Analysis of Oral Health in Analysis of Oral Health in Montana:Montana:
Point-in-Time PRAMS Point-in-Time PRAMS
Family and Community Health BureauFamily and Community Health BureauData Monitoring SectionData Monitoring Section
Report Prepared By Rosina Everitte, MPHReport Prepared By Rosina Everitte, MPHMCH Epidemiological StatisticianMCH Epidemiological Statistician
[email protected]@mt.gov
Why PRAMS?Why PRAMS?
The PRAMS surveyThe PRAMS survey
is an invaluable toolis an invaluable tool
because..because..
it attempts to collect data not readilyit attempts to collect data not readily
accessible by other means including as Vitalaccessible by other means including as Vital
Statistics, Census Data, registries, Statistics, Census Data, registries,
or other structured data repositoriesor other structured data repositories
For Montana, it also serves as a baseline forFor Montana, it also serves as a baseline for
many projects and programs such as many projects and programs such as
Oral HealthOral Health
CDC PRAMSCDC PRAMS
Pregnancy Risk Assessment Monitoring Survey (PRAMS) 5-Pregnancy Risk Assessment Monitoring Survey (PRAMS) 5-year, ongoing surveillance studyyear, ongoing surveillance study
Originated from the CDC in 1987Originated from the CDC in 1987 Collects state-specific, population-based dataCollects state-specific, population-based data Approximately 1,300 to 3,400 unweighted live births collected via Approximately 1,300 to 3,400 unweighted live births collected via
birth certificates every yearbirth certificates every year State-optional over-sampling of minority populationsState-optional over-sampling of minority populations Standardized protocol for data collection, including mailings and Standardized protocol for data collection, including mailings and
telephone communicationtelephone communication Core and state-tailored questionnaireCore and state-tailored questionnaire Maternal information including behaviors and risk factors relative to Maternal information including behaviors and risk factors relative to
the pre-,intermediate, and post-pregnancy experiencethe pre-,intermediate, and post-pregnancy experience Minimum 70% response rateMinimum 70% response rate
Montana PRAMSMontana PRAMS
3-year, point-in-time cross-sectional surveillance study initiated in 3-year, point-in-time cross-sectional surveillance study initiated in 20022002
One-year sampling of live birth cohort via birth certificates from first One-year sampling of live birth cohort via birth certificates from first three months of 2002three months of 2002
Over-sampling of young mothers under 20 years of ageOver-sampling of young mothers under 20 years of age
1,363 unweighted responses, 10,720 weighted1,363 unweighted responses, 10,720 weighted
77% success rate77% success rate
12.34% response rate12.34% response rate
Other aspects of Montana PRAMS are not markedly different than Other aspects of Montana PRAMS are not markedly different than the basic CDC PRAMSthe basic CDC PRAMS
Oral Health:Oral Health:Why do we care?Why do we care?
Definitive oral health disparities in the MCH populationDefinitive oral health disparities in the MCH population
Bacteria affiliated with oral disease can be transmitted to babyBacteria affiliated with oral disease can be transmitted to baby
Oral health diseases are preventableOral health diseases are preventable
Oral health risk factors are prominent including:Oral health risk factors are prominent including:Low fluoridation rates in water systems ( ~ 24% in 2002)Low fluoridation rates in water systems ( ~ 24% in 2002)33rdrd highest smokeless tobacco rate highest smokeless tobacco rateAccess to oral health care is problematic across the stateAccess to oral health care is problematic across the state
Poor oral health may lead to negative birth outcomesPoor oral health may lead to negative birth outcomes
Briefing on Oral HealthBriefing on Oral HealthCommon oral diseases – Early Childhood Caries (ECC – i.e. baby bottle tooth Common oral diseases – Early Childhood Caries (ECC – i.e. baby bottle tooth decay), caries, periodontal disease, and oral cancerdecay), caries, periodontal disease, and oral cancer
Caries process involves fermentation of carbohydrates into acids, which Caries process involves fermentation of carbohydrates into acids, which demineralize the tooth enamel causing cariesdemineralize the tooth enamel causing caries
