental services.²⁸ Due to the high importance of oral health during pregnancy, disparities in dental care compared to general healthcare in Canada especially for vulnerable populations, and the gap in data focusing on expectant mothers in Ontario, this exploratory study aims to provide baseline data on self-perceived oral health status and patterns of oral health service utilisation among pregnant women drawn from a prenatal clinic which services patients who do not have access to family doctors. This choice of source population aligns with the emphasis of the Global Oral Health Action Plan – Action 32 on addressing oral health throughout the life course, including pregnancy, with a focus on the poor, vulnerable, and marginalised members of society.²⁹ Moreover, the unique demography is more likely part of a more vulnerable population that has limited access to comprehensive healthcare and may share similar reasons for limited access to care such as being an immigrant. Specific research questions include:

• 1.What is the self-perceived oral health status among a sample of pregnant women in southwestern Ontario, and how do predisposing factors from the A&N framework influence it?
• 2.What are the dental visit patterns of a sample of pregnant women in southwestern Ontario, and how do predisposing, enabling, and need factors from the A&N framework influence them?

Hypotheses:

• h1. There will be no significant association between the predisposing factors from the A&N framework and the self-perceived oral health status of the sample.

• h2. There will be no significant association between the predisposing factors from the A&N framework and the time since last dental visit among the sample.

• h3. There will be no significant association between the enabling factors from the A&N framework and time since the last dental visit among the sample.

• h4. There will be no significant association between the need factors from the A&N framework and time since the last dental visit among the sample.

Methods

Sample

The study adhered to the STROBE (STtrengthening the Reporting of OBservational studies in Epidemiology) guidelines for cross-sectional studies (Appendix A). Ethical approval was obtained from the Western University Health Science Research Ethics Board (Review Reference: 2022-121440-70801) and Lawson Health Research Institute (Approval number: R-22-505). Participants were recruited from the Family Medicine Obstetrics Clinic at London Health Sciences Centre, Ontario. This clinic specialises in providing antenatal care to pregnant women who do not have a family physician or other antenatal care provider. The reasons for this may vary, including individuals being newcomers to Canada, relocating to London from other areas, or facing challenges in accessing comprehensive family medicine services in Ontario.

Participant recruitment took place in the clinic during 2 rounds: from November 8th to December 6th, 2022, and from May 1st to May 30th, 2023. On each clinic day, approximately 15-25 pregnant women receive antenatal care. Among them, typically 2 to 3 are new registrants, while the rest attend regular follow-up visits. Each round of participant recruitment initially yielded a promising pool of potential participants. However, due to the nature of sequential care, as the study progressed, an increasing fraction of clinic patients in attendance had already been recruited into the study on their prior visit(s); thus, there was a decline in the number of new potential subjects available for recruitment.

Eligible participants were pregnant women aged 18 or older. Prior to initiating the study, the objectives, consent form, questionnaire, and recruitment process were discussed with clinic nurses and the clinic assistant in a 30-minute meeting. This ensured that all participants received the same instruction and information and therefore a consistent data collection to improve internal validity. Potential participants were approached by clinic staff, who provided a brief explanation of the study and presented the consent form. Upon reviewing the informed consent document, individuals who expressed their willingness to participate were given a 33-item questionnaire (Appendix B). To improve the reliability of the measure through language support, the questionnaire was available in English, Arabic, or Spanish, and if a participant was unable to read or speak any of these languages, an interpreter (provided by the London Health Services Center (LHSC) as part of routine care) assisted with questionnaire completion. To prevent duplication, the clinic assistant utilised a tracking system to avoid re-approaching individuals who had already agreed to or declined participation in the questionnaire. Completed questionnaires were assigned an ID code and completion date. Due to the exploratory nature of this preliminary study, no formal sample size calculation was undertaken. The results of this study will guide future sample size calculations in similar populations.

Survey questions

The construction of the questionnaire included questions adapted from 3 established instruments: the Canadian Community Health Survey (CCHS) – 2019,³⁰ the Survey of Maternal Health,³¹ and Canadian Health Measures Survey (CHMS).³² The questionnaire development was guided by the objectives and intended analysis within the context of the A&N framework of health service utilisation. Two dentists and 3 specialists in maternal health reviewed the final questionnaire to ensure it covered all relevant aspects.

Study variables

Dependent variables

The 2 dependent variables were self-reported oral health status (dichotomised to poor/fair and good/very good/excellent³³) and the time since last dental visit dichotomised to “equal to or less than 2 years ago” and “more than 2 years ago”.

