No. 1, January 2005
Dental Care Use Among
Pregnant Women in the United States Reported in 1999 and 2002
Peggy Timothé, DDS, MPH, Paul I. Eke, PhD, MPH, PhD,
Scott M. Presson, DDS, MPH, Dolores M. Malvitz, DrPH
Suggested citation for this article: Timothé P,
Eke PI, Presson SM, Malvitz DM. Dental care use among pregnant women in the United
States reported in 1999 and 2002. Prev Chronic Dis [serial online] 2005 Jan
[date cited]. Available from: URL:
The purpose of this study was to determine national and
state-specific estimates of dental care use among adult pregnant
women in the United States using data from two 12-month periods. The study also
determined person-level characteristics that may predict a lack
of dental care use within this subgroup.
Responses were analyzed from 4619 pregnant women aged 18 to
44 years who participated in the 1999 and 2002 state-based
Behavioral Risk Factor Surveillance System. Dental care
use was defined as having a dental visit or a dental cleaning in the
12 months preceding the interview. State-specific estimates were
adjusted to the 2000 U.S. population distribution. Multivariable
regression analysis was used to evaluate person-level
characteristics that may predict not obtaining dental care during
Overall, 70% of pregnant women in 1999 and 2002 had received
dental care in the previous 12 months. Age-adjusted estimates
ranged from 36% (Nevada) to 89% (Vermont) to 91% (Puerto Rico).
In 19 states, 75% or more of pregnant women had obtained dental
care in the previous 12 months (age-adjusted figure). Most pregnant
women with dental care were non-Hispanic white and married, and
they had a greater than high school education. Income and smoking status
were significant predictors for not using dental care.
In several states, more than 70% of pregnant women reported a dental visit
or dental cleaning during the previous 12 months.
Relative to the general population, pregnant women are as likely to receive dental care, but certain subgroups need to do
much better. However, these estimates may be biased toward a
population with a higher socioeconomic status and may not represent dental care
use among pregnant women in the general U.S.
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An estimated 6 million women in the United States become pregnant each year (1). Although preventive dental care (e.g.,
dental cleaning) will improve the overall health of pregnant
women and may reduce their risk of adverse pregnancy outcomes,
women who are pregnant are known to use dental services less
frequently and at lower levels than the general population (2-4).
An interrelated set of financial, personal, and social barriers
have been identified as possible reasons why subgroups in most
need of dental care may be less likely to receive dental care
Evidence is increasing that poor oral health may be associated
with adverse pregnancy outcomes. Several observational studies
have reported associations between periodontal infections and
increased risk for poor birth outcomes, such as preterm labor or
premature rupture of membranes (6-8). These findings are further
supported by experimental animal studies that found maternal
exposure to periodontal pathogens resulted in abnormal fetal
outcomes (9,10). Preliminary findings from intervention studies
also suggest that treatment of advanced periodontal infections
may reduce the risk of adverse birth outcomes (11,12).
Currently, information is limited at the national and state
levels on patterns of dental care use, particularly dental
cleaning, among pregnant women. The current literature is limited
to estimates from five states (Louisiana, Illinois, New Mexico,
Arkansas, Washington) participating in the Pregnancy Risk
Assessment Monitoring System (PRAMS); the proportion of new
mothers who received dental care during their most recent
pregnancy ranged from 23% to 58% in these
five states (13,14).
The purpose of the present study was to determine national and
state-specific estimates of dental care use (i.e., having a
dental visit or a dental cleaning) during two 12-month periods among
pregnant women aged 18 to 44 years in the United States. These
estimates were generated after combining data obtained in 1999
and 2002 by the Behavioral Risk Factor Surveillance System
(BRFSS). In addition, this study examined person-level
characteristics that predicted not obtaining dental care during
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The BRFSS is a random, state-based telephone survey of major
health risk behaviors, clinical preventive health practices, and
health care access that relies on a representative sample of
noninstitutionalized adults (aged >18) in the 50 states,
District of Columbia, Guam, Puerto Rico, and the U.S. Virgin
Islands. Details of the survey are available elsewhere (15).