With optimal amounts of fluoride (@ 1 PPM), early caries can be prevented and 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 preventedeven 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, Approximately 76% of Montanans do not have access to optimal fluoridated water, however, there are locations in Montana where natural fluoride levels are extremely however, there are locations in Montana where natural fluoride levels are extremely elevated, which may cause fluorosiselevated, which may cause fluorosis
Maternal transmission of Maternal transmission of Streptococcus Mutans – Streptococcus Mutans – a common bacteria found in the a common bacteria found in the mouth is passed on via the mother, with an infant having a typical window of mouth is passed on via the mother, with an infant having a typical window of infectivity for children less than 2 years of ageinfectivity for children less than 2 years of age
New evidence suggests caesarian infants may have an earlier window of infectivity at New evidence suggests caesarian infants may have an earlier window of infectivity at around 17 months, when compared to vaginally-delivered infants (29 months)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 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 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. Adult health are affected as well, especially with regard to periodontal disease, i.e. new associations with stroke and cardiovascular disease and negative birth new associations with stroke and cardiovascular disease and negative birth outcomes to name a fewoutcomes to name a few
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
ValleyPhillips
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
TreasureGolden Valley
Powder River
Madison
Ravalli
Powell
Lake
Missoula
Granite
Mineral
Sanders
Flathead
Silver Bow
Hill
Blaine
Park
Glacier
ChouteauTeton
Toole
Cascade
Meagher
Lewis & Clark
Liberty
Pondera
Broadwater
Jefferson
Beaverhead
Deer Lodge
Lincoln
Gallatin
µ=1.09 µ=0.40
µ=0.63
µ=0.63
µ=0.34
µ=0.67
µ=0.66
µ=0.67µ=0.21
µ=0.22
µ= 0.09
µ=1.45
µ=0.37
µ=0.38µ=0.66
µ=0.38 µ=0.89
µ=0.60
µ=1.14
µ=0.24
µ=0.25
µ=1.07
µ=1.75
µ=0.80
µ=2.20µ=0.90
µ=0.13
µ=0.36
µ=0.29
µ=0.62µ=0.18
µ=0.22
µ=0.81
µ=0.33
µ= 0.55
µ=0.15
µ=4.42
µ=0.17µ=2.48
µ=0.47
µ=0.49
µ=0.51
µ=2.31
µ=0.20
µ=0.46
µ=1.25
µ=0.27
µ=0.45
µ=0.48µ=0.84
µ=0.74
µ=0.37µ=1.24
µ= 2.06
µ=0.79
µ= 0.24
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
ValleyPhillips
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
TreasureGolden Valley
Powder River
Madison
Ravalli
Powell
Lake
Missoula
Granite
Mineral
Sanders
Flathead
Silver Bow
Hill
Blaine
Park
Glacier
ChouteauTeton
Toole
Cascade
Meagher
Lewis & Clark
Liberty
Pondera
Broadwater
JeffersonDeer Lodge
Lincoln
Gallatin
µ=1.09 µ=0.40
µ=0.63
µ=0.63
µ=0.34
µ=0.67
µ=0.66
µ=0.67µ=0.21
µ=0.22
µ= 0.09
µ=1.45
µ=0.37
µ=0.38µ=0.66
µ=0.38 µ=0.89
µ=0.60
µ=1.14
µ=0.24
µ=0.25
µ=1.07
µ=1.75
µ=0.80
µ=2.20µ=0.90
µ=0.13
µ=0.36
µ=0.29
µ=0.62µ=0.18
µ=0.22
µ=0.81
µ=0.33
µ= 0.55
µ=0.15
µ=4.42
µ=0.17µ=2.48
µ=0.47
µ=0.49
µ=0.51
µ=2.31
µ=0.20
µ=0.46
µ=1.25
µ=0.27
µ=0.45
µ=0.48µ=0.84
µ=0.74
µ=0.37µ=1.24
µ=0.79
µ= 0.24
Beaverhead
µ= 2.06
MT PRAMS Oral Health QuestionMT 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 clinicNo (40.8%)
c. A dental or other health care worker talked to me about how to care for my teeth and gumsNo (37.5%)
Oral Health Inter-state Comparisons Oral Health Inter-state Comparisons
PRAMS Comparisons of Oral Health for Colorado1 and Montana2
Prevalence Rates and 95% Confidence Intervals
0 10 20 30 40 50 60 70 80 90
100
1
Pe r cen t age
Dental Problems - CO Dental Problems - MT Visited dentist - CO Visited dentist - MT Dental care talk - CO Dental care talk - MT
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%)
Oral Health Inter-state Comparisons Oral Health Inter-state Comparisons
PRAMS Comparisons of Dental Problems for New Mexico, Illinois, and Louisiana - Prevalence Rates1
0 10 20 30 40 50 60 70 80 90
100
Oral Health Indicator
Dental Problems - NM Dental Problems - IL Dental Problems - LA
Pe r cen t age
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
MethodologyMethodology
SUDAAN-callable software utilized through SAS 9.13SUDAAN-callable software utilized through SAS 9.13
Cross-checks with SAS 9.1 Survey-callsCross-checks with SAS 9.1 Survey-calls
Quality assurance of dataQuality assurance of data
Independent variables: demographical, social, financial, Independent variables: demographical, social, financial, psychological, and physiological in naturepsychological, and physiological in nature
Outcome variables: Outcome variables: Needed to Visit the Dentist, Talked to Needed to Visit the Dentist, Talked to Dentist/HCW about Dental Care, and Visited the DentistDentist/HCW about Dental Care, and Visited the Dentist
