Improving Access to Dental Care for Pregnant Women through Education, Integration of Health Services, Insurance Coverage, an Appropriate Dental Workforce, and Research

Abstract

Oral health is integral to overall health and a healthy pregnancy. Periodontal disease (gum disease) during pregnancy increases the risk for delivering a preterm and/or low birth weight infant. Only 46% of U.S. women have an oral prophylaxis (dental cleaning) during pregnancy. Routine prophylaxes reduce the potential for periodontal disease. In addition, children of mothers with untreated dental caries (tooth decay) are at high risk for developing tooth decay, the most prevalent chronic disease among U.S. children. Dental care during pregnancy is safe, important, and recommended by multiple health organizations. Improving access to dental care during pregnancy requires many actions. Prenatal and dental students and providers, community-based program staff, and pregnant women should be educated about the safety and importance of dental care during pregnancy and where care can be obtained. Pregnant women should be educated about the importance of consuming fluoridated water to prevent tooth decay. Prenatal providers and community programs should integrate oral health education into visits with pregnant women and collect and report oral health data. Medicaid programs should include comprehensive dental benefits for women during pregnancy and 1 year postpartum. Medicaid reimbursement rates should be increased to attract more dental providers. Increased funding for public health programs and research focused on improving perinatal and infant oral health is essential. These strategies have the potential to significantly improve access to dental care, thus improving the oral and overall health of pregnant women and their children.

Relationship to Existing APHA Policy Statements

The following APHA policy statements are relevant to the proposed policy statement:

• APHA Policy Statement 20189: Achieving Health Equity in the United States
• APHA Policy Statement 20161: Access to Integrated Medical and Oral Health Services
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
• APHA Policy Statement 20005: Effective Interventions for Reducing Racial and Ethnic Disparities in Health
• APHA Policy Statement 20109: Health Literacy: Confronting a National Public Health Problem
• APHA Policy Statement 20064: Support for the Alaska Dental Health Aide Therapist and Other Innovative Programs
• APHA Policy Statement 200117: Support the Framework for Action on Oral Health in America: A Report of the Surgeon General
• APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States

Problem Statement

The World Health Organization defines oral health as a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal disease (gum disease), dental caries (tooth decay), tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and social well-being.[1] Oral health is integral to overall health and a healthy pregnancy and should be maintained or improved during the prenatal period. Pregnancy is an opportune time for oral health interventions and serves as a “teachable moment” when women may be motivated to adopt healthy behaviors. Pregnancy may qualify women for public health insurance that includes dental benefits, improving access to dental care during a period when risk for oral diseases is elevated. In 2017, 36% of women reported having health insurance through Medicaid during pregnancy, an increase from 23% who reported having Medicaid coverage prior to becoming pregnant.[2]

Physiological (hormonal, vascular, immunological) and behavioral (vomiting, increased frequency of snacking, lethargy, decreased attention to oral hygiene) changes during pregnancy may adversely affect oral health. Because of these changes, dental caries and periodontal diseases may progress more rapidly. Although reported figures on the prevalence of periodontitis in pregnancy vary, an estimated 42% of U.S. adults 30 years and older have this inflammatory condition, which is characterized by destruction of bone and soft tissue that support the teeth.[3] Studies show that pregnant women with periodontitis are at increased risk for developing preeclampsia — a complication characterized by high blood pressure — and delivering a preterm and/or low birth weight infant.[4] Periodontitis is also associated with an increased risk for gestational diabetes mellitus, which increases the risk for fetal complications and mothers’ risk for developing type 2 diabetes later in life.[5,6] Oral diseases during pregnancy can cause pain, nutritional deficiencies, lost workdays, and reduced employability, all of which affect a woman’s quality of life. Women with good oral health earn 4.5% more than their peers.[7] As six in 10 adults with low wages who lack dental coverage report that their oral health status impedes job prospects, helping pregnant women address their dental needs can boost employment and family incomes.[8]

In addition, children born to mothers with poor oral health and high levels of Mutans streptococcus (the primary bacterium that causes dental caries) are at increased risk for developing dental caries, the most prevalent—but largely preventable—chronic disease among children in the United States.[9] The consequences of dental caries among children include acute and chronic pain, treatment under sedation or general anesthesia, hospitalizations and emergency room visits, high treatment costs, loss of school days, diminished ability to learn, a high risk of new caries lesions, and diminished oral health–related quality of life.[10] Dental costs for children younger than 5 years have been estimated at more than $1.5 billion.[11]

