1. Analysis of Oral Health in Montana: Point-in-Time PRAMS Family and Community Health Bureau Data Monitoring Section Report Prepared By Rosina Everitte, MPH MCH Epidemiological Statistician reveritte@mt.gov

2. Why PRAMS? The PRAMS survey is an invaluable tool because.. it attempts to collect data not readily accessible by other means including as Vital Statistics, Census Data, registries, or other structured data repositories For Montana, it also serves as a baseline for many projects and programs such as Oral Health

3. CDC PRAMS Pregnancy Risk Assessment Monitoring Survey (PRAMS) 5- year, ongoing surveillance study Originated from the CDC in 1987 Originated from the CDC in 1987 Collects state-specific, population-based data Collects state-specific, population-based data Approximately 1,300 to 3,400 unweighted live births collected via birth certificates every year Approximately 1,300 to 3,400 unweighted live births collected via birth certificates every year State-optional over-sampling of minority populations State-optional over-sampling of minority populations Standardized protocol for data collection, including mailings and telephone communication Standardized protocol for data collection, including mailings and telephone communication Core and state-tailored questionnaire Core and state-tailored questionnaire Maternal information including behaviors and risk factors relative to the pre-,intermediate, and post-pregnancy experience Maternal information including behaviors and risk factors relative to the pre-,intermediate, and post-pregnancy experience Minimum 70% response rate Minimum 70% response rate

4. Montana PRAMS 3-year, point-in-time cross-sectional surveillance study initiated in 2002 One-year sampling of live birth cohort via birth certificates from first three months of 2002 Over-sampling of young mothers under 20 years of age 1,363 unweighted responses, 10,720 weighted 77% success rate 12.34% response rate Other aspects of Montana PRAMS are not markedly different than the basic CDC PRAMS

5. Oral Health: Why do we care? Definitive oral health disparities in the MCH population Bacteria affiliated with oral disease can be transmitted to baby Oral health diseases are preventable Oral health risk factors are prominent including: Low fluoridation rates in water systems ( ~ 24% in 2002) 3 rd highest smokeless tobacco rate Access to oral health care is problematic across the state Poor oral health may lead to negative birth outcomes

6. Briefing on Oral Health Common oral diseases – Early Childhood Caries (ECC – i.e. baby bottle tooth decay), caries, periodontal disease, and oral cancer Caries process involves fermentation of carbohydrates into acids, which demineralize the tooth enamel causing caries With optimal amounts of fluoride (@ 1 PPM), early caries can be prevented and even reversed. Root caries in adults, due to gum recession, can also be prevented Approximately 76% of Montanans do not have access to optimal fluoridated water, however, there are locations in Montana where natural fluoride levels are extremely elevated, which may cause fluorosis Approximately 76% of Montanans do not have access to optimal fluoridated water, however, there are locations in Montana where natural fluoride levels are extremely elevated, which may cause fluorosis Maternal transmission of Streptococcus Mutans – a common bacteria found in the mouth is passed on via the mother, with an infant having a typical window of infectivity for children less than 2 years of age New evidence suggests caesarian infants may have an earlier window of infectivity at around 17 months, when compared to vaginally-delivered infants (29 months) New evidence suggests caesarian infants may have an earlier window of infectivity at around 17 months, when compared to vaginally-delivered infants (29 months) Children’s health may be impacted by caries, i.e. growth retardation and failure to thrive, inability to learn in school, spread of disease to other areas of the body Adult health are affected as well, especially with regard to periodontal disease, i.e. new associations with stroke and cardiovascular disease and negative birth outcomes to name a few

8. Legend Average >= 1.21 PPM 0.71 – 1.20 PPM (Optimal) 0.41 – 0.70 PPM 0.00 – 0.40 PPM µ Averaged fluoride per county Montana Public Water Systems Average Fluoridation Levels By County Data originally from DEQ - November 8, 2005 ♀ Map created by Rosina Everitte, MCH Epidemiological Statistician

