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University Gazette

The University of North Carolina at Chapel Hill

Schools cross disciplines to debunk myths and misinformation about prenatal oral health

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Fourth-year dental student Amanda Kerns, left, treats patient Laura Hilliard at the School of Dentistry.

A few months ago, Rocio Quinonez and her pediatric dentistry students were volunteering at a clinic in Durham when Quinonez noticed a very pregnant patient awaiting care.

Quinonez, an associate professor at the School of Dentistry, approached the woman to offer a pamphlet about caring for an infant’s oral health. The patient drew back the corner of her mouth, revealing a row of abscessed teeth. Her oral health had long been neglected, and the situation was dire.

“She told me she’d been repeatedly turned away by dentists who did not think it would be safe to treat a pregnant woman. Other clinics had refused to see her until the baby was born,” Quinonez said.

The idea that dental care should be postponed in pregnancy is an outdated one, she said, but in some dental practices, it still holds. And because of misinformation, this patient had been living unnecessarily in excruciating pain.

“I told her, ‘Don’t worry, we’ll help you,’” Quinonez said. “We stopped the clinic to get her triaged and come up with a plan.”

By that afternoon, the woman was seen in a clinic especially for pregnant patients where a UNC dental student treated her and extracted the problem teeth.

The clinic is a part of the Prenatal Oral Health Program (POHP) at UNC, a joint venture of the schools of Dentistry and Medicine that educates students and the public about oral health and pregnancy. Students at both schools are trained to include oral health in prenatal care and encouraged to carry that care forward into their professional practices.

“The mouth is the window to the body,” Quinonez said. “Education is the key to getting other health professionals to consider that dental health is a part of overall health.”

Training in teams

The diagnosis of a dental problem requires a dental professional, said Kim Boggess, professor of obstetrics and gynecology. Through POHP, medical students and residents learn what obstetricians can ask in an office visit to determine if a patient needs a referral.

“We can ask about loose teeth and tooth pain, previous periodontal disease, and most importantly,” she said, “we can ask, ‘Do you have a dentist? When did you last go?’”

Myths surrounding oral health and pregnancy abound: You lose a tooth for every pregnancy. X-rays are unsafe, and so is local anesthesia. You should postpone prophylactic care, like regular cleanings, until the baby is born. To visit the dentist, you need a note of approval from the obstetrician.

None of these is true, Boggess said. Worse, an oral infection can develop into something dangerous if untreated. If a dentist recommends delaying care, there can be negative consequences for both mother and baby.

“A pregnant woman in poor oral health with no access to care, or with nutritional habits that promote poor dental health, can pass bad bacteria, bad habits and the same lack of access to her children, who run the risk of passing them on,” Boggess said. “It’s a cycle.”

The American Academy of Pediatric Dentistry and the American College for Obstetricians and Gynecologists have issued guidelines on treating pregnant women. The consensus reached by these two national groups should help allay any concerns held by a dentist who is reluctant to treat a pregnant woman.

Alice Chuang, associate professor of obstetrics and gynecology, is the clerkship director for the department and works with POHP. She said she understood how some dentists could be tentative – if she thought a procedure was unsafe she’d defer treatment as well.

“This is why education for both dentists and the obstetricians is really important,” she said. “There are a lot of barriers to great medical care. We should train students in team settings with the hope that in the future they will continue to work in teams.”

It was the teamwork of Quinonez and Boggess that helped get POHP off the ground. Together they received a Blue Cross Blue Shield grant to train medical obstetric providers about oral health in pregnant women, and they began reaching out and developing educational materials.

As a pediatric dentist, Quinonez said, “I wanted to catch those babies, but I’d realized the mother is the entrée to the family. We’d need to start earlier.”

The two soon realized that, though they were providing great information about when to refer a pregnant patient to a dentist, there was not always a place to refer them.

“Where could doctors send a patient who said she had no dental home, and be sure she’d get care?” Boggess said.

Confidence in care

In August 2012, POHP opened a special section in the general dentistry clinic at the dental school. Patients are seen by Carolina’s student dentists, all of whom rotate through the clinic and graduate with experience treating pregnant women.

“If you’re not trained to do it, you’re probably not going to do it when you get out into clinical practice,” Quinonez said. “And, if you’ve been trained to be tentative about it, that’s exactly where you’re going to be.”

Amanda Kerns, a fourth-year dental student, said she had interacted with dentists who suggested women delay dental care during pregnancy, and it was often because the dentist was simply unsure. Training new students in prenatal care can have an effect on those practices by introducing a dentist who feels confident about providing that care.

“This program works on all sides,” she said. “Women are getting to the dentist, which is the most important thing. Also, they are coming here to the school where a fourth-year student will have the opportunity to triage and treat a pregnant woman. That dentist will go into practice saying, ‘I’ve done that before. I know how to treat her.’”

The peer-to-peer component of POHP earned Kerns and fellow student Jeff Jackson an Albert Schweitzer Fellowship last year to implement an oral health messaging session with third-year medical students entering clerkships in obstetrics and gynecology.

“We survey them before the session, and we teach them about the importance of including oral health as part of their prenatal care, and then we survey them again,” Kerns said. Then they have their six-week clerkship where they have the opportunity to use the POHP materials to educate their patients and refer women to a dental home.”

The materials include an educational flipchart, posters, handouts and the POHP website (www.prenataloralhealth.org), which has videos, questionnaires and detailed information for patients and providers.

Jane Weintraub, dean of the School of Dentistry, said POHP was something to be proud of.

“We want all of our dental students to have the experience of providing treatment to pregnant women so they will be comfortable and confident doing so after graduation, and also to work with their medical colleagues to increase women’s understanding of their own oral health and that of their children,” she said.

In its first year, the POHP clinic saw 59 women who received affordable cleanings, exams, X-rays and fluoride. All were exposed to the educational pieces of the program, too, and provided information about infant oral health. Each woman seen in the clinic will receive a follow-up postcard with information for the school’s Baby Oral Health Program, which reinforces national guidelines that encourage children to see the dentist by age 1.

“One of the things that inspires me as an educator is the impact that one can have long-term,” said Quinonez. “By working at many different levels, we can mold a whole new generation of providers.”