All female participants (aged ≤44 years) in the BRFSS survey are asked
about their pregnancy status
with the question, “To your knowledge, are
you now pregnant?” In 1999 and 2002, three oral health questions
were included in the core module, asked of all participants: 1)
“How long has it been since you last visited a dentist or a dental clinic for any
reason?” 2) “How many of your permanent
teeth have been removed because of tooth decay or gum disease?” and 3) “How long has it been since you had your teeth cleaned by
a dentist or dental hygienist?” In the present study, dental care
use was defined as having either a dental visit or dental
cleaning within the preceding 12 months. BRFSS data for 1999 and
2002 were pooled to increase the samples of pregnant women at the
state levels. Analysis was restricted to the dentate, and missing
data or persons not responding to the questions were removed from
the denominator (<1%). The average nonresponse rate
combined across the various characteristics examined in this
analysis was 0.80%.
Analysis by SUDAAN (Research Triangle Institute, Triangle Park, NC) (16) was used to account for the complex
sampling design of the survey and sampling weights. In separate
analyses, estimates were age-adjusted based on the U.S. census
population distribution of persons aged ≥18 years in
2000 (17) to provide a sounder basis for comparing estimates
among states (18). Estimates of dental care use by pregnant
women were stratified by age, level of education, diabetes
status, health insurance status, income, marital status,
smoking status, and race/ethnicity (Hispanic is a category of ethnicity that may
include women of all races). Logistic
regression modeling was used to examine characteristics
that were significant predictors of pregnant women not
receiving dental services within the preceding 12 months,
adjusting for other potential explanatory variables. Covariates
in the model were selected a priori based on previous
evidence that the variable was associated with dental care use
and that measures of the variable were available in BRFSS.
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National and state estimates for dental care use in the past
12 months among pregnant and nonpregnant dentate women are shown
in Table 1. The national estimate for pregnant women having a
dental visit or cleaning in the previous 12 months, age-adjusted to the 2000
population, was 70.03% (SE =
1.46%), with state percentages ranging from 48.32% (Nevada) to
87.02% (Vermont). Estimates for nonpregnant women ranged from
62.77% (Texas) to 84.14% (Connecticut). When age-adjusted to the
2000 population, estimates ranged from 36.16% (Nevada) to 91.34%
(Puerto Rico). In 19 states, the age-adjusted estimates were 75%
The distribution of age, race/ethnicity, marital status,
education, household income, health insurance status, and smoking
status was similar when all pregnant women were compared with
those receiving dental care in the past 12 months (Table 2). Most
pregnant women reporting a dental visit or cleaning in the
preceding 12 months were non-Hispanic white, married, between
the ages of 20 and 34 years, and educated beyond high school.
In addition, most had health insurance (90.92%, SE = 0.91).
Compared with pregnant women who received dental services, those
not receiving dental care were more likely to be aged 20 to 34
years, be active smokers (smoking every day or some days), have
less than a high school education, and have diabetes (excluding
gestational diabetes). These respondents were also less likely
to be married and to have health insurance. Pregnant women who
reported not having had dental care in the preceding 12 months
were twice as likely to lack health insurance and to use public
health clinics or hospital outpatient services. In multivariable
logistic modeling, only household income and smoking were
significant predictors for not reporting dental services
in the previous 12 months (Table 3).
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This study reports the first national and state estimates for
dental care use during two 12-month periods among pregnant women in the
United States. Estimates were obtained from a representative
sample of pooled data from the BRFSS in 1999 and 2002. For most
states, the BRFSS is the only source of information on dental care
use and risk factors for chronic diseases. Analyzing this
combined dataset, we find about 70% of pregnant women in the U.S.
had either a dental visit or a dental cleaning within the
preceding 12 months. This estimate was similar to estimates for
the general U.S. population (BRFSS 2002 estimate 70.8%).
In the general population, behaviors related to use of dental
care are known to be related to demographic characteristics such
as level of education and ethnicity (2,19). Among personal
characteristics of pregnant women examined in this study, only
income and smoking status were significant predictors for
not obtaining dental care in the previous 12 months,
suggesting that low-income pregnant women may be at higher risk
for not receiving dental care. This finding is consistent with
reports from PRAMS that pregnant women receiving no dental care
were more likely to use tobacco (14). Because low-income women
are more likely to smoke, smoking in this subpopulation may be a
proxy for low income. Pregnant women who did not receive dental
care were skewed toward a younger age, probably because younger
women are more likely to have lower incomes. The BRFSS does not
collect information on dental insurance, parity, or perceived
fears of harm to the fetus, which are important determinants in
whether pregnant women obtain dental care. Previous reports
also suggest that low-income pregnant women are less likely than their
higher-income counterparts to visit the dentist (20). We found
that 95% of pregnant women who reported a dental visit in the
previous 12 months also had a dental cleaning during that period.