9. Montana Public Water Systems Proportional Fluoridation Level Inadequacy By County ♀ Map created by Rosina Everitte, MCH Epidemiological Statistician Legend 75.01 to 100.0% Inadequacy 50.01 to 75.00% Inadequacy 25.01 to 50.00% Inadequacy 0.00 to 25.00% Inadequacy µ Averaged fluoride per county Montana Public Water Systems Proportional Fluoridation Level Inadequacy By County Overall Inadequacy = 83.76%* a * Inadequacy criteria = less than 0.7 parts per million a DEQ data pulled on November 8, 2005 ♀ Map created by Rosina Everitte, MCH Epidemiological Statistician µ= 2.06

10. MT PRAMS Oral Health Question This question is about the care of your teeth during your most recent pregnancy. For each thing, circle Y (Yes) if it is true or circle N (No) if it is not true. a. I need to see a dentist for a problem Yes (36.2%) b. I went to a dentist or dental clinic No (40.8%) c. A dental or other health care worker talked to me about how to care for my teeth and gums No (37.5%)

11. Oral Health Inter-state Comparisons 1 Colorado PRAMS was a 5-year study with estimates generated in 2000 2 Montana PRAMS was a 3-year point-in-time study with estimates generated in 2002 Colorado PRAMS’ Oral Health was highly comparable to Montana PRAMS’ Oral Health Disparities exist between the two states for Needing to Visit the Dentist, with Montana mothers reporting significantly higher percentages than Colorado mothers (11.09% difference, Montana PRAMS 36.20%)

12. Oral Health Inter-state Comparisons 1 Confidence intervals could not be calculated for other states, due to lack of crude numbers Montana PRAMS’ Oral Health exceeds all other reporting states for Needing to Visit the Dentist, with differences exceeding 10% for all comparison states If confidence intervals for the reported states were similar to Colorado, there would be a significant difference between all reporting states and Montana for the reported variable Needing to Visit the Dentist

13. Methodology SUDAAN-callable software utilized through SAS 9.13 Cross-checks with SAS 9.1 Survey-calls Cross-checks with SAS 9.1 Survey-calls Quality assurance of data Quality assurance of data Independent variables: demographical, social, financial, psychological, and physiological in nature Independent variables: demographical, social, financial, psychological, and physiological in nature Outcome variables: Needed to Visit the Dentist, Talked to Dentist/HCW about Dental Care, and Visited the Dentist Outcome variables: Needed to Visit the Dentist, Talked to Dentist/HCW about Dental Care, and Visited the Dentist Regional assessments comprised of Eastern, Western and Central Service Area divisions Regional assessments comprised of Eastern, Western and Central Service Area divisions

14. Regional Divisions Map* Valley Phillips Fergus Garfield Big Horn Custer Rosebud Carter McCone Dawson Carbon Prairie Fallon Richland Roosevelt Yellowstone Stillwater Daniels Sheridan Petroleum Musselshell Judith Basin Sweet Grass Wheatland Wibaux Treasure Golden Valley Powder River Eastern Madison Ravalli Powell Lake Missoula Granite Mineral Sanders Flathead Western Silver Bow Hill Blaine Park Glacier Chouteau Teton Toole Gallatin Cascade Meagher Lewis & Clark Liberty Pondera Broadwater Central Jefferson Sampling: 31% Eastern 34% Central 35% Western Beaverhead Deer Lodge Lincoln *Regional division designations defined by MT DPHHS