Independent variables

Independent variables are itemised below, organised by the 3 domains of the Andersen and Newman framework including predisposing, enabling, and need factors.²⁵

Predisposing variables collected were age (categorised into 18 to 21, 22 to 34, and 35 to 43 years old), education (did not complete high school, high school diploma or equivalency certificate, trade school or vocational college or some community college/university, or complete college/university) trimester, marital status (married, living common law, or other), birth country (Canada or other), language (English or non-English), refugee status (Yes or No), years in Canada (dichotomised as equal to or less than 5 years and more than 5 years),³⁴ self-reported general health status and quality of life (QoL) (both dichotomised to poor/fair and good/very good/excellent,³⁵ medical condition (mental health conditions, physical health conditions, or none), morning sickness (Yes or No), substance use (Yes or No), and tooth brushing (twice a day or more, once a day, less often) and dental flossing frequency (daily, weekly, less often).

Enabling factors collected were employment status (employed part-time, employed full-time, unemployed, on prenatal/maternity leave, or other), annual income (in CAD $40.000 quantiles with the last category being equal to or more than CAD $80.000), possession of dental insurance (Yes or No), and COVID-19 as a barrier to dental visits.

Need variables collected included oral health importance (rated on a 5-level Likert scale ranging from extremely important to not important) and self-reported oral health status (investigated as both a dependent variable (objective 2) and a predictor for the time since last dental visit (objective 3)).

Statistical analysis

Data were imported and analyzed using STATA 18.0. Frequencies (percentages) were used to describe all predisposing, enabling, and need factors as well as the self-reported oral health status and dental visit patterns.

Before conducting any univariable analysis, some categorical variables were re-coded due to cell size considerations. These variables included age (dichotomised at maternal age of 35 years),³⁶ education (high school or lower versus post-secondary education), medical condition (mental and/or physical health conditions versus no health conditions), employment status (categorised as unemployed, employed (part-time or full-time), or other (including maternity leave, self-employment, student, Ontario Disability Support Program recipients, Ontario Works beneficiaries, and Stay-At-Home Mothers)), oral health importance (extremely important versus less important), and time since last dental visit was (equal to or less than 2 years ago versus more than 2 years ago (including never)).

For univariable analysis, Fisher's exact test for statistical significance (p < .05) was used to determine the associations between the predisposing factors from the A&N framework and oral health status. Similarly, the association between predisposing, enabling, and need factors with time since last dental visit was examined using Fisher's exact test. Variables with a p-value equal to or less than .1 in the univariable analyses (p ≤ .1 Fisher's exact test) were considered for entry into a multivariable logistic regression with forward stepwise variable selection with a significance level of p < .1 to construct a predictive model. Model fit was assessed using the Hosmer–Lemeshow goodness of fit test.³⁷ The significance of associations was defined at p-value < .05.

The missingness of 2 variables with a high missing rate (“number of years in Canada” [6.8%] and “income” [15.4%]) was deemed to be Completely At Random (MCAR) and the missing rate of other variables was less than 5 percent.³⁸ Therefore, Complete Case Analysis was taken to deal with missing data.

Results

Study sample

An attempt was made to recruit a 183 pregnant women who presented at the Family Medicine Obstetrics Clinic over the study period. However, a complete census was not obtained (33 could not be approached) due to either the cancellation of their appointments or the clinic assistant's workflow during rush hours. One-hundred-thirty-one of those approached agreed to participate with an overall participation rate of 87.3%. One questionnaire was incomplete and therefore not included in the data analysis (Figure 1). Given the exploratory nature of this preliminary study, a formal sample size calculation was not conducted, as the primary aim of this study was to gather initial insights and identify potential trends for further investigation.

Fig. 1.

Sampling flow of participants recruited from the family medicine obstetrics clinic, Southwestern, Ontario.

Characteristics of the study sample

Table 1 presents the frequency distribution of the independent variables organised according to the 3 A&N framework domains (predisposing, enabling, and need factors). Regarding predisposing factors, the mean age of the participants was 30.4 (SD: ± 5.0) years. A majority of 96 (73.6%) women were in the age range of 22 to 34 years. One-hundred-eleven (85.4%) respondents were English speakers. Eighty-six women were married (66.2%) and regarding the education level, 84 (64.6%) women had completed college or university. Eighty-eight (67.7%) participants were born in countries other than Canada (Albania, Argentina, Bhutan, Brazil, Cameroun, China, Colombia, Egypt, Ghana, Guatemala, Hungary, Iran, Iraq, India, Italy, Jamaica, Kuwait, Lebanon, Libya, Mexico, Nigeria, Pakistan, Philippines, Saudi Arabia, Spain, Syria, Turkey, the United States, the United Arab Emirate, and Venezuela) out of which, 15 (17.1%) had refugee status. Among non-Canadians, 58 (70.3%) respondents came to Canada equal to or less than 5 years ago and the longest time in Canada was 24 years. Almost one-third (76.6%) had no diagnosed medical conditions; however, 85 (65.4%) had experienced morning sickness during their pregnancies. Ten (7.8%) respondents used at least one substance (cigarette, alcohol, or cannabis). Regarding oral hygiene practices, 98 (75.4%) individuals reported brushing their teeth at least twice a day and 38 (29.7%) stated daily use of dental floss.