State-specific estimates of dental care use in the previous 12 months among
pregnant women varied greatly and generally followed the dental use pattern of the overall
population of women aged 18 to 44 in each state. We found relatively higher
percentages in states or territories with aggressive preventive dental care
programs for pregnant women, such as Puerto Rico. Lower estimates for pregnant
women were seen in states such as Virginia, Nevada, and Arkansas and were
consistent with lower estimates of dental care use in the general population of
these states. It is unclear what factors most influence variation by state.
However, the number of community centers with a dentist or dental
health program is an important explanatory factor for dental care use among low-socioeconomic status (SES) populations.
Importantly, these estimates do not represent the percentage
of women reporting dental care use while pregnant. Depending on
the term of pregnancy when surveyed by the BRFSS, there would be a
period in the 12 months preceding the interview when women
were not pregnant. Health care providers and dentists treat women
differently according to pregnancy status, and pregnant women
seek dental care differently. A relatively higher or lower
percentage of dental visits or cleaning when not pregnant would
skew these estimates up or down, respectively.
Notably, state-specific estimates from this study were higher
than those published previously from the five states that
participated in PRAMS, which ranged from 23% to 58% (11,14).
Several factors may account for these differences. First, in
PRAMS, questions on use of dental care were restricted to the
period when pregnant. Second, while the BRFSS included only adults
(i.e., those aged ≥18 years), PRAMS includes all pregnant
women (i.e., including those <18 years) and over-samples
two or three characteristics, typically low SES. Finally, the BRFSS
is a telephone survey and probably includes a higher SES
population than PRAMS.
Some limitations should be noted in the use of the BRFSS to obtain
estimates for dental care use among pregnant women. First, the
survey is based on self reports, which can be influenced by
recall bias. Self-reported dental care, however, has been found
to be a valid measure for dental care use given adequate sample
size and study design (21). Second, the BRFSS is a telephone survey
that generally excludes women without residential phones;
therefore, the survey might exclude persons of lower SES or
households with only cellular phones. Finally, because a
relatively small percentage of women are pregnant at any time,
samples for pregnant women in most states often were small,
sometimes less than 50. We pooled data for 1999 and 2002 to
increase the samples and improve estimate reliability, but even
then, samples for Maine, Mississippi, and the District of
Columbia were small (less than 50), and so estimates from these
states may be considered less reliable.
Because preventive dental care may reduce risk for adverse
pregnancy outcomes, we must assess how current patterns of dental
care use among pregnant women compare with those of the general
population. Estimates from this study suggest that dental care
use in the previous 12 months among pregnant women is about the same
in the general population; in both populations, indicators of
SES appear to be important predictors of not using services for
those persons (approximately 30%) who have not recently had any dental
care. However, we note that lack of health insurance,
use of public health clinics, and the use of hospital outpatient
services were twice as likely among pregnant women not reporting
dental care. One approach to reduce lack of dental care among
pregnant women may include providing health insurance. Additionally,
health care providers in these health care settings are more
likely to come in contact with pregnant women who do not receive
dental care. This may present an opportunity to provide important
oral health education to these pregnant women.
Barriers to obtaining dental cleaning need to be explored
further and be better understood. One approach to addressing
dental care use could involve prenatal and professional education
on the importance of dental care and the adverse effects of
smoking during pregnancy. Overall, these estimates provide
baseline information on dental visits and cleaning among pregnant
women in the United States and may be useful in formulating oral
health policies and programs to improve the health and well-being
of pregnant women.
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Corresponding Author: Paul I. Eke, PhD, MPH, Surveillance, Investigations, and Research Team, Division of Oral
Health (DOH), Centers for Disease Control and Prevention (CDC), 4770 Buford
Highway, Mail Stop F-10, Chamblee, GA 30341. Telephone:
770-488-6092. Email: email@example.com.