15. Demographic Characteristics of Montana Resident Birth Mothers Maternal CharacteristicsState Total% State TotalMT PRAMS TotalMT PRAMS % Total Total11,045100.01,363100.0 Maternal Age < 201,27711.628711.7 20-243,15528.620225.4 25-345,34748.444250.1 35+1,26311.411412.8 Maternal Education < 12 years1,62314.721115.1 12 years3,67233.234934.3 > 12 years5,56250.448350.6 Marital Status Married7,41567.139368.9 Unmarried3,62432.865231.1 Medicaid Status Medicaid During Pregnancy2,05859.040834.7 No Medicaid During Pregnancy1,43041.062665.3 Baby’s Birth Weight (Grams) LBW (< 2500 grams)7586.9545.0 NBW (2500+ grams)10,28393.199195.0 Prenatal Health Care 1 st Trimester9,19083.277075.8 2 nd Trimester1,48713.523721.5 3 rd Trimester2422.2161.6 No Care610.6111.1

16. Valley Phillips Fergus Garfield Big Horn Custer Rosebud Carter McCone Dawson Prairie Fallon Richland Roosevelt Yellowstone Stillwater Daniels Petroleum Judith Basin Sweet Grass Wheatland Treasure Golden Valley Powder River Madison Ravalli Powell Lake Missoula Granite Sanders Flathead Silver Bow Hill Blaine Park Glacier Chouteau Teton Toole Meagher Lewis & Clark Liberty Pondera Broad water Jefferson Deer Lodge Lincoln Gallatin Beaverhead Cascade Sheridan Wibaux Carbon Musselshell Mineral Proportion of Pregnant Women Having a Dental Problem During Pregnancy (PRAMS) Legend 75.01 to 100.0% 50.01 to 75.00% No Data 25.01 to 50.00% 0.00 to 25.00%

17. Demographic Variables Sample Distribution (%) Needed to visit a dentist Went to visit a dentist (=no) Dentist discussed how to care for teeth (=no) % yes p- value Prevalence Ratio (PR) 95% CI % no p- value PR95% CI % no p- value PR95% CI Maternal Education (n=10,698) < 12 years 15.0921.61<0.00013.002.03- 4.43 16.440.02691.571.05- 2.33 15.6 3 0.43621.170.79- 1.74 5 12 years34.3342.26<0.00012.301.68- 3.16 35.470.15491.240.92- 1.68 5 34.0 9 0.96750.990.73- 1.355 > 12 years 50.5836.13Reference Group 48.09Reference Group 50.2 8 Reference Group Paternal Education (n=9,610) < 12 years 9.3612.97<0.00012.731.63- 4.56 10.480.07751.59 13 0.95- 2.66 5 10.7 7 0.10251.58 13 0.91- 2.74 5 12 years39.9350.58<0.00012.321.68- 3.21 42.310.03941.371.02- 1.86 38.9 4 0.72600.95 13 0.70- 1.29 5 > 12 years 50.7136.45Reference Group 47.21Reference Group 50.2 9 Reference Group Geographic Area (n=10,720) Eastern31.3135.670.01751.521.08- 2.15 32.790.32221.181.18 0.85- 1.65 5 31.8 2 0.67871.070.77- 1.51 5 Western34.4634.310.23530.810.87- 1.74 34.300.58001.101.10 0.79- 1.51 5 34.7 8 0.56021.100.79- 1.54 5 Central34.2330.02Reference Group 32.91Reference Group 33.4 0 Reference Group Marital Status (n=10,720) Other31.0842.66<0.00012.251.68- 3.02 32.620.10741.271.27 0.95- 1.71 5 31.3 7 0.81081.040.77- 1.39 5 Married68.9257.34Reference Group 67.38Reference Group 68.6 3 Reference Group There were no significant associations between oral health talks and these demographic variables. Demographics Analyses There were no significant associations between visiting the dentist and these demographic variables.