Only 46% of pregnant women in the United States report having an oral prophylaxis (dental cleaning) during pregnancy, and that percentage is much lower among socially disadvantaged women.[2] Access to dental care is directly related to income level; women with low incomes are less likely than those with higher incomes to receive dental care during pregnancy.[12] Pregnant women without dental insurance are twice as likely to skip routine preventive dental visits as those who have dental coverage.[13] While states are required to provide comprehensive dental care for children in Medicaid and the Children’s Health Insurance Program (CHIP), Medicaid dental benefits for working-age adults, including pregnant women, are optional and vary from state to state, making them routinely vulnerable to state budget cuts. States determine the scope of dental services covered and whether to limit coverage to specific populations. As of 2019, only 22 state Medicaid programs offered extensive dental benefits to pregnant women, but there may be key procedures not covered or limits to service frequency or charges.[14] Dental benefits for pregnant women are typically time bound, beginning at pregnancy and ending at the conclusion of pregnancy or 60 or 90 days postpartum. This finite window of time is typically insufficient for women to receive all necessary dental care. During pregnancy, women have competing interests for their time, including medical appointments, work, and family responsibilities, while the first few months after delivery are primarily focused on infant care.

Also, pregnant women insured by Medicaid frequently have difficulty finding Medicaid-contracted dental providers. Only 39% of dentists nationwide accept Medicaid or CHIP.[15] Reasons cited for not participating in these programs include burdensome administration requirements, missed appointments, lengthy payment wait times, and low reimbursement rates.[16,17] National conversations about universal health coverage have given rise to numerous legislative proposals; however, many do not include dental benefits.[18] Because of these financial barriers, it is essential that legislative proposals aimed at expanding coverage or achieving universal health coverage include comprehensive, affordable dental care for all Americans throughout the life span.

Racial and ethnic oral health inequities also exist. Non-Hispanic Blacks, Hispanics, American Indians, and Alaska Natives generally have the poorest oral health of any racial/ethnic groups nationwide.[19] Relative to non-Hispanic White women and women with higher incomes or more education, non-Hispanic Black and Mexican American women, women with low incomes, and women with less than a high school education are less likely to report having very good or good oral health, having had a dental visit in the previous year, or having had their most recent dental visit be for preventive care.[20] Health literacy is also associated with access to dental care during pregnancy. A 2019 study showed that most pregnant women were unaware of the importance of prenatal oral health care, lacked understanding of how to prevent tooth decay, did not practice behaviors to prevent the disease, and were unaware of their Medicaid dental benefit.[21] Cultural differences between providers and patients can also present barriers to care. Dental providers and staff may lack cultural competency training, which affects their ability to effectively communicate health information and guidance to diverse populations.[22] Poor communication can have a negative impact on patient understanding and trust, which can influence patients’ adherence to treatment plans.[22] For many populations, cultural norms and beliefs inform pregnant women’s attitudes regarding oral health and dental care during pregnancy. For example, some cultures believe that prenatal dental care is not safe, bleeding gums are normal during pregnancy, and drinking tap water is not safe.[22,23] Also, women may trust health information from family members over that received from a dental provider.[22,23]

Access to dental care is affected by geographic location. There are relatively few dental providers in rural America, resulting in longer distances and lack of public transportation systems to travel to a dentist; moreover, poverty rates are higher in these areas, reducing affordability of services or purchasing of dental insurance.[24] More than 56 million people live in areas with dentist shortages, and approximately 60% of the nation’s dental Health Professional Shortage Areas (HPSAs) are in rural America.[25] With respect to improving access to dental care and reducing disparities, expansion of the dental workforce is a key approach supported by various groups. Strategies include authorizing dental therapy, increasing the scope of practice and settings for dental hygienists, and eliminating restrictions to enhance the use of teledentistry. Disagreements persist among organized dentistry and dental hygiene about how best to reach vulnerable individuals while preserving professional autonomy and control over delivery of care. Because of these disagreements, workforce expansion and improvements in access to dental care can be slow.