Table 1.

General characteristics according to predisposing, enabling, and need domains in a sample of pregnant women recruited from the family medicine obstetrics clinic, southwestern Ontario.

Characteristics	Distribution of responses n (%)
Predisposing factors
Age (n = 130)
18-21	7 (5.4)
22-34	96 (73.6)
35-43	27 (20.8)
Language (n = 130)
English	111 (85.4)
Non-English	19 (14.6)
Trimester (n = 130)
First	20 (15.4)
Second	50 (38.5)
Third	60 (46.2)
Marital status (n = 130)
Married	86 (66.2)
Living common law	31 (23.9)
Other	13 (10.0)
Education (n = 130)
Did not complete high school	8 (6.2)
High school diploma or equivalency certificate	22 (16.9)
Some community college/university, trade school/vocational college	16 (12.3)
Complete college or university	84 (64.6)
Birth country (n = 130)
Canada	42 (32.3)
Other	88 (67.7)
Years of living in Canada (n = 82)
≤5 years	58 (70.3)
>5 years	24 (29.3)
Refugee (n = 88)
No	73 (83.0)
Yes	15 (17.1)
Quality of life (n = 130)
Fair, poor	11 (8.5)
Good, very good, excellent	119 (91.5)
General health status (n = 130)
Fair, poor	11 (8.5)
Good, very good, excellent	119 (91.5)
Medical condition (n = 128)
Mental health condition	23 (18.0)
Physical health condition	7 (5.5)
No health condition	98 (76.6)
Morning sickness (n = 130)
No	45 (34.6)
Yes	85 (65.4)
Substance use (n = 129)
No	119 (92.3)
Yes	10 (7.8)
Tooth brushing (n = 130)
Twice a day or more	98 (75.4)
Once a day	30 (23.1)
Less often	2 (1.5)
Dental flossing (n = 128)
Daily	38 (29.7)
Weekly	31 (24.2)
Less often	59 (46.1)
Enabling factors
Employment status (n = 130)
Employed (full-time)	52 (40.0)
Employed (part-time)	10 (7.7)
On maternity leave	9 (6.9)
Unemployed	47 (36.2)
Other	12 (9.2)
Income (n = 127)
<$40.000	50 (39.4)
$40.000-$80.000	32 (25.2)
>$80.000	28 (22.0)
Prefer not to answer	17 (13.4)
Dental insurance (n = 129)
No	50 (38.8)
Yes	79 (61.2)
COVID-19 as a barrier to dental care utilisation (n = 129)
No	97 (75.2)
Yes	32 (24.8)
Need factors (perceived)
Oral health status (n = 130)
Fair, poor	34 (26.2)
Good, very good, excellent	96 (73.9)
Oral health importance (n = 129)
Extremely important	63 (48.8)
Very important	56 (43.4)
Moderately important	9 (7.0)
Somewhat important	1 (0.8)
Not important	0 (0.0)

Note 1: The sample size for each question varies due to missing data or differences in the number of participants who were eligible to answer a question (i.e., years of living in Canada, refugee status, medical condition, dental insurance, COVID-19 as a barrier to dental care utilisation, and oral health importance).

Note 2: Other marital statuses included: separated, divorced, engaged, and never married.

Note 3: Other employment statuses included: self-employed, student, on Ontario Disability Support Program, on Ontario works, and SAHM (Stay-At-Home-Mother).

Regarding enabling factors, 47 (36.2%) participants were unemployed, and 50 (39.4%) participants had an annual income of less than $40,000 CAD. The dental expenses of 79 (61.2%) women were fully or partially covered by a government program or insurance. COVID-19 prevented 32 (24.8%) respondents from having access to dental care services.

Regarding need factors, 63 respondents (48.8%) rated oral health as ‘extremely important’ and no one considered it ‘not important’. Ninety-six participants (73.9%) perceived their oral health as good, very good, or excellent.

Oral health status and associated factors

Figure 2 presents the self-reported oral health symptoms of the survey respondents. Only 18 (13.6%) reported being free of any conditions. Among all respondents, the most prevalent oral health conditions were bleeding gums (49.6%), tooth sensitivity (37.2%), bad breath (23.3%), and swollen gums (19.4%).

Fig. 2.

Self-reported oral health conditions of a sample of pregnant women recruited from the family medicine obstetrics clinic, Southwestern Ontario. (n = 129).Note 1: The percentages add up to more than 100% as participants could report more than one condition. Note 2: There are some errors in the percentages due to rounding. Note 3: Other reported oral health conditions: blocked salivary gland, irritated tongue, increased saliva, and a chipped tooth.