18. Pre- pregnancy Medicaid (n=10,694) Yes8.8514.79<0.00012.941.81- 4.78 9.010.65181.120.68- 1.85 5 7.620.13690.690.43- 1.12 5 No91.1585.21Reference Group 90.99Reference Group 92.38Reference Group Pre- pregnancy Insurance (n=10,702) No39.5555.54<0.00012.812.11- 3.74 44.29<0.00011.771.33- 2.35 41.800.01871.411.06- 1.88 Yes60.4544.46Reference Group 55.71Reference Group 58.20Reference Group People per Room in Home (n=10,489) 1+ People 10.0713.320.01871.741.10- 2.77 10.630.41151.220.76- 1.97 5 10.380.63391.120.70- 1.80 5 0-1 people 89.9386.68Reference Group 89.37Reference Group 89.62Reference Group Previous Live Births (n=10,581) Yes61.4666.94<0.00011.451.33- 1.57 60.060.28250.860.66- 1.13 5 59.180.09760.800.60- 1.04 5 No38.5433.06Reference Group 39.94Reference Group 40.82Reference Group Demographic Variables Sample Distribution (%) Needed to visit a dentist Went to visit a dentist (=no) Dentist discussed how to care for teeth (=no) % yes p- value Prevalence Ratio (PR) 95% CI % no p- value PR95% CI % no p- value PR95% CI There were no significant associations between these oral health measures and these demographic variables. Abuse Before Pregnancy (n=10,660) Yes8.8213.960.00032.401.49- 3.85 10.860.02281.791.08- 2.96 10.320.13901.470.88- 2.45 5 No91.1886.04Reference Group 89.14Reference Group 89.68Reference Group Abuse During Pregnancy (n=10,662) Yes5.056.580.15471.540.85- 2.78 5 6.380.01792.181.14- 4.15 5.800.23441.500.77- 2.94 5 No94.9593.42Reference Group 93.62Reference Group 94.20Reference Group Smoking Before Pregnancy (n=10,297) Yes29.6841.64<0.00012.361.74- 3.20 32.380.00961.501.10- 2.03 32.440.00671.541.13- 2.11 No70.3258.36Reference Group 67.62Reference Group 67.56Reference Group Smoking During Pregnancy (n=10,509) Yes15.8724.81<0.00012.651.83- 3.84 18.370.00721.701.15- 2.49 18.470.00181.901.27- 2.83 No84.1375.19Reference Group 81.63Reference Group 81.53Reference Group Demographics Analyses

19. Smoking After Pregnancy (n=10,518) Yes20.8431.49<0.00012.581.85 - 3.59 23.850.00221.731.22- 2.44 22.840.01791.541.08- 2.19 No79.1668.51Reference Group 76.15Reference Group 77.16Reference Group Drinking During Pregnancy (n=10,519) Yes6.786.570.87350.950.54- 1.70 5 8.730.01652.061.14- 3.72 8.930.00452.521.33- 4.77 No93.2293.43Reference Group 91.27Reference Group 91.07Reference Group Demographic Characteristics associated with heightened risk of reporting a perceived dental problem: Younger women Women with maternal education ≤ 12 years Women whose partners had ≤ 12 years of education Women living in Eastern Montana Unmarried women Women with pre-pregnancy Medicaid Women with no pre-pregnancy insurance (Medicaid excluded) Women with more than one person per room in the home Women with at least one previous live birth Women with abuse before pregnancy Women who smoked before, during, and after pregnancy Demographic Variables Sample Distribution (%) Needed to visit a dentist Went to visit a dentist (=no) Dentist discussed how to care for teeth (=no) % yes p- value Prevalence Ratio (PR) 95% CI % no p- value PR95% CI % no p- value PR95% CI

20. However... When Visiting the Dentist outcomes were assessed, some of the same demographic characteristics held steadfast in their associations, including: Women with maternal education < 12 years Women with partners with education = 12 years Women with no pre-pregnancy insurance (Medicaid excluded) Women abused before pregnancy Women who smoked before, during or after pregnancy Women having pre-pregnancy Medicaid in Eastern Montana These findings suggest women with these characteristics not only had a heightened risk of having a perceived dental problem, but they were also less likely to visit a dentist.