Despite the publication of national guidance documents for health care providers—such as the 2012 landmark publication Oral Health Care During Pregnancy: A National Consensus Statement—clearly stating that dental care during pregnancy is important, safe, and recommended, pregnant women continue to experience significant barriers to accessing dental care.[26] Dental providers have been hesitant to provide care during pregnancy, either postponing it until after delivery or limiting it to the second trimester. A national survey revealed that 77% of obstetrician-gynecologists (OB/GYNs) reported having patients who were denied care by dental providers because they were pregnant.[27] Hesitancy to provide care to pregnant women may stem from a lack of knowledge and understanding of current guidelines or concerns about liability. Refusing to provide care to pregnant women may call into question the professional ethics of dental providers. The codes of ethics of the American Dental Association and the American Dental Hygienists’ Association include values and principles to guide decisions and conduct.[28,29] The principle of nonmaleficence is the professional obligation to protect patients from harm. Refusing to provide care or postponing it until after pregnancy has the potential to cause harm if dental and periodontal conditions progress and worsen, especially for women who are denied care during pregnancy, which may be the only time they have access to dental benefits. Dental providers are obligated to keep their knowledge and skills current; it could be argued that providers are not following current evidence-based guidance and standards of care by refusing or postponing care for pregnant women. Other ethical principles could also be questioned such as patient autonomy (the right to make informed decisions prior to treatment), justice (fairness and access to high-quality health care), and veracity (truthfulness).

Approximately 60% of primary care physicians provide oral health counseling to pregnant women; physicians with oral health–specific instruction during medical training and favorable oral health–related attitudes, behaviors, knowledge, and preparedness are more likely to provide counseling.[30] According to a 2013 study examining prenatal oral health education in U.S. OB/GYN residencies, less than half of OB/GYN residency program directors reported that they were aware of current prenatal oral health guidelines and included prenatal oral health training in their programs.[31] In addition, a recent study of OB/GYN residents reported that oral health is typically not discussed because of lack of time, and most residents noted that they were uncomfortable discussing oral health because of their limited knowledge about the topic and where to send women for dental care.[32]

Furthermore, national public health surveillance systems lack robust and reliable mechanisms for collecting data on the oral health status of pregnant women or their access to dental care during pregnancy. If there is to be a full appreciation of oral health disparities and the oral disease burden of pregnant women throughout the United States, data should be collected routinely at the national level. Unfortunately, Healthy People has never included an objective on the oral health of pregnant women in any topic area. A multipronged approach that includes national-, state-, and local-level strategies is needed to reduce or eliminate health disparities and achieve health equity among all pregnant women.

Evidence-Based Strategies to Address the Problem

Studies indicate that the most promising evidence-based strategies include (1) educating pregnant women, prenatal providers and students, and community-based program staff about perinatal and infant oral health; (2) integrating oral health and primary care practice; (3) ensuring a competent and adequate dental workforce; (4) ensuring comprehensive Medicaid dental coverage for women during pregnancy through 1 year postpartum and adequate reimbursement rates for dental services; (5) collecting and analyzing data on oral health among pregnant women at national, state, local, and program levels; and (6) conducting research to determine effective strategies and best practices to improve access to dental care among pregnant women.

Educate pregnant women, prenatal providers and students, and community-based program staff about perinatal and infant oral health: If access to dental care is to be improved, pregnant women need education about oral changes that occur during pregnancy, the importance and safety of receiving dental care while pregnant, how their oral health is connected to that of their child, dental benefits available in their state, and how to find a dentist.[33] Women should receive information about oral hygiene practices, proper nutrition, and other key evidence-based strategies to prevent oral diseases, such as drinking fluoridated water. Women should be taught that most bottled water does not contain adequate amounts of fluoride. Seventy-five years of research has proven that optimally fluoridated water is the most cost-effective, safe, and equitable way to prevent tooth decay.[34–37] All major health organizations support this preventive measure.[34] Fluoridated public water benefits everyone who consumes it regardless of age, income, or level of education.[38]

Prenatal providers (obstetricians, family physicians, nurses, midwives) are often first to care for pregnant women, so they play a critical role in addressing oral health and connecting women to dental care. Since 2006, when New York State published the first perinatal oral health guidelines in the United States, several state and national documents have included recommendations for health care providers to counsel pregnant women on the prevention and treatment of oral diseases as well as healthy oral health behaviors for both themselves and their child. The American College of Obstetricians and Gynecologists recommends that health care providers discuss oral health with all pregnant and postpartum women; reassure patients that prevention, diagnosis, and treatment of oral conditions, including X-rays and local anesthesia, are safe during pregnancy; be aware of patients’ dental insurance during pregnancy; and refer patients for dental care.[12]