Regional assessments comprised of Eastern, Western and Regional assessments comprised of Eastern, Western and Central Service Area divisionsCentral Service Area divisions
Regional Divisions Map*Regional Divisions Map*
ValleyPhillips
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
TreasureGolden Valley
Powder River
Eastern
Madison
Ravalli
Powell
Lake
Missoula
Granite
Mineral
Sanders
Flathead
Western
Silver Bow
Hill
Blaine
Park
Glacier
ChouteauTeton
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
Demographic Characteristics of Montana Resident Birth Mothers
Maternal Characteristics State Total % State Total MT PRAMS Total MT PRAMS % Total
Total 11,045 100.0 1,363 100.0
Maternal Age
< 20 1,277 11.6 287 11.7
20-24 3,155 28.6 202 25.4
25-34 5,347 48.4 442 50.1
35+ 1,263 11.4 114 12.8
Maternal Education
< 12 years 1,623 14.7 211 15.1
12 years 3,672 33.2 349 34.3
> 12 years 5,562 50.4 483 50.6
Marital Status
Married 7,415 67.1 393 68.9
Unmarried 3,624 32.8 652 31.1
Medicaid Status
Medicaid During Pregnancy 2,058 59.0 408 34.7
No Medicaid During Pregnancy 1,430 41.0 626 65.3
Baby’s Birth Weight (Grams)
LBW (< 2500 grams) 758 6.9 54 5.0
NBW (2500+ grams) 10,283 93.1 991 95.0
Prenatal Health Care
1st Trimester 9,190 83.2 770 75.8
2nd Trimester 1,487 13.5 237 21.5
3rd Trimester 242 2.2 16 1.6
No Care 61 0.6 11 1.1
Valley
Phillips
Fergus Garfield
Big Horn
Custer
Rosebud
Carter
McCone
Dawson
Prairie
Fallon
Richland
Roosevelt
Yellowstone
Stillwater
Daniels
PetroleumJudith Basin
Sweet Grass
WheatlandTreasureGolden
Valley
Powder River
Madison
Ravalli
Powell
Lake
Missoula
Granite
Sanders
Flathead
Silver Bow
Hill
Blaine
Park
Glacier
ChouteauTeton
Toole
Meagher
Lewis & Clark
Liberty
Pondera
Broadwater
JeffersonDeer 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%
DemographicVariables
SampleDistribution
(%)
Needed tovisit a dentist
Went to visita dentist (=no)
Dentist discussed howto care for teeth (=no)
% yes
p-value
Prevalence Ratio (PR)
95%CI
% no
p-value
PR 95%CI
% no
p-value
PR 95%CI
Maternal Education(n=10,698)
< 12 years
15.09 21.61 <0.0001 3.00 2.03-4.43
16.44 0.0269 1.57 1.05-2.33
15.63
0.4362 1.17 0.79-1.745
12 years 34.33 42.26 <0.0001 2.30 1.68-3.16
35.47 0.1549 1.24 0.92-1.685
34.09
0.9675 0.99 0.73-1.355
> 12 years
50.58 36.13 Reference Group
48.09 Reference Group
50.28
Reference Group
Paternal Education(n=9,610)
< 12 years
9.36 12.97 <0.0001 2.73 1.63-4.56
10.48 0.0775 1.5913 0.95-2.665
10.77
0.1025 1.5813 0.91-2.745
12 years 39.93 50.58 <0.0001 2.32 1.68-3.21
42.31 0.0394 1.37 1.02-1.86
38.94
0.7260 0.9513 0.70-1.295
> 12 years
50.71 36.45 Reference Group
47.21 Reference Group
50.29
Reference Group
GeographicArea
(n=10,720)
Eastern 31.31 35.67 0.0175 1.52 1.08-2.15
32.79 0.3222 1.18
0.85-1.655
31.82
0.6787 1.07 0.77-1.515
Western 34.46 34.31 0.2353 0.81 0.87-1.74
34.30 0.5800 1.10
0.79-1.515
34.78
0.5602 1.10 0.79-1.545
Central 34.23 30.02 Reference Group
32.91 Reference Group
33.40
Reference Group
Marital Status
(n=10,720)
Other 31.08 42.66 <0.0001 2.25 1.68-3.02
32.62 0.1074 1.27
0.95-1.715
31.37
0.8108 1.04 0.77-1.395
Married 68.92 57.34 Reference Group
67.38 Reference Group
68.63
Reference Group
There were no significant associations between oral health talks and these demographic variables.
Demographics AnalysesDemographics Analyses
There were no significant associations between visiting the dentist and these demographic variables.
Pre-pregnancy Medicaid
(n=10,694)
Yes 8.85 14.79 <0.0001 2.94 1.81-4.78
9.01 0.6518 1.12 0.68-1.855
7.62 0.1369 0.69 0.43-1.125
No 91.15 85.21 Reference Group
90.99 Reference Group
92.38 Reference Group
Pre-pregnancy Insurance(n=10,702)
No 39.55 55.54 <0.0001 2.81 2.11-3.74
44.29 <0.0001 1.77 1.33-2.35
41.80 0.0187 1.41 1.06-1.88
Yes 60.45 44.46 Reference Group
55.71 Reference Group
58.20 Reference Group
People per Room in
Home(n=10,489)
1+ People
10.07 13.32 0.0187 1.74 1.10-2.77
10.63 0.4115 1.22 0.76-1.975
10.38 0.6339 1.12 0.70-1.805
0-1 people
89.93 86.68 Reference Group
89.37 Reference Group
89.62 Reference Group
Previous Live Births (n=10,581)
Yes 61.46 66.94 <0.0001 1.45 1.33-1.57
60.06 0.2825 0.86 0.66-1.135
59.18 0.0976 0.80 0.60-1.045
No 38.54 33.06 Reference Group
39.94 Reference Group
40.82 Reference Group
DemographicVariables
SampleDistribution
(%)
Needed tovisit a dentist
Went to visita dentist (=no)
Dentist discussed howto care for teeth (=no)
% yes
p-value
Prevalence Ratio (PR)
95%CI
% no
p-value
PR 95%CI
% no
p-value
PR 95%CI
There were no significant associations between these oral health measures and these demographic variables.