21. Additionally... Newly associated maternal demographic characteristics include: Abuse during pregnancy Drinking during pregnancy Maternal characteristics still associated with Talked with Dentist/HCW about Oral Health Care include: Women with no pre-pregnancy insurance (Medicaid excluded) Women with no pre-pregnancy insurance (Medicaid excluded) Women who smoked before, during, or after pregnancy Women who smoked before, during, or after pregnancy Women who drank during pregnancy Women who drank during pregnancy

22. Demographic Findings... These findings suggest a large number of high-risk demographic characteristics may predispose mothers to having a perceived dental problem during pregnancy However, only a select few of these characteristics were associated with inhibited visits to the dentist, including three new associations with no prior affiliation with Needing to Visit the Dentist Regional Divisions were no longer significant for Needing to Visit the Dentist, which may be contradictory to other Access to Care reports. However, pre-pregnancy Medicaid participants (subgroup) continued to have access to care issues during pregnancy for Needing to Visit the Dentist Lack of pre-pregnancy insurance (Medicaid-excluded) and all levels of smoking are the only demographic characteristics reported which demonstrated risk at every level of PRAMS oral health surveillance

23. Additional Demographic Findings Though the results suggest women who drank during pregnancy were less likely to have a perceived dental problem, they were also less likely to visit a dentist or ask about oral health care. However, underreporting may be an issue and may have biased these results. These findings should help target the highest risk subgroups of Montana mothers, to implement intervention and prevention with appropriate oral health strategies These associations/findings may be proxies for low SES or other high-risk characteristics

24. Eastern Western Central

25. Eastern Western Central Population per Dentist Ratios Montana, 2004 1000 - 1999 2000 - 3999 4000 - 13000 No dentist Number of People Per Dentist

26. Poor Birth Outcomes Exposure Variables Sample Distribution (%) 7 Low Birth Weight Infant Admitted To ICU % yes p- value Prevalence Ratio (PR) 95% CI % yes p- value PR95% CI Needed to Visit the Dentist (n=10,376) Yes36.1952.110.02451.991.09-3.6350.470.00981.901.17-3.08 No63.8147.89Reference Group 49.53Reference Group Visited the Dentist (n=10,421) No59.2360.290.88471.050.56-1.96 5 54.680.43080.820.51-1.37 5 Yes40.7739.71Reference Group 45.32Reference Group Talked with the Dentist (n=10,256) No62.4960.730.80770.930.49-1.74 5 65.110.63701.130.68-1.89 5 Yes37.5139.27Reference Group 34.89Reference Group Reported Needing to Visit the Dentist was correlated with both low birth weight (<2500 grams) and NICU admission outcomes The association suggests women who perceived a dental problem during pregnancy had 99% more occurrences of low birth weight outcomes and 90% more occurrences of NICU admissions than those women not reporting a dental problem during pregnancy There were no significant associations between these oral health measures and these birth outcome variables.