Univariable analyses of factors associated with self-reported oral health status are presented in Table 2. Marital status (p = .004), education level (p = .001), QoL (p = .007), general health (p = .035), and morning sickness (p = .034) were statistically significantly associated with self-reported oral health status. Unlike married women or those with living common law status, women with other marital statuses (separated, divorced, engaged, and never married) were more likely to self-report poor or fair oral health. Participants with post-secondary education were more likely to self-report their oral health status as good to excellent. Similarly, those who indicated a higher QoL or better overall health tended to perceive their oral health more favorably (good, very good, or excellent). Individuals who experienced morning sickness during pregnancy were more likely to report poorer oral health.

Table 2.

Univariable associations with self-reported oral health status in a sample of pregnant women recruited from the family medicine obstetrics clinic, southwestern Ontario.

	Poor or fair n (%)	Good to excellent n (%)	p-value
Predisposing factors
Age (n = 130)			.976
18-34	27 (26.2%)	76 (73.8%)
35-43	7 (25.9%)	20 (74.1%)
Language (n = 130)
English	30 (27.0%)	81 (73%)	.408
Non-English	4 (21.1%)	15 (79.0%)
Trimester (n = 130)
First	8 (40.0%)	12 (60.0%)	.195
Second	14 (28.0%)	36 (72.0%)
Third	12 (20.0%)	48 (80.0%)
Marital Statusa(n = 130)			.004
Married	16 (18.6%)	70 (81.4%)
Living common law	10 (32.3%)	21 (67.7%)
Other	8 (61.5%)	5 (38.5%)
Educationa(n = 130)			.001
High school or lower	15 (50.0%)	15 (50.0%)
Post-secondary education	19 (19.0%)	81 (81.0%)
Birth country (n = 130)			.257
Canada	13 (31.0%)	29 (70.0%)
Other	21 (23.9%)	67 (76.1%)
Years of living in Canada (n = 82)			.351
≤5 years	13 (22.4)	45 (77.6%)
>5 years	7 (29.2%)	17 (70.8%)
Refugee (n = 88)			.749
No	17 (23.3%)	56 (76.7%)
Yes	4 (26.7%)	11 (73.3%)
Quality of lifea(n = 130)			.007
Fair, poor	7 (63.6%)	4 (36.4%)
Good, very good, excellent	27 (22.7%)	92 (77.3%)
General health statusa(n = 130)			.035
Fair, poor	6 (54.6%)	5 (45.5%)
Good, very good, excellent	28 (23.5%)	91 (76.5%)
Medical condition (n = 128)			.280
Mental or physicalhealth condition	10 (33.3%)	20 (66.7%)
No health condition	23 (23.5%)	75 (76.5%)
Morning sicknessa(n = 130)			.034
No	7 (15.6%)	38 (84.4%)
Yes	27 (31.8%)	58 (68.2%)
Substance use (n = 129)			.250
No	30 (25.2%)	89 (74.8%)
Yes	4 (40.0%)	6 (60.0%)
Tooth brushinga(n = 130)			.093
Twice a day or more	22 (22.5%)	76 (77.6%)
Less often	12 (37.5%)	20 (62.5%)
Dental flossinga(n = 128)			.059
Daily	5 (13.2%)	33 (86.8%)
Weekly	10 (32.3%)	21 (67.7%)
Less often	19 (32.2%)	40 (67.8%)

Note 1: Other marital statuses included: separated, divorced, engaged, and never married.

^aIncluded variables in the forward stepwise selection procedure.

Based on univariable p-value < .1, the variables considered for entry into the forward stepwise regression were marital status, education, QoL, general health, morning sickness, and toothbrushing and dental flossing frequency. Three factors remained in the final model (data not shown in a table). Statistical significance was found for 2 of these factors: women with college and/or university education were more likely to report good, very good, or excellent oral health status (p-value .005, OR = 3.7, 95% CI: 1.5 to 9.4) and those who reported a better QoL were more likely to report better oral health (p = .028, OR = 5.0, 95% CI: 1.2- 20.7). Although not significant (p = .063), having morning sickness was negatively associated with better oral health (OR = 0.4, 95% CI: 0.1-1.0). (data not shown in the table)

Dental visit patterns and factors associated with time since last dental visit

Table 3 presents data on the time since last dental visit and the use of dental services during pregnancy. A majority of one-hundred-one (77.7%) participants had visited a dentist within the last 2 years while 5 (3.9%) respondents indicated they had never visited a dentist. Only 35 (26.9%) participants had visited a dentist during their pregnancies. Among these visits, 24 (68.6%) women reported attending for regular checkups and cleaning, while 10 (28.6%) and 5 (14.3%) underwent emergency and non-emergency care, respectively. Of the 91 respondents who reported reasons for not visiting a dentist, cost was reported by 33 (36.3%) as a barrier while 27 (29.7%) thought a dental visit was not necessary and 13 (14.3%) had visited dental professionals before getting pregnant. Out of 32 women who reported COVID-19 as a barrier to dental care services utilisation, 18 (56.3%) were afraid of getting infected.