Abuse Before Pregnancy(n=10,660)
Yes 8.82 13.96 0.0003 2.40 1.49-3.85
10.86 0.0228 1.79 1.08-2.96
10.32 0.1390 1.47 0.88-2.455
No 91.18 86.04 Reference Group
89.14 Reference Group
89.68 Reference Group
Abuse During
Pregnancy(n=10,662)
Yes 5.05 6.58 0.1547 1.54 0.85-2.785
6.38 0.0179 2.18 1.14-4.15
5.80 0.2344 1.50 0.77-2.945
No 94.95 93.42 Reference Group
93.62 Reference Group
94.20 Reference Group
Smoking Before
Pregnancy(n=10,297)
Yes 29.68 41.64 <0.0001 2.36 1.74-3.20
32.38 0.0096 1.50 1.10-2.03
32.44 0.0067 1.54 1.13-2.11
No 70.32 58.36 Reference Group
67.62 Reference Group
67.56 Reference Group
Smoking During
Pregnancy(n=10,509)
Yes 15.87 24.81 <0.0001 2.65 1.83-3.84
18.37 0.0072 1.70 1.15-2.49
18.47 0.0018 1.90 1.27-2.83
No 84.13 75.19 Reference Group
81.63 Reference Group
81.53 Reference Group
Demographics AnalysesDemographics Analyses
Demographics AnalysesDemographics Analyses
Smoking After
Pregnancy(n=10,518)
Yes 20.84 31.49 <0.0001 2.58 1.85-
3.59
23.85 0.0022 1.73 1.22-2.44
22.84 0.0179 1.54 1.08-2.19
No 79.16 68.51 Reference Group
76.15 Reference Group
77.16 Reference Group
Drinking During
Pregnancy(n=10,519)
Yes 6.78 6.57 0.8735 0.95 0.54-1.705
8.73 0.0165 2.06 1.14-3.72
8.93 0.0045 2.52 1.33-4.77
No 93.22 93.43 Reference Group
91.27 Reference Group
91.07 Reference GroupDemographic 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
DemographicVariables
SampleDistribution
(%)
Needed tovisit a dentist
Went to visita dentist (=no)
Dentist discussed howto care for teeth (=no)
% yes
p-value
Prevalence Ratio (PR)
95%CI
% no
p-value
PR 95%CI
% no
p-value
PR 95%CI
However...However...
When When Visiting the DentistVisiting the Dentist outcomes were assessed, some of outcomes were assessed, some of the same demographic characteristics held steadfast in their the same demographic characteristics held steadfast in their associations, including:associations, including:
Women with maternal education < 12 years Women with maternal education < 12 years
Women with partners with education = 12 yearsWomen with partners with education = 12 years
Women with no pre-pregnancy insurance (Medicaid excluded)Women with no pre-pregnancy insurance (Medicaid excluded)
Women abused before pregnancyWomen abused before pregnancy
Women who smoked before, during or after pregnancyWomen who smoked before, during or after pregnancy
Women having pre-pregnancy Medicaid in Eastern MontanaWomen having pre-pregnancy Medicaid in Eastern Montana
These findings suggest women with these characteristics not These findings suggest women with these characteristics not only had a heightened risk of having a perceived dental only had a heightened risk of having a perceived dental problem, but they were also less likely to visit a dentist.problem, but they were also less likely to visit a dentist.
Additionally...Additionally...
Newly associated maternal demographic characteristics Newly associated maternal demographic characteristics include:include:
Abuse during pregnancyAbuse during pregnancy
Drinking during pregnancyDrinking during pregnancy
Maternal characteristics still associated with Maternal characteristics still associated with Talked with Talked with Dentist/HCW about Oral Health CareDentist/HCW about Oral Health Care include: include:
Women with no pre-pregnancy insurance (Medicaid excluded)Women with no pre-pregnancy insurance (Medicaid excluded)
Women who smoked before, during, or after pregnancyWomen who smoked before, during, or after pregnancy
Women who drank during pregnancyWomen who drank during pregnancy
Demographic Findings...Demographic Findings...