27. Maternal Morbidity Analyses Exposure Variables Sample Distribution (%) 7 BedrestHospitalization > 7 daysHospitalization from 1-7 days % yes p- value Prevalence Ratio (PR) 95% CI % yes p- valuePR 95% CI % yes p- valuePR 95% CI Needed to Visit the Dentist (n=6,602) Yes36.1940.380.97961.000.68- 1.46 5 53.600.27211.720.65- 4.58 5 41.380.85261.050.65- 1.67 5 No63.8159.62Reference Group 46.40Reference Group 58.62Reference Group Visited the Dentist (n=6,586) No59.2359.710.83381.040.71- 1.53 5 48.070.35950.640.24- 1.68 5 59.430.92771.020.64- 1.63 5 Yes40.7740.29Reference Group 51.93Reference Group 40.57Reference Group Talked with the Dentist (n=6,499) No62.4967.340.19351.300.88- 1.94 5 63.640.95021.030.38- 2.83 5 60.620.63170.890.56- 1.43 5 Yes37.5132.66Reference Group 36.36Reference Group 39.38Reference Group Exposure Variables Sample Distribution (%) 7 Hospitalization < 1 dayPremature Rupture of MembranesCervix Sewn Shut % yes p- value Prevalence Ratio (PR) 95% CI % yes p- valuePR 95% CI % yes p- valuePR 95% CI Needed to Visit the Dentist (n=6,602) Yes36.1948.070.01241.591.11- 2.28 33.18 (n=10349) 0.71130.870.41- 1.84 5 28.46 (n=10367) 0.49390.700.25- 1.97 5 No63.8151.93Reference Group 66.82Reference Group 71.54Reference Group Visited the Dentist (n=6,586) No59.2365.440.03201.501.04- 2.16 74.21 (n=10394) 0.07902.030.92- 4.48 5 60.79 (n=10412) 0.89061.070.41- 2.83 5 Yes40.7734.56Reference Group 25.79Reference Group 39.21Reference Group Talked with the Dentist (n=6,499) No62.4971.000.00661.701.16- 2.50 72.11 (n=10229) 0.23501.580.74- 3.37 5 62.62 (n=10246) 0.98800.990.39- 2.60 5 Yes37.5129.00Reference Group 27.89Reference Group 37.38Reference Group There were no significant associations between these oral health measures and these maternal morbidity variables.

28. Maternal Morbidity Analyses Exposure Variables Sample Distribution (%) 7 Car AccidentsNauseaDiabetes % yes p- valuePR 95% CI % yes p- valuePR 95% CI % yes p- valuePR 95% CI Needed to Visit the Dentist (n=10,371) Yes36.1963.790.03593.161.08- 9.27 44.440.00541.581.14- 2.17 43.27 (n=10354) 0.30521.370.75- 2.51 5 No63.8136.21Reference Group 55.56Reference Group 56.73Reference Group Visited the Dentist (n=10,416) No59.2345.440.25360.570.22- 1.50 5 59.080.96520.990.72- 1.36 5 59.67 (n=10399) 0.95461.020.55- 1.89 5 Yes40.7754.56Reference Group 40.92Reference Group 40.33Reference Group Talked with the Dentist (n=10,250) No62.4955.920.58220.760.28- 2.03 5 60.960.61090.920.67- 1.27 5 61.40 (n=10233) 0.87030.950.52- 1.75 5 Yes37.5144.08Reference Group 39.04Reference Group 38.60Reference Group There were no significant associations between these oral health measures and these maternal morbidity variables. Only Hospitalization < 1 day was significantly associated with all three of the PRAMS oral health indicators, with odds ratios ranging from 1.50 to 1.70 This association may be a proxy for SES and/or Access to Care, as short duration hospitalization during pregnancy correlated with lack of oral health prevention and intervention Needed to Visit the Dentist was associated with both Car Accidents and Nausea

29. Oral Health Modeling Used a cumulative stressor index, based on the total number of stressors experienced by the mother 12 months before pregnancy – similar to the threshold research done by Whitehead et al. from the CDC Stressors include home disputes and problems, familial drug abuse or illness, and monetary problems or joblessness Stressors include home disputes and problems, familial drug abuse or illness, and monetary problems or joblessness Modeled the linearity of the cumulative stressor index with the binary outcome of having a perceived dental problem during pregnancy Used simple, unconditional logistic regression in both SAS SURVEYLOGISTIC and SUDAAN RLOGIST μ= 2.15 (95% CI=2.01 - 2.29), Range= 0 to 12 Cumulative Stressors Logit Odds (Ŷ=1)= -1.3360 + 0.3375 (Cumulative Stressors) + 0.0429 (Standard Error) Odds ratio=1.401 (95% CI= 1.29 - 1.52) This finding suggests pregnant women who selected listed stressors had a 40% higher prevalence of a perceived dental problem during pregnancy than women who did not report the stressors 12 months before pregnancy For every two additional stressors, the odds of having a dental need increase 96.28% C-statistic=0.678