Table 3.

Dental visit patterns and reasons for visiting and not visiting a dentist reported by a sample of pregnant women recruited from the family medicine obstetrics clinic, southwestern Ontario.

	Distribution of responses n (%)
Last dental visit (n = 130)
Less than 2 years ago	101 (77.7)
2 years ago or more	24 (18.5)
Never	5 (3.9)
Dental visit during pregnancy (n = 130)
No	95 (73.1)
Yes	35 (26.9)
Reasons for dental visit during pregnancy (n = 35)
Regular check-up and cleaning	24 (68.6)
Emergency care	10 (28.6)
Non-emergency care	5 (14.3)
Reasons for not visiting a dentist during pregnancy (n = 91)
Cost	33 (36.3)
Did not think it is necessary	27 (29.7)
Had a dental visit before pregnancy	13 (14.3)
Other	10 (11.0)
Fear of harm to my child	7 (7.7)
Fear of pain	6 (6.6)
Personal/family responsibilities	4 (4.4)
Not available in the area	3 (3.3)
Transportation problems	2 (2.2)
Language barriers	2 (2.2)
How COVID-19 hindered dental care utilisation (n = 32)
Fear of getting infected	18 (56.3)
Lockdown	17 (53.1)
Financial problems due to the pandemic	8 (25.0)
Losing an appointment due to a positive test	3 (9.4)
Poor prevention measures of clinics	2 (6.3)
Dental professionals refused to provide treatment	2 (6.3)
Other	2 (6.3)

Note 1: The sample size for each question varies due to missing data (reasons for not visiting a dentist during pregnancy) or with respect to differences in the number of participants who were eligible to answer a question (the last 3 variables).

Note 2: The percentages may add up to more than 100% as participants could give more than one answer to the last 3 questions.

Note 3: There are some errors in the percentages due to rounding.

Note 4: Other reported reasons for not visiting a dentist during pregnancy: was told by the dental office to wait till after pregnancy for cleaning, not bad pain, need dental work that requires anesthesia (wisdom tooth removal) and fillings - have to wait till after pregnancy, not needed, been said – COVID-19, very sensitive, plan to go before the end of pregnancy, just moved to London, tried one and did not like them - need to find a new one, and long waiting time.

Note 5: The 2 other reported ways COVID-19 hindered dental care utilisation were not specified by the participants.

Univariable analyses of factors associated with time since last dental visit are presented in Table 4. Tooth brushing frequency, a predisposing factor, was the only factor which showed a significant association with time since last dental visit (p = .007). Toothbrushing frequency, dental flossing frequency, and oral health importance were considered for entry into the multivariable model, based on the a-priori consideration of univariable p-value < .1. Only toothbrushing frequency remained in the final model. Those who brushed their teeth at least twice a day had higher odds of having visited a dentist within the last 2 years (p = .003; OR = 4.0, 95% CI: 1.6-9.8).

Table 4.

Univariable associations of last dental visit in a sample of pregnant women recruited from the family medicine obstetrics clinic, southwestern Ontario.