Community-based programs that serve pregnant women (e.g., the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]; Early Head Start [EHS]; and home visiting) can play an important role by educating staff about perinatal and infant oral health so that they can provide risk assessments, counseling, help in goal setting, dental referrals, and follow-up to ensure receipt of dental care. Developing a reliable network of dental providers in the community is a key component in improving access to dental care.[39,40] For example, Wisconsin implemented oral health education, preventive care, and structured dental referrals in WIC programs. WIC partnered with a community health center dental hygienist or nurse to integrate preventive oral health services into patient workflows. WIC clinics sent a referral to a dental clinic, which scheduled appointments and closed the loop by sending information back to WIC.[41] EHS is an example of oral health being prioritized in a national, community-based program that enrolls pregnant women. EHS includes a performance standard that requires EHS programs to address oral health and support women in accessing dental care during pregnancy.[42] In addition, data are available at the program, local, and state levels to drive improvement efforts.

Evidence-based resources should be promoted and utilized to improve knowledge and understanding among prenatal providers and community-based program staff; these resources include national and state perinatal oral health practice guidance (e.g., Oral Health Care During Pregnancy: A National Consensus Statement) as well as curricula such as Smiles for Life: A National Oral Health Curriculum, which has shown effectiveness in improving primary health care providers’ attitudes toward oral health and oral health knowledge.[43,44] Another example is the Oral Health Nursing Education and Practice program at New York University, which helps nurse practitioners, nurse-midwives, nurses, and other health providers incorporate oral health into patient care. In 2019, the program released a Web-based interprofessional oral health faculty toolkit intended to facilitate the integration of oral-systemic health content and clinical competencies into nurse practitioner and midwifery curricula.[45] Tribal, state, territorial/jurisdiction, and local health department oral health programs and Medicaid agencies can also provide educational resources on oral health and information about Medicaid dental benefits and participating dental providers to pregnant women. Innovative social marketing strategies that are culturally tailored to specific populations can be used to increase oral health literacy among pregnant women.

Integrate oral health and primary care practice: Integrating oral health and primary care practice is an important strategy for reducing oral health disparities and improving the oral and overall health of pregnant women. Primary care providers often have more frequent contact than dental providers with patients at the highest risk for oral diseases. It is estimated that each year there are 108 million Americans who see a physician but do not see a dentist.[46] In 2014, the Health Resources and Services Administration (HRSA) released Integration of Oral Health and Primary Care Practice, which includes a starter set of interprofessional oral health core clinical domains and competencies to facilitate change in the clinical practice of primary care providers working in the safety net community.[47] The domains include risk assessment, oral health evaluation, preventive intervention (e.g., fluoride varnish applications), communication and education, and interprofessional collaborative practice (e.g., dental referrals). HRSA recommends that, for maximum impact, the core clinical competencies be incorporated into existing accreditation and certification standards to facilitate adoption in primary care education and practice.

Primary care providers are members of a health care delivery system that could incorporate oral health into their existing scope of practice with assistance from support staff. These providers often deliver care to populations who are vulnerable, are underserved, and lack or have limited access to dental care. National, state, and local professional associations can serve an important role in championing the integration of oral health and primary care practice. For example, professional networks can share evidence-based guidelines, integration models, best practices, and lessons learned and advocate for policy changes that support oral health equity for all. In addition, alternative care delivery models that embed dental providers in prenatal care settings can expand the bandwidth of the practice to address the oral health needs of pregnant women. Bringing preventive services to pregnant women in the medical setting has potential to reduce long-standing barriers to dental care.[48] A study of medical and dental care integration activities conducted between 2000 and 2017 showed that integration of oral health increased access to and coordination of care.[49] The Oral Health Delivery Framework is a national example that includes five actionable steps primary care teams can take to incorporate oral health into primary care practice: ask, look, decide, act, and document. An implementation guide including information on ways to integrate oral health care in a variety of workplace settings and strategies to address common challenges was developed after pilot testing of the framework in 19 primary care practices.[50]

Ensure a competent and adequate dental workforce: A competent and adequate dental workforce is critical in improving access to dental care among pregnant women, especially the vulnerable. However, dental and allied dental education programs do not always sufficiently prepare future dental providers to care for pregnant women. A 2013 study examining prenatal oral health education in U.S. dental schools showed that although the majority of dental school deans reported providing such education and being aware of current guidelines, there was limited clinical exposure to pregnant patients.[31] The American Dental Education Association patient care competencies for general dentists do not include a competency for care of pregnant women.[51] Perinatal clinical competencies should be developed and integrated into dental school and dental hygiene program education, training, and board certification, as well as continuing education courses, to adequately prepare dental providers to meet the needs of all pregnant women.[33] Collaborative efforts by academic institutions, professional health organizations, and state agencies are necessary to educate health professionals about how to provide the best perinatal oral health care.[33]