30. Periodontal Disease and Maternal Nausea Li et al. suggests, in the publication “Systemic Diseases Caused by Oral Infection”, maternal nausea may be associated with maternal dental problems during pregnancy. Initial, crude associations from maternal morbidity and Needed to Visit the Dentist variables suggest there is a significant relationship, when reporting PRAMS mothers were analyzed Additional investigation is warranted

31. Oral Health Modeling Model Variables 6 Y- Intercept Beta Coefficients Adjusted Odds Ratios 95% CI’s R-Squared/ C- Statistic Values -1.5283 Maternal Nausea0.37451.451.03 - 2.05 Smoking 3 Months Before Pregnancy 0.75032.121.51 - 2.97 Medical Insurance (YES)/(NO) -0.82390.44/2.280.32 - 0.60/ 1.66 - 3.13 Previous Live Birth0.48661.631.19 - 2.22AdjR 2 =0.61/ C=0.67 6 This model was selected based on the most parsimonious model with the best-fitting independent variables being selected through forward selection methods with an alpha of 0.20 and a final selection using manual, stepwise methods and an alpha of 0.05. Interactions were assessed for after the former forward selection method was utilized. Confounders were not assessed for due to Simpson’s Paradox existing with the variable “insure” when stratification was done for interaction. Sample size was the issue for the paradox, therefore, adjusted odds ratios from the controlled model were used for this report.

32. Interpretation The adjusted odds ratio for the association between maternal nausea and dental need is significant at 1.45, suggesting there is a 45% difference in dental need prevalence between women reporting maternal nausea and those not reporting maternal nausea during pregnancy The 0.13 or 13% risk difference in the crude and adjusted odds ratio for maternal nausea is attributable to the other maternal factors included in the model: having a previous live birth, lacking pre- pregnancy insurance, and smoking 3 months before pregnancy However, after controlling other maternal factors, there is still a significant association between maternal nausea and Needed to Visit the Dentist, supporting some of the findings of Li et al. The data supports the recommendations for dental health prevention information being disseminated early in pregnancy, to counteract the risk associated with maternal nausea

33. Additional Findings Self-reported Needed to Visit the Dentist appears to be highly associated with both reported admissions to NICU and low birth weight outcomes, confirming the findings of Li et al. regarding poor infant outcomes and poor oral health Cumulative modeling of maternal stressors during pregnancy suggested heightened risk of dental need, confirming similar research by Whitehead et al. Modeling of maternal nausea during pregnancy also suggested heightened risk of dental need, when other factors were controlled for in the model Few maternal morbidity variables were significantly associated with the oral health indicators collected by Montana PRAMS, negating the publication by Li et al. that suggested PRM, pre-term labor, maternal diabetes and other maternal problems were associated with poor oral health during pregnancy However, indirect pathways of causation may play an integral part in maternal susceptibility to poor infant outcomes Further research is needed to fully understand the relationship of dental need, specifically oral health problems such as periodontal disease, and poor infant outcomes Mapping the indirect and direct pathways of how poor oral health is affected by maternal nausea is important, due to associations with the weight and health of infants at birth Mapping the indirect and direct pathways of how poor oral health is affected by maternal nausea is important, due to associations with the weight and health of infants at birth