	Equal to or less than 2 years ago	More than 2 years ago	p-value
Predisposing factors
Age (n = 130)			.128
18-34	83 (80.6%)	20 (19.4%)
35-43	18 (66.7%)	9 (33.3%)
Language (n = 130)			.221
English	88 (79.3%)	23 (20.7%)
Non-English	13 (68.4%)	6 (31.6%)
Trimester (n = 130)			.581
First	15 (75.0%)	5 (25.0%)
Second	37 (74.0%)	13 (26.0%)
Third	49 (81.7%)	11 (18.3%)
Marital Status (n = 130)			.181
Married	66 (76.7%)	20 (23.3%)
Living common law	27 (87.1%)	4 (12.9%)
Other	8 (61.5%)	5 (38.5%)
Education (n = 130)			1.000
High school or lower	23 (76.7%)	7 (23.3%)
Post-secondary education	78 (78.00%)	22 (22.0%)
Birth country (n = 130)			1.000
Canada	33 (78.6%)	9 (21.4%)
Other	68 (77.3)	20 (22.7%)
Years of living in Canada (n = 82)			.781
≤5 years	45 (77.6%)	13 (22.4%)
>5 years	18 (75.0%)	6 (25.0%)
Refugee (n = 88)			.316
No	58 (79.5%)	15 (20.6%)
Yes	10 (66.7%)	5 (33.3%)
Quality of life (n = 130)			1.000
Fair, poor	9 (81.8%)	2 (18.2%)
Good, very good, excellent	92 (77.3%)	27 (22.7%)
General health status (n = 130)			.208
Fair, poor	7 (63.6%)	4 (36.4%)
Good, very good, excellent	94 (79.0%)	25 (21.0%)
Medical condition (n = 128)			1.000
Mental or physical health condition	23 (76.7%)	7 (23.3%)
No health condition	76 (77.6%)	22 (22.5%)
Morning sickness (n = 130)			.194
No	38 (84.4%)	7 (15.6%)
Yes	63 (74.1%)	22 (25.9%)
Substance use (n = 129)			.452
No	94 (79.0%)	25 (21.0%)
Yes	7 (70.0%)	3 (30.0%)
Tooth brushinga(n = 130)			.007
Twice a day or more	82 (83.7%)	16 (16.3%)
Less often	19 (59.4%)	13 (40.6%)
Dental flossinga(n = 128)			.068
Daily	33 (86.8%)	5 (13.2%)
Weekly	27 (87.1%)	4 (12.9%)
Less often	41 (69.5%)	18 (30.5%)
Enabling factors
Employment status (n = 130)			.609
Unemployed	35 (74.5%)	12 (25.5%)
Employed	48 (77.4%)	14 (22.6%)
Other	18 (85.7%)	3 (14.3%)
Income (n = 110)			.954
<$40.000	40 (80.0%)	10 (20.0%)
$40.000 to $80.000	25 (78.1%)	7 (21.9%)
>$80.000	23 (82.1%)	5 (17.9%)
Dental insurance (n = 129)			.518
No	37 (74.0%)	13 (26.0%)
Yes	63 (79.8%)	16 (20.3%)
COVID-19 as a barrier to dental care utilisation (n = 129)			.329
No	78 (80.4%)	19 (19.6%)
Yes	23 (71.9%)	9 (28.1%)
Need factors (perceived)
Oral health status (n = 130)			.337
Fair, poor	24 (70.6%)	10 (29.4%)
Good, very good, excellent	77 (80.2%)	19 (19.8%)
Oral health importancea(n = 129)			.094
Extremely important	53 (84.1%)	10 (15.9%)
Less important	47 (71.2%)	19 (28.8%)

Note 1: Due to the small sample size, the two categories of “never” and “2 years ago and more” for the time since last dental visit were combined.

Note 2: For analysis purposes, participants who chose “prefer not to answer” to the annual income question were considered as missing data.

Note 3: Other marital statuses included: separated, divorced, engaged, and never married.

Note 4: Other employment statuses included: maternity leave, self-employed, student, on Ontario Disability Support Program, on Ontario works, and SAHM (Stay-At-Home-Mother).

^aIncluded variables in the forward stepwise selection procedure.

Discussion

Our study focused on a sample of vulnerable pregnant women sourced from an outpatient antenatal clinic in southwestern Ontario to gather baseline information on oral health status and patterns of dental care utilisation. These women were identified as vulnerable due to their lack of access to family physicians or other sources of prenatal care, coupled with their immigrant status. Descriptive statistics revealed that the majority of our sample consisted of recent immigrants to Canada, with over one-third having arrived within the past 5 years. Moreover, significant proportions of the sample lacked dental insurance, or post-secondary education, and had annual incomes below 40,000 CAD. These findings underscore the heightened vulnerability of our study population compared to the broader cohort of pregnant patients, highlighting the imperative for targeted interventions to address their distinct oral health needs.

The majority of study participants reported their oral health as good, very good, or excellent. However, the frequency was modestly lower than that reported by CHMS 2007/2009 for the general Canadian population (74% vs 84%).³⁹ Understanding the reason for this may be important for tailoring oral health interventions and resources to address specific needs within different demographic groups.²⁹ Although most participants reported good to excellent oral health, the majority still experienced at least one oral health symptom, indicating a possible discrepancy between their perception and actual oral health status. This highlights the benefit of regular dental visits for objective clinical examinations, which can provide a clearer understanding of their oral health needs. Notably, one question from the 2-item Maternal Oral Screening (MOS) test – regarding the presence of any oral symptoms/problems – has demonstrated relatively good sensitivity in assessing oral health.⁷ This supports the recommendation for pregnant women to seek further professional evaluation to assess any self-report any symptoms. In this study, the most reported oral health conditions included gum bleeding, tooth sensitivity, bad breath, and swollen gums. These findings align with those of prior research.^40,41 Gum bleeding, in particular, is a prevalent oral health issue during pregnancy, and could be attributed to behavioral changes, hormonal alterations, and changes in oral flora and immune responses.⁴² This emphasises the importance of seeking preventative oral health care during this period for more professional plaque control as well as adhering to oral hygiene practices to alleviate the effects of hormonal alterations.⁴²