In 2014, the American Dental Association adopted a policy acknowledging that preventive, diagnostic, and restorative dental treatment to promote health and eliminate disease is safe throughout pregnancy and effective in improving and maintaining the oral health of the mother and her child.[52] Although the policy encourages dentists and dental hygienists to provide care to pregnant women at any time during pregnancy, they have been hesitant in doing so, often postponing care until after delivery or limiting it to the second trimester. This is compounded by a shortage of Medicaid-participating dentists and inadequate education and responsibility for meeting the oral health needs of populations that are vulnerable. To ensure access, there must be enough dental providers to meet the needs of pregnant women. With more than 56 million people living in dental HPSAs, the dental workforce lacks capacity to meet current needs. Strategies to ensure an adequate workforce include authorizing dental therapists, expanding the scope of practice of dental hygienists, and ensuring that all members of the dental team can work at the top of their license. Paired with comprehensive dental coverage, an expanded dental workforce will help create a future in which all people can access dental care. Dental therapists offer the additional benefit of providing community-based care and building a dental workforce representative of the communities it serves.[18]

Ensure comprehensive Medicaid dental coverage for women during pregnancy through 1 year postpartum and adequate reimbursement rates for dental services: To achieve a more equitable society, all pregnant women must have access to comprehensive and affordable dental coverage. State Medicaid programs should provide dental coverage during pregnancy through 1 year postpartum to maximize the window for dental care and provide reimbursement for oral health services delivered by prenatal providers to sustain the integration of oral health into primary care practice. Most important, state Medicaid programs should make efforts to educate pregnant women and health care providers about the importance of perinatal and infant oral health, dental benefits available, and where to find participating dental providers. Medicaid dental reimbursement rates must also be attractive to dental providers. States with higher reimbursement rates have larger proportions of dentists who participate in the Medicaid program.[53] A 2008 study showed that dental provider participation increased by at least one third, and sometimes more than doubled, following dental reimbursement rate increases. Rate increases that bring reimbursement rates to a level at which they at least meet dental providers’ overhead expenses are necessary—but are not sufficient on their own—to improve access to dental care. Easing administrative processes and involving state dental societies and individual dentists as active partners in program improvements also are critical steps.[54]

Collect and analyze data on oral health among pregnant women at national, state, local, and program levels: It is critical to collect and analyze data at all levels to monitor pregnant women’s oral health status and access to and use of dental care. Few national, state, or local organizations capture data on pregnant women’s oral health. The Virginia Department of Health is an example of a state that captures data for pregnant women. In 2018, Virginia conducted a basic screening survey of pregnant women at WIC agencies throughout the state and found that most of the women knew the importance of taking care of their teeth and gums during pregnancy; many reported needing to see a dentist for a problem, but only a few had visited a dentist or had a preventive dental cleaning in the preceding year. Only 37% of pregnant women reported knowing that they had Medicaid dental coverage during pregnancy, and clinical screenings revealed that 42% of pregnant women had untreated tooth decay and 26% needed periodontal treatment.[55] In 2020, the Center for Oral Health Systems Integration and Improvement published oral health quality indicators for the maternal and child population, including pregnant women, to promote state efforts to monitor and improve dental care quality.[56]

Conduct research to determine effective strategies and best practices to improve access to dental care among pregnant women: Research needs to be conducted to determine whether prenatal providers are delivering oral health education and other important oral health services such as risk assessments, screenings, preventive interventions, education, dental referrals, and follow-up and care coordination. Research is also needed to identify how and when to educate all relevant health care providers and pregnant women on the benefits of dental care during pregnancy. In the case of physicians, should predoctoral curricula include this information, or is it best reserved for residency training? Should the training be didactic, clinical, or both? The role of continuing education for all provider groups should be examined. Research is needed to identify which health care providers are most successful in these educational efforts to further develop models to improve oral health outcomes among pregnant women and their families. If pregnant women are to be educated about the value of oral health during pregnancy, the cultural contexts and channels to deliver these messages must be determined. Furthermore, practice-based research and demonstration projects should continue to elucidate best practices and models for integrating oral health care into prenatal care and measure the impact of oral health integration on health outcomes. Determining the impact of using shared (medical and dental) electronic health records (EHRs) to foster oral health for pregnant women is critical. For example, can postvisit summaries generated from EHRs help educate pregnant women about oral health and obtaining dental care, and will obstetric providers use EHRs to refer women for dental care? Do women obtain dental care following a referral from an obstetrician? Most important, long-term studies should be conducted to determine the benefits for children of providing comprehensive dental care and education to pregnant women.