34. What Can Be Done? Step 1: Understand/Identify who is most at risk Using data to make sound risk assessments Using data to make sound risk assessments Refer to “checklist” of risk factors Refer to “checklist” of risk factors Counsel client on potential risk of negative outcome, due to risk assessment Counsel client on potential risk of negative outcome, due to risk assessment Step 2: Intervene, where applicable Give referrals to area dentists/PhDs/healthcare workers for counseling and intervention Give referrals to area dentists/PhDs/healthcare workers for counseling and intervention Give out dental floss and new toothbrushes, coupons for fluoride rinses Give out dental floss and new toothbrushes, coupons for fluoride rinses Network and collaborate with area stakeholders such as the Department of Environmental Quality (DEQ), the Environmental Protection Agency (EPA), and state/county health departments to insure optimal levels of fluoridation during pregnancy through assessment and intervention of household water supply Network and collaborate with area stakeholders such as the Department of Environmental Quality (DEQ), the Environmental Protection Agency (EPA), and state/county health departments to insure optimal levels of fluoridation during pregnancy through assessment and intervention of household water supply Step 3: EDUCATE, EDUCATE, EDUCATE Train non-dental and medical health professionals on the value of oral health during pregnancy and how to screen for basic conditions, such as caries formation, periodontal disease, and “mottled teeth” Train non-dental and medical health professionals on the value of oral health during pregnancy and how to screen for basic conditions, such as caries formation, periodontal disease, and “mottled teeth” Inform pregnant clients of the importance of good oral health during pregnancy Inform pregnant clients of the importance of good oral health during pregnancy Educate clients on the effects of proper nutrition on good oral health Educate clients on the effects of proper nutrition on good oral health Educate clients on signs of gingivitis, periodontal disease, and fluorosis Educate clients on signs of gingivitis, periodontal disease, and fluorosis Explain the risk of bacteria transference after birth to clients highlighting preventive efforts Explain the risk of bacteria transference after birth to clients highlighting preventive efforts Disseminate information/education through available resources, such as WIC distributions to clients and distributions to physicians and hospitals/clinics Disseminate information/education through available resources, such as WIC distributions to clients and distributions to physicians and hospitals/clinics Step 4: Resources for change Empowering personal change=enabling personal control Empowering personal change=enabling personal control Give resources for education and information Give resources for education and information Direct collaboration of multiple sectors within your community – encase client with support Direct collaboration of multiple sectors within your community – encase client with support

35. Limitations Montana PRAMS is a self-reported survey Additionally, partner characteristics were not self-reported Recall bias may be an issue, especially for socially stigmatizing behaviors Minorities were not expressly over-sampled and minority stratification on maternal characteristics could not be utilized In some instances, missing values were larger than 10% Confidence intervals for comparison states could not always be calculated Measures of association were often crude, with binary variable levels Data quality could only be checked post-hoc Inferences were made regarding the nature of the oral health indicators Logistic regression assumptions were only partially tested Rural well water could not be ascertained for this presentation

36. References and Resources Gaffield, M., et al. Oral Health During Pregnancy: An Analysis of Information Collected by the Pregnancy Risk Assessment Monitoring System. JADA. 2001; 132: 1009-16. Offenbacher, S., and Slade, G. Role of periodontitis in systemic health: Spontaneous pre-term birth. Journal of Dental Education. 1998: 62 (10): 852- 58. Whitehead, Nedra, et al. Exploration of Threshold Analysis in the Relation between Stressful Life Events and Pre-term Labor. American Journal of Epidemiology. 2002; 155 (2): 117-24. Li, Xiaojing, et al. Systemic Diseases Caused by Oral Infection. Clinical Microbiology Reviews. 2000; 13(4);547-58. Presentation by Dr. Wendy Mouradian, MD, MS. Montana’s Spring Public Health Conference. 2005. National Institute of Dental and Craniofacial Research. 2000. Oral Health in America: A Report of the Surgeon General – Executive Summary. Rockville, MD: National Institute of Dental and Craniofacial Research.

37. References and Resources Montana Behavioral Risk Factor Surveillance Survey (BRFSS), 2002 Survey Data. Montana Central Tumor Registry, 2005 Data. Zeeman, GG, Veth EO, Dennison DK. 2001. Periodontal disease: Implications for women’s health. Obstetrical & Gynecological Survey 56(1): 43-49. Jeffcoat MK, Geurs NC, Reddy MS, Cliver Sp, Goldenberg RL, Hauth Jc. 2001. Periodontal infection and preterm birth: Results of a prospective study. Journal of the American Dental Association 132(7): 875 – 880. DPHHS School Oral Health Report, 2002 – 2004 Data.