In examining predisposing factors from A&N framework which may be associated with self-reported oral health status, we found a strong multivariable association with higher education levels. This finding aligns with the findings of previous studies.^8,13 It has been shown that higher education level is directly associated with better oral health literacy which subsequently improves oral health behaviors such as oral hygiene and regular dental examinations.⁴³ Higher education also correlates with a higher employment likelihood and, thus, better financial status leading to better access to dental care.⁴⁴

Our findings rejected hypothesis h1 by showing strong associations between pre-disposing factors and oral health status. Participants reporting a higher quality of life tended to report better oral health, ranging from good to excellent. This positive correlation aligns with findings from previous research.^4,35 However, given the cross-sectional design of the study, directionality cannot be demonstrated. Thus, the observed association could be attributed to the adverse impacts of poor oral health, such as pain and discomfort, on quality of life.⁴ Further, it's important to note that both the variables QoL and self-perceived oral health were based on a simple Likert scale. The use of self-report data for these measures may lead to aligned responses between these 2 questions, as participants might consistently report their health and well-being perceptions.

Contrary to expectation, our study did not establish a statistically significant association between age and oral health status in multivariable analyses. It is worth noting that our study population was exclusively comprised of individuals of reproductive age, potentially rendering them too young for age-related effects typically observed in studies which include elderly population sub-groups, such as the study by Treasure et al.⁴⁵ However, it is interesting to also note that Kim et al.¹³ identified a negative correlation between age and oral health status in a sample of 1630 pregnant and breastfeeding women aged 19 to 55 years of age. The contrasting findings observed in our study, which included individuals aged 18 to 43 years, might be due to our deficit of participants in the more at-risk age groups. Additionally, our analysis of age as a dichotomous rather than continuous variable precluded the opportunity to assess correlations,⁴⁶ a contrast to Kim et al.’s methodology.

The dental visit patterns revealed that just above half of the participants visited a dentist within the last twelve months. This proportion is lower than survey results in the general Canadian population (65.4%) reported by the most recent CCHS report.⁴⁷ Also, only one-fourth of the participants visited a dental professional during pregnancy, predominantly for regular check-ups. It is important to note that, of those who did not visit a dentist during pregnancy, 14% indicated that this was because they had visited a dentist just before pregnancy. For the remainder of those who refrained from dental visits, cost was the predominant barrier. This is consistent with broader trends in Canada, particularly among immigrants.⁴⁷ This underscores the need for initiatives and reforms such as the Canadian Dental Care Plan (CDCP), introduced in the 2023 budget, aimed at expanding dental care coverage and reducing cost barriers for uninsured Canadians, particularly those with lower incomes.⁴⁷ By addressing financial obstacles to dental care, the CDCP has the potential to significantly improve access to oral health services, particularly among vulnerable populations such as pregnant individuals, thus promoting better oral health outcomes and overall mothers’ and children's well-being.

In our examination of predisposing, enabling, and need factors associated with having had a dental visit in the past 2 years, our findings showed that toothbrushing frequency was the sole predisposing factor with a significant association with time since the last dental visit (hypothesis h2 was rejected). Previous research also showed that individuals who brushed their teeth more frequently were likely to have had a recent dental visit.^48,49 A possible reason for this correlation is the heightened awareness and value placed on oral health by individuals who endure both behaviors, regular toothbrushing routines and dental visits. These individuals may be more informed or motivated about the benefits of preventative dental care, leading them to seek professional check-ups more frequently.

Our results failed to reject hypotheses h3 and h4. Despite literature suggesting that education level, marital status,⁵⁰ language,²² age,⁶ and immigration status²⁶ are correlated with dental care utilisation, these factors were not found to be significantly associated with the time since last dental visit in our study. While our study's small sample size may be responsible for the absence of significant associations with age, language, and marital status, the p-values for the other 2 variables, education and birth country, are so close to 1 that it's unlikely a larger sample size would change these findings significantly. The lack of association between education level and birth country with the time since last dental visit warrants careful consideration, particularly in the context of our sample's distinctive characteristics. Our sample comprises individuals without a family physician, a circumstance that may arise from various factors beyond immigration status., especially since nearly a third of the participants are Canadian. Consequently, the obstacles faced by these individuals in accessing healthcare systems can impact their access to oral health services irrespective of nationality. Similarly, underlying challenges in accessing oral health services can mitigate the advantages and positive outcomes associated with education.