Author Affiliations: Peggy Timothé, DDS, MPH, formerly
research fellow of the Association of Schools of Public Health,
CDC, Chamblee, Ga; Scott
M. Presson, DDS, MPH, Program Services Team, and Dolores M. Malvitz, DrPH, Surveillance, Investigations, and
Research Team, DOH, CDC, Chamblee, Ga.
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- Ventura SJ, Mosher WD, Curtin SC, Abma JC, Henshaw S.
in pregnancy rates for the United States, 1976-97: an update. Natl Vital Stat Rep 2001;49(4):1-9.
- U.S. Department of Health and Human Services.
Oral health in America: report of the Surgeon General. Rockville (MD):
U.S. Department of Health and Human Services, National Institute
of Dental and Craniofacial Research, National Institutes of
- Bolden AJ, Henry JL, Allukian M.
Implications of access,
utilization and need for oral health care by low income groups
and minorities on the dental delivery system. J Dent Educ 1993;57(12):888-900.
- Atchison KA, Davidson PL, Nakazono TT.
enabling, and need for dental treatment characteristics of ICS-II
USA ethnically diverse groups. Adv Denl Res 1997;11 (2):223-34.
- Gilbert GH, Shelton BJ, Chavers LS, Bradford EH Jr.
paradox of dental need in a population-based study of dentate
adults. Med Care 2003;41(1):119-34.
- Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al.
Periodontal infection as a possible risk factor for
preterm low birth weight. J Periodontol 1996;67(10 Suppl):
- Dasanayake AP.
Poor periodontal health of the pregnant women
as a risk factor for low birth weight. Ann Periodontol. 1998;3:206-12.
- Offenbacher S, Beck JD, Lieff S, Slade G.
Role of periodontitis in systemic health: spontaneous preterm birth. J
Dent Educ 1998;62(10):852-8.
- Collins JG, Smith MA, Arnold RR, Offenbacher S.
Effects of Escherichia coli and Porphyromonas gingivalis
lipopolysaccharide on pregnancy outcome in the golden hamster.
Infect Immun 1994;62(10):4652-5.
- Collins JG, Windley HW 3rd, Arnold RR, Offenbacher S.
Effects of a Porphyromonas gingivalis infection on inflammatory
mediator response and pregnancy outcome in hamsters. Infect Immun 1994;62(10):4356-61.
- Lopez NJ, Smith PC, Gutierrez J.
Periodontal therapy may
reduce the risk of pre-term low birth weight in women with
periodontal disease: a randomized controlled trail. J Periodontol 2002;73(8):911-24.
- Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL,
Periodontal infection and preterm birth: results of a
prospective study. J Am Dent Assoc 2001;132:875-80.
- Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R.
during pregnancy: an analysis of information collected by the
pregnancy risk assessment monitoring system. J Am Dent Assoc 2001;132(7):1009-16.
- Lydon-Rochelle M, Krakowiak P, Hujoel P, Peters RM.
care use and self-reported dental pregnancy problems in relation
to pregnancy. Am J Public Health 2004;94:765-71.
- Mokdad AH, Stroup DF, Giles WH.
Public health surveillance
for behavioral risk factors in a changing environment:
Recommendation from the Behavioral Risk Factor Surveillance Team. Morb Mortal Wkly Rep (RR09);1-12.
- Shah BV, Barnwell BG, Bieler GS. SUDAAN: software for the
analysis of correlated data. User’s manual release 7.00.
Research Triangle Park (NC): Research Triangle Institute;
- Perry MJ, Mackun PJ.
Population change and distribution: 1990
to 2000. Washington (DC): U.S. Department of Commerce, U.S. Census Bureau;
- Klein RJ, Schoenborn CA.
Age adjustment using the 2000
projected U.S. population. Healthy People 2010 Stat Notes 2001(20):1-10.
- Gilbert GH, Shah GR, Shelton BJ, Heft MW, Bradford EH,
Racial differences in predictors of dental care use.
Health Serv Res 2002;37:1487-507.
- Mangskau KA, Arrindell B.
Pregnancy and oral health:
utilization of the oral health care system by pregnant women in
North Dakota. Northwest Dent 1996;75(6):23-8.
- Gilbert GH, Rose JS, Shelton BJ.
A prospective study of the
validity of data on self-reported dental visits. Community Dent
Oral Epidemiol 2002;30:352-62.
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