These findings suggest a large number of high-risk demographic These findings suggest a large number of high-risk demographic characteristics may predispose mothers to having a perceived characteristics may predispose mothers to having a perceived dental problem during pregnancydental problem during pregnancy
However, only a select few of these characteristics were associated However, only a select few of these characteristics were associated with inhibited visits to the dentist, including three new associations with inhibited visits to the dentist, including three new associations with no prior affiliation with with no prior affiliation with Needing to Visit the DentistNeeding to Visit the Dentist
Regional Divisions were no longer significant for Regional Divisions were no longer significant for Needing to Visit the Needing to Visit the DentistDentist, which may be contradictory to other Access to Care reports. , which may be contradictory to other Access to Care reports. However, pre-pregnancy Medicaid participants (subgroup) However, pre-pregnancy Medicaid participants (subgroup) continued to have access to care issues during pregnancy for continued to have access to care issues during pregnancy for Needing to Visit the DentistNeeding to Visit the Dentist
Lack of pre-pregnancy insurance (Medicaid-excluded) and all levels Lack of pre-pregnancy insurance (Medicaid-excluded) and all levels of smoking are the only demographic characteristics reported which of smoking are the only demographic characteristics reported which demonstrated risk at every level of PRAMS oral health surveillancedemonstrated risk at every level of PRAMS oral health surveillance
Additional Demographic FindingsAdditional Demographic Findings
Though the results suggest women who drank during pregnancy Though the results suggest women who drank during pregnancy were less likely to have a perceived dental problem, they were also 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, less likely to visit a dentist or ask about oral health care. However, underreporting may be an issue and may have biased these results.underreporting may be an issue and may have biased these results.
These findings should help target the highest risk subgroups of These findings should help target the highest risk subgroups of Montana mothers, to implement intervention and prevention with Montana mothers, to implement intervention and prevention with appropriate oral health strategiesappropriate oral health strategies
These associations/findings may be proxies for low SES or other These associations/findings may be proxies for low SES or other high-risk characteristicshigh-risk characteristics
EasternWestern
Central
EasternWestern
Central
Population per Dentist Ratios
Montana, 2004
1000 - 1999
2000 - 3999
4000 - 13000
No dentist
Number of People Per Dentist
Poor Birth OutcomesPoor Birth Outcomes
ExposureVariables
SampleDistribution (%)7
Low BirthWeight
Infant Admitted To ICU
% yes
p-value
Prevalence Ratio (PR)
95%CI
% yes
p-value
PR 95%CI
Needed to Visit the Dentist
(n=10,376)
Yes 36.19 52.11 0.0245 1.99 1.09-3.63 50.47 0.0098 1.90 1.17-3.08
No 63.81 47.89 Reference Group
49.53 Reference Group
Visited the Dentist
(n=10,421)
No 59.23 60.29 0.8847 1.05 0.56-1.965 54.68 0.4308 0.82 0.51-1.375
Yes 40.77 39.71 Reference Group
45.32 Reference Group
Talked with the Dentist
(n=10,256)
No 62.49 60.73 0.8077 0.93 0.49-1.745 65.11 0.6370 1.13 0.68-1.895
Yes 37.51 39.27 Reference Group
34.89 Reference 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.
Maternal Morbidity AnalysesMaternal Morbidity Analyses
ExposureVariables
SampleDistribution
(%)7
Bedrest Hospitalization > 7 days Hospitalization from 1-7 days
% yes
p-value
Prevalence Ratio (PR)
95%CI
% yes
p-value PR
95%CI
% yes
p-value PR
95%CI
Needed to Visit the Dentist
(n=6,602)
Yes 36.19 40.38 0.9796 1.00 0.68-1.465
53.60 0.2721 1.72 0.65-4.585
41.38 0.8526 1.05 0.65-1.675
No 63.81 59.62 Reference Group
46.40 Reference Group
58.62 Reference Group
Visited the Dentist
(n=6,586)
No 59.23 59.71 0.8338 1.04 0.71-1.535
48.07 0.3595 0.64 0.24-1.685
59.43 0.9277 1.02 0.64-1.635
Yes 40.77 40.29 Reference Group
51.93 Reference Group
40.57 Reference Group
Talked with the Dentist(n=6,499)
No 62.49 67.34 0.1935 1.30 0.88-1.945
63.64 0.9502 1.03 0.38-2.835
60.62 0.6317 0.89 0.56-1.435
Yes 37.51 32.66 Reference Group
36.36 Reference Group
39.38 Reference Group
ExposureVariables
SampleDistribution
(%)7
Hospitalization < 1 day Premature Rupture of Membranes Cervix Sewn Shut
% yes
p-value
Prevalence Ratio (PR)
95%CI
% yes
p-value PR
95%CI
% yes
p-value PR
95%CI
Needed to Visit the Dentist
(n=6,602)
Yes 36.19 48.07 0.0124 1.59 1.11-2.28
33.18 (n=10349)
0.7113 0.87 0.41-1.845
28.46 (n=10367)
0.4939 0.70 0.25-1.975
No 63.81 51.93 Reference Group
66.82 Reference Group
71.54 Reference Group
Visited the Dentist
(n=6,586)
No 59.23 65.44 0.0320 1.50 1.04-2.16
74.21 (n=10394)
0.0790 2.03 0.92-4.485
60.79 (n=10412)
0.8906 1.07 0.41-2.835
Yes 40.77 34.56 Reference Group
25.79 Reference Group
39.21 Reference Group
Talked with the Dentist(n=6,499)
No 62.49 71.00 0.0066 1.70 1.16-2.50
72.11 (n=10229)
0.2350 1.58 0.74-3.375
62.62 (n=10246)
0.9880 0.99 0.39-2.605
Yes 37.51 29.00 Reference Group
27.89 Reference Group
37.38 Reference Group
There were no significant associations between these oral health measures and these maternal morbidity variables.