None of the enabling or need factors were shown to be predictors of time since last dental visit in our study. Interestingly, despite reporting cost as the main reason for not visiting a dentist during pregnancy, our findings did not show a significant association between dental insurance possession and time since last dental visit. Our result is in contrast to existing literature which suggests that dental insurance coverage can mitigate the deterrent impact of cost.⁵¹ Al Habashneh et al. showed that pregnant women with dental insurance were almost 5 times more likely to visit a dentist.⁵² In another study conducted in Australia, more than 80% of the participants reported a lack of dental insurance as a barrier to dental care.¹⁹ This discrepancy could be attributed to the inadequacy of insurance plans in covering the oral healthcare needs of our sample. Binary data on dental insurance possession status do not necessarily indicate if the insurance covers patients’ needs. Azarshahri et al. showed that utilisation of oral healthcare services was significantly influenced by having insurance coverage tailored to the participant's specific needs.⁴⁹ However, the mere presence of insurance, regardless of its suitability for the individual's requirements, did not demonstrate a statistically significant association with oral healthcare utilisation. Additionally, a systematic review showed that among barriers to pregnant women visiting the dentist is the lack of awareness of government programs, the eligibility terms for the insurance, and the coverage that is offered.¹⁸ Thus, a public program that covers the costs of prenatal dental care for women, particularly those from financially disadvantaged groups, can enhance dental care utilisation patterns.⁵⁰

Time since last dental visit was not associated with COVID-19 as a barrier to dental care services utilisation. The lack of a significant relationship may be attributed to the fact that the COVID-19 outbreak started in December 2019 (3 years before the start of this study) and is still a concern.⁵³ The time since last dental visit was dichotomised at a 2-year cut point and it is plausible that people who reported fear of getting infected might still avoid dental care for the same reason. While in a study by Choi et al. in which a significant decrease was shown in dental care use patterns due to COVID-19, that study compared pre and post-pandemic circumstances.⁵⁴

Implications and future research

The study underscores the necessity of crafting targeted oral health policies for vulnerable pregnant women. Key implications include advocating for expanded dental coverage akin to the Canadian Dental Care Plan (CDCP), including preventive and routine care during pregnancy to alleviate financial constraints and enhance oral health outcomes. Additionally, integrating oral health assessments and education into standard prenatal care protocols and fostering interdisciplinary collaboration between dental and prenatal care providers is vital to ensure pregnant women receive essential oral health information and referrals for dental care. Future research should focus on evaluating the effectiveness of oral health interventions targeting specific barriers to dental care for vulnerable pregnant women such as financial barriers, lack of oral health literacy, and immigration-specific barriers, and conducting longitudinal studies to monitor changes in oral health over time.

Strength and limitations

This study explored the oral health status and dental services utilisation among pregnant women without family physicians, a clinically important yet understudied demographic, in London, Ontario. By focusing on the Sloe clinic serving this population, the study's localised approach enhances its relevance and potential impact on informing evidence-based strategies to address oral health disparities within this vulnerable group. However, it's important to acknowledge the study's limitations. While there were some factors found to be significantly associated with self-reported oral health and with dental visit utilisation, for factors which failed to show significance, some had wide 95% Confidence Intervals. This may be due to the relatively small sample size, which introduces a threat to precision in estimating effect size. This underscores the importance of future studies with larger sample sizes, for a more nuanced interpretation of results. Social desirability bias is another potential bias in this study which incorporates behavioral questions. However, we attempted to avoid this bias by considering the “prefer not to answer” option where possible and reassuring respondents about the anonymity and confidentiality of this self-administered survey. Additionally, the convenient sampling limits the generalisability of the findings and might introduce selection bias due to voluntary participation. However, it is important to note that the attempt to approach all pregnant women referred to the clinic as well as the high response rate achieved, suggests a potentially representative sample within the target population served by the clinic. While this targeted approach was crucial for gathering data on this specific vulnerable population (pregnant women), it raises questions about the applicability of these results to similar vulnerable groups with potentially different experiences and challenges. To address this limitation, future endeavors will aim to broaden the scope by including diverse source populations.

Conclusions

This study provides baseline data about oral health status and dental services utilisation, as well as factors associated with each, in a sample of pregnant women in southwestern Ontario. Future oral public health planning and policymaking such as the provision of dental insurance and integrating oral health care into prenatal care routines necessitates the availability of preliminary data in this field. Our findings revealed that almost three-fourths of the women reported good, very good, or excellent oral health and over 77% had visited a dentist within the last 2 years. Further studies with larger sample sizes and more diverse populations are needed for a better understanding of pregnant women's unmet oral and dental needs.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Yasaman Mohammadi Kamalabadi, M. Karen Campbell, Robert Gratton, and Abbas Jessani declare NO financial interests or personal relationships that could be perceived as potential competing interests.