Introduction
Oral health is a significant component of overall health and well-being. The World Health Organization (WHO) considers oral health an essential aspect of health.[1] Oral microorganisms play a role in common diseases affecting general health. Maintaining oral health for pregnant women is necessary as maternal health and behaviors significantly impact coral health outcomes later in life.[2]
[3] The first stage of primary tooth development begins around 6 weeks of pregnancy (gestation), and any disturbance during the development process can affect the tooth morphology and composition.[4] The hormonal changes during pregnancy may affect oral tissues, causing gingival sensitivity or inflammation, decreasing the saliva flow and increasing the bacterial plaque.[5] These factors make many pregnant women avoid brushing their teeth properly and taking good oral care, negatively affecting their own and their babies' oral health.[6] Thus, prenatal and postnatal health care is essential for the mother and baby. Studies have shown a strong association between untreated caries and high level of salivary Streptococcus mutans during pregnancy and increased risk of early childhood caries (ECC).[3]
[7] According to the American Academy of Pediatric Dentistry, the disease of ECC is the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child aged ≤71 months.[8] Children who experience ECC are at higher risk of having new caries in both primary and permanent dentition.[3]
[9] Moreover, maternal dietary habits, oral hygiene practices, and maternal-infant feeding patterns can significantly influence the oral microbial environment within the child's mouth, further contributing to caries susceptibility.[10] These findings emphasize the importance of maternal oral health and caries experience as crucial factors in assessing and preventing childhood dental caries.
Public health interventions upstream of disease onset are successful in preventing disease, and those downstream of disease onset are helpful in mitigating the more deleterious health outcomes. Upstream approaches address the root causes of disease and tooth morbidity, while downstream approaches focus on early disease detection and management.[11] Health promotion is a cost-effective upstream approach that aims to prevent people from acquiring a disease or significantly delaying its onset.[12] Health promotion comprises health education and the implementation of health policies to empower people to control and improve their own or their children's health.
Health education encompasses a variety of learning experiences intended to promote voluntary actions that support good health. These actions or behaviors may involve individuals, families, institutions, or communities and can include educational interventions for children, parents, policymakers, or health care providers. The goal of oral health education is to enhance knowledge, potentially resulting in the adoption of positive oral health behaviors that contribute to improved oral health.[13] The knowledge gained should serve to empower population groups with accurate information about health and health care technologies, enabling them to take action to protect their health or avoid practices that can be detrimental.
Collaboration between health care providers has become a practical approach to achieving a well-functioning health care system. This cooperation can improve care delivery and patient outcomes since teamwork among professionals would ensure that patient needs are met.[14] Health care professionals can promote the importance of obtaining good oral health during pregnancy and early childhood.[2] Medical teams, including family physicians, pediatricians, nurses, nurse practitioners, and midwives, are encouraged to practice oral health assessment during routine prenatal and child checkup appointments. In addition, some simple preventive measures can be learned and addressed for patients. Collaboration between medical and dental teams effectively delivers quality oral health care to pregnant women and young children.
Current health care practices can be improved in managing different oral lesions and proper oral diagnosis and assessment.[15]
[16] Delayed patient referrals or improper diagnosis may worsen oral health. Therefore, undergraduate and postgraduate medical training should implement oral health promotion curricula.
The main objectives of this review were to summarize the role of interprofessional education (IPE) in oral health promotion, and demonstrate how the collaboration between dentists and other health care providers could improve the oral outcomes of pregnant women and young children.
Methods
The systematic search comprised seven electronic databases: PubMed, MEDLINE, EMBASE, Cochrane Library, Google Scholar, Scopus, and Web of Science. These databases encompass a broad international range of literature. Including a larger number of studies is essential to ensure the validity of the review. The search was limited by date (2014–2024, the last 10 years), and to English-language publications, using the Boolean method to combine search terms. The gray literature search was also conducted, which included clinical trial registries, the International Prospective Register of Systematic Reviews (PROSPERO) and dissertation databases.
Four search queries were used to ensure comprehensive coverage of the topic, focusing on pregnancy and childhood.
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Detailed query 1:
(“interprofessional education”[MeSH Terms] OR (“interprofessional”[All Fields] AND “education”[All Fields]) OR “interprofessional education”[All Fields]) AND ((“oral health”[MeSH Terms] OR (“oral”[All Fields] AND “health”[All Fields]) OR “oral health”[All Fields]) AND (“promote”[All Fields] OR “promoted”[All Fields] OR “promotes”[All Fields] OR “promoting”[All Fields] OR “promotion”[All Fields] OR “promotional”[All Fields] OR “promotions”[All Fields] OR “promotive”[All Fields])) AND (“pregnancy”[MeSH Terms] OR “pregnancy”[All Fields] OR “pregnancies”[All Fields] OR “pregnancy's”[All Fields])) AND ((y_10[Filter]) AND (english[Filter]))
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Detailed query 2:
(“interprofessional education”[MeSH Terms] OR (“interprofessional”[All