There were no significant associations between these oral health measures and these maternal morbidity variables.
Maternal Morbidity AnalysesMaternal Morbidity Analyses
ExposureVariables
SampleDistribution
(%)7
Car Accidents Nausea Diabetes
% yes
p-value PR
95%CI
% yes
p-value PR
95%CI
% yes
p-value PR
95%CI
Needed to Visit the Dentist
(n=10,371)
Yes 36.19 63.79 0.0359 3.16 1.08-9.27
44.44 0.0054 1.58 1.14-2.17
43.27 (n=10354)
0.3052 1.37 0.75-2.515
No 63.81 36.21 Reference Group
55.56 Reference Group
56.73 Reference Group
Visited the Dentist
(n=10,416)
No 59.23 45.44 0.2536 0.57 0.22-1.505
59.08 0.9652 0.99 0.72-1.365
59.67 (n=10399)
0.9546 1.02 0.55-1.895
Yes 40.77 54.56 Reference Group
40.92 Reference Group
40.33 Reference Group
Talked with the Dentist(n=10,250)
No 62.49 55.92 0.5822 0.76 0.28-2.035
60.96 0.6109 0.92 0.67-1.275
61.40 (n=10233)
0.8703 0.95 0.52-1.755
Yes 37.51 44.08 Reference Group
39.04 Reference Group
38.60 Reference 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
Oral Health ModelingOral Health Modeling
Used a cumulative stressor index, based on the total number of stressors Used a cumulative stressor index, based on the total number of stressors experienced by the mother 12 months before pregnancy – similar to the experienced by the mother 12 months before pregnancy – similar to the threshold research done by Whitehead et al. from the CDCthreshold research done by Whitehead et al. from the CDC
Stressors include home disputes and problems, familial drug abuse or illness, and monetary Stressors include home disputes and problems, familial drug abuse or illness, and monetary problems or joblessnessproblems or joblessness
Modeled the linearity of the cumulative stressor index with the binary outcome Modeled the linearity of the cumulative stressor index with the binary outcome of having a perceived dental problem during pregnancyof having a perceived dental problem during pregnancy
Used simple, unconditional logistic regression in both SAS SURVEYLOGISTIC Used simple, unconditional logistic regression in both SAS SURVEYLOGISTIC and SUDAAN RLOGISTand SUDAAN RLOGIST
μμ= 2.15 (95% CI=2.01 - 2.29), Range= 0 to 12 Cumulative Stressors= 2.15 (95% CI=2.01 - 2.29), Range= 0 to 12 Cumulative StressorsLogit Odds (Ŷ=1)= -1.3360 + 0.3375 (Logit Odds (Ŷ=1)= -1.3360 + 0.3375 (Cumulative StressorsCumulative Stressors) + 0.0429 () + 0.0429 (Standard ErrorStandard Error))Odds ratio=1.401 (95% CI= 1.29 - 1.52)Odds ratio=1.401 (95% CI= 1.29 - 1.52)
This finding suggests pregnant women who selected listed stressors had a 40% This finding suggests pregnant women who selected listed stressors had a 40% higher prevalence of a perceived dental problem during pregnancy than women higher prevalence of a perceived dental problem during pregnancy than women who did not report the stressors 12 months before pregnancywho did not report the stressors 12 months before pregnancy
For every two additional stressors, the odds of having a dental need increase For every two additional stressors, the odds of having a dental need increase 96.28%96.28%
C-statistic=0.678C-statistic=0.678
Periodontal Disease and Periodontal Disease and Maternal NauseaMaternal Nausea
Li et al. suggests, in the publication “Systemic Diseases Caused by Li et al. suggests, in the publication “Systemic Diseases Caused by Oral Infection”, maternal nausea may be associated with maternal Oral Infection”, maternal nausea may be associated with maternal dental problems during pregnancy. dental problems during pregnancy.
Initial, crude associations from maternal morbidity and Initial, crude associations from maternal morbidity and Needed to Needed to Visit the DentistVisit the Dentist variables suggest there is a significant relationship, variables suggest there is a significant relationship, when reporting PRAMS mothers were analyzedwhen reporting PRAMS mothers were analyzed
Additional investigation is warrantedAdditional investigation is warranted
Oral Health ModelingOral Health Modeling
ModelVariables6
Y-Intercept
BetaCoefficients
Adjusted Odds
Ratios
95%CI’s
R-Squared/C-
Statistic Values
-1.5283
Maternal Nausea 0.3745 1.45 1.03 - 2.05
Smoking 3 Months Before Pregnancy
0.7503 2.12 1.51 - 2.97
Medical Insurance (YES)/(NO)
-0.8239 0.44/2.28 0.32 - 0.60/1.66 - 3.13
Previous Live Birth 0.4866 1.63 1.19 - 2.22 AdjR2=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.