Opposing Arguments/Evidence

Opposing views or arguments essentially consist of (1) underlying values or myths held by pregnant women, (2) values held by some dental providers, and (3) myths held by the public and dental providers related to fluoride safety.[57–59] Pregnant women with low levels of education sometimes hold the unfounded belief that it is not safe to go to a dentist during pregnancy and frequently do not value oral health.[57] Dispelling these misunderstandings regarding the safety and benefits of dental care during pregnancy is essential to improving the oral health of pregnant women and their infants. In addition, some dental providers do not treat pregnant women. A 2010 study showed that the primary reasons were as follows: an incorrect belief on the part of many providers that procedures such as X-rays, amalgam fillings, and periodontal surgery, as well as pain medication, were dangerous for the woman and fetus; low insurance reimbursement rates for providing oral health counseling to pregnant women; and providers’ belief that their practice was too busy to provide oral health counseling for pregnant women.[57] Educating dental and allied dental students and dental residents would help improve their comfort level in treating pregnant women. In both cases, the underlying issue is largely a lack of appropriate education and understanding.[31,32]

With regard to fluoride safety, community water fluoridation (CWF) is safe and effective in preventing tooth decay.[34,35,60] A vocal and active minority are opposed to CWF. Untruths are spread about CWF to prevent communities from adopting this proven method for preventing dental caries, and opponents of CWF use studies with questionable methods or conclusions as evidence against fluoride.[58,59] A 2019 study reported an association between fluoride and lower IQ scores in children.[61] Public health and governmental organizations, public health faculty, and researchers raised serious concerns about the quality of the study and concluded that it involved “potential errors and biases” in estimations of fluoride exposure and in IQ measurement, as well as uncontrolled confounders.[62–64] These organizations continue to recommend community water fluoridation as safe, effective, and necessary in preventing tooth decay.[35,36,60]

Action Steps  
Federal Level

• APHA recommends that accreditation bodies for primary care, dental, and allied dental education programs require curriculum content on perinatal and infant oral health, including national and state guidelines.
• APHA recommends that professional organizations of primary care providers promote Smiles for Life: A National Oral Health Curriculum nationwide for primary care educational programs and practicing primary care providers.
• APHA recommends that HRSA’s Maternal and Infant Early Childhood Home Visiting Program include an oral health program performance measure for pregnant women as part of benchmark domains for demonstrating measurable improvement.
• APHA recommends that federal public health agencies and dental, allied dental, and primary care professional associations disseminate information about perinatal and infant oral health to improve the health literacy of the public and its consequent ability to make informed health care decisions.
• APHA recommends that the U.S. Congress include comprehensive dental coverage in any proposal aimed at expanding coverage or achieving universal coverage for all populations.
• APHA recommends that the U.S. Congress make comprehensive dental care a mandatory component of pregnancy-related benefits in Medicaid.
• APHA recommends that federal public health agencies work together to develop reliable and consistent mechanisms for collecting and publishing data on pregnant women’s oral health status, dental insurance coverage, and access to and utilization of dental care.
• APHA recommends that the Centers for Disease Control and Prevention, HRSA, the National Institutes of Health, and other federal public health agencies increase funding for public health programs and research focused on improving perinatal and infant oral health.
• APHA recommends that Healthy People include a specific objective on the oral health of pregnant women.

State/Local Level

• APHA recommends that community-based programs (e.g., WIC, EHS, and home visiting) that enroll pregnant women provide culturally tailored education on the importance of perinatal and infant oral health and oral health supplies, make referrals to dental providers, provide care coordination, and collect, document, and report oral health findings.
• APHA recommends that Medicaid programs include comprehensive dental coverage for women during pregnancy through 1 year postpartum.
• APHA recommends that all Medicaid programs provide reimbursement for oral health services delivered by prenatal providers.
• APHA recommends that Medicaid dental reimbursement rates be increased to attract more participating dental providers.
• APHA recommends that state and local public health agencies work together to develop reliable and consistent mechanisms for collecting and publishing data on pregnant women’s oral health status, dental insurance coverage, and access to dental care.

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