InterpretationInterpretation
The adjusted odds ratio for the association between maternal The adjusted odds ratio for the association between maternal nausea and dental need is significant at 1.45, suggesting there is a nausea and dental need is significant at 1.45, suggesting there is a 45% difference in dental need prevalence between women reporting 45% difference in dental need prevalence between women reporting maternal nausea and those not reporting maternal nausea during maternal nausea and those not reporting maternal nausea during pregnancypregnancy
The 0.13 or 13% risk difference in the crude and adjusted odds ratio The 0.13 or 13% risk difference in the crude and adjusted odds ratio for maternal nausea is attributable to the other maternal factors for maternal nausea is attributable to the other maternal factors included in the model: having a previous live birth, lacking pre-included in the model: having a previous live birth, lacking pre-pregnancy insurance, and smoking 3 months before pregnancypregnancy insurance, and smoking 3 months before pregnancy
However, after controlling other maternal factors, there is still a However, after controlling other maternal factors, there is still a significant association between maternal nausea and significant association between maternal nausea and Needed to Needed to Visit the Dentist, Visit the Dentist, supporting some of the findings of Li et al.supporting some of the findings of Li et al.
The data supports the recommendations for dental health The data supports the recommendations for dental health prevention information being disseminated early in pregnancy, to prevention information being disseminated early in pregnancy, to counteract the risk associated with maternal nauseacounteract the risk associated with maternal nausea
Additional FindingsAdditional Findings
Self-reported Self-reported Needed to Visit the DentistNeeded to Visit the Dentist appears to be highly appears to be highly associated with both reported admissions to NICU and low birth associated with both reported admissions to NICU and low birth weight outcomes, confirming the findings of Li et al. regarding poor weight outcomes, confirming the findings of Li et al. regarding poor infant outcomes and poor oral healthinfant outcomes and poor oral healthCumulative modeling of maternal stressors during pregnancy Cumulative modeling of maternal stressors during pregnancy suggested heightened risk of dental need, confirming similar research suggested heightened risk of dental need, confirming similar research by Whitehead et al.by Whitehead et al.Modeling of maternal nausea during pregnancy also suggested Modeling of maternal nausea during pregnancy also suggested heightened risk of dental need, when other factors were controlled for heightened risk of dental need, when other factors were controlled for in the modelin the modelFew maternal morbidity variables were significantly associated with Few maternal morbidity variables were significantly associated with the oral health indicators collected by Montana PRAMS, negating the the oral health indicators collected by Montana PRAMS, negating the publication by Li et al. that suggested PRM, pre-term labor, maternal publication by Li et al. that suggested PRM, pre-term labor, maternal diabetes and other maternal problems were associated with poor oral diabetes and other maternal problems were associated with poor oral health during pregnancyhealth during pregnancyHowever, indirect pathways of causation may play an integral part in However, indirect pathways of causation may play an integral part in maternal susceptibility to poor infant outcomesmaternal susceptibility to poor infant outcomesFurther research is needed to fully understand the relationship of Further research is needed to fully understand the relationship of dental need, specifically oral health problems such as periodontal dental need, specifically oral health problems such as periodontal disease, and poor infant outcomesdisease, and poor infant outcomes
Mapping the indirect and direct pathways of how poor oral health is Mapping the indirect and direct pathways of how poor oral health is affected by maternal nausea is important, due to associations with the affected by maternal nausea is important, due to associations with the weight and health of infants at birthweight and health of infants at birth
What Can Be Done?What Can Be Done?Step 1: Understand/Identify who is most at riskStep 1: Understand/Identify who is most at risk
Using data to make sound risk assessmentsUsing data to make sound risk assessments Refer to “checklist” of risk factorsRefer to “checklist” of risk factors Counsel client on potential risk of negative outcome, due to risk assessmentCounsel client on potential risk of negative outcome, due to risk assessment
Step 2: Intervene, where applicableStep 2: Intervene, where applicable Give referrals to area dentists/PhDs/healthcare workers for counseling and interventionGive referrals to area dentists/PhDs/healthcare workers for counseling and intervention Give out dental floss and new toothbrushes, coupons for fluoride rinsesGive out dental floss and new toothbrushes, coupons for fluoride rinses Network and collaborate with area stakeholders such as the Department of Environmental Quality 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 (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 optimal levels of fluoridation during pregnancy through assessment and intervention of household water supplywater supply
Step 3: EDUCATE, EDUCATE, EDUCATE Step 3: EDUCATE, EDUCATE, EDUCATE Train non-dental and medical health professionals on the value of oral health during pregnancy and 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” 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 pregnancyInform pregnant clients of the importance of good oral health during pregnancy Educate clients on the effects of proper nutrition on good oral healthEducate clients on the effects of proper nutrition on good oral health Educate clients on signs of gingivitis, periodontal disease, and fluorosisEducate clients on signs of gingivitis, periodontal disease, and fluorosis Explain the risk of bacteria transference after birth to clients highlighting preventive effortsExplain the risk of bacteria transference after birth to clients highlighting preventive efforts Disseminate information/education through available resources, such as WIC distributions to clients Disseminate information/education through available resources, such as WIC distributions to clients
and distributions to physicians and hospitals/clinicsand distributions to physicians and hospitals/clinics
Step 4: Resources for changeStep 4: Resources for change Empowering personal change=enabling personal controlEmpowering personal change=enabling personal control Give resources for education and informationGive resources for education and information Direct collaboration of multiple sectors within your community – encase client with supportDirect collaboration of multiple sectors within your community – encase client with support
LimitationsLimitations
Montana PRAMS is a self-reported surveyMontana PRAMS is a self-reported survey
Additionally, partner characteristics were not self-reportedAdditionally, partner characteristics were not self-reported
Recall bias may be an issue, especially for socially stigmatizing Recall bias may be an issue, especially for socially stigmatizing behaviorsbehaviors
Minorities were not expressly over-sampled and minority stratification on Minorities were not expressly over-sampled and minority stratification on maternal characteristics could not be utilizedmaternal characteristics could not be utilized
In some instances, missing values were larger than 10%In some instances, missing values were larger than 10%
Confidence intervals for comparison states could not always be Confidence intervals for comparison states could not always be calculated calculated
Measures of association were often crude, with binary variable levelsMeasures of association were often crude, with binary variable levels
Data quality could only be checked post-hocData quality could only be checked post-hoc
Inferences were made regarding the nature of the oral health indicatorsInferences were made regarding the nature of the oral health indicators
Logistic regression assumptions were only partially tested Logistic regression assumptions were only partially tested
Rural well water could not be ascertained for this presentationRural well water could not be ascertained for this presentation
References and ResourcesReferences and Resources
Gaffield, M., et al. Oral Health During Pregnancy: An Analysis of Information Gaffield, M., et al. Oral Health During Pregnancy: An Analysis of Information Collected by the Pregnancy Risk Assessment Monitoring System. JADA. Collected by the Pregnancy Risk Assessment Monitoring System. JADA. 2001; 132: 1009-16.2001; 132: 1009-16.
Offenbacher, S., and Slade, G. Role of periodontitis in systemic health: Offenbacher, S., and Slade, G. Role of periodontitis in systemic health: Spontaneous pre-term birth. Journal of Dental Education. 1998: 62 (10): 852-Spontaneous pre-term birth. Journal of Dental Education. 1998: 62 (10): 852-58.58.
Whitehead, Nedra, et al. Exploration of Threshold Analysis in the Relation Whitehead, Nedra, et al. Exploration of Threshold Analysis in the Relation between Stressful Life Events and Pre-term Labor. American Journal of between Stressful Life Events and Pre-term Labor. American Journal of Epidemiology. 2002; 155 (2): 117-24.Epidemiology. 2002; 155 (2): 117-24.
Li, Xiaojing, et al. Systemic Diseases Caused by Oral Infection. Clinical Li, Xiaojing, et al. Systemic Diseases Caused by Oral Infection. Clinical Microbiology Reviews. 2000; 13(4);547-58.Microbiology Reviews. 2000; 13(4);547-58.
Presentation by Dr. Wendy Mouradian, MD, MS. Montana’s Spring Public Presentation by Dr. Wendy Mouradian, MD, MS. Montana’s Spring Public Health Conference. 2005.Health Conference. 2005.
National Institute of Dental and Craniofacial Research. 2000. National Institute of Dental and Craniofacial Research. 2000. Oral Health in Oral Health in America: A Report of the Surgeon General – Executive Summary. America: A Report of the Surgeon General – Executive Summary. Rockville, Rockville, MD: National Institute of Dental and Craniofacial Research.MD: National Institute of Dental and Craniofacial Research.
References and ResourcesReferences and Resources
Montana Behavioral Risk Factor Surveillance Survey (BRFSS), 2002 Survey Montana Behavioral Risk Factor Surveillance Survey (BRFSS), 2002 Survey Data.Data.
Montana Central Tumor Registry, 2005 Data.Montana Central Tumor Registry, 2005 Data.
Zeeman, GG, Veth EO, Dennison DK. 2001. Periodontal disease: Implications Zeeman, GG, Veth EO, Dennison DK. 2001. Periodontal disease: Implications for women’s health. for women’s health. Obstetrical & Gynecological SurveyObstetrical & Gynecological Survey 56(1): 43-49. 56(1): 43-49.
Jeffcoat MK, Geurs NC, Reddy MS, Cliver Sp, Goldenberg RL, Hauth Jc. 2001. Jeffcoat MK, Geurs NC, Reddy MS, Cliver Sp, Goldenberg RL, Hauth Jc. 2001. Periodontal infection and preterm birth: Results of a prospective study. Periodontal infection and preterm birth: Results of a prospective study. Journal Journal of the American Dental Association of the American Dental Association 132(7): 875 – 880.132(7): 875 – 880.
DPHHS School Oral Health Report, 2002 – 2004 Data.DPHHS School Oral Health Report, 2002 – 2004 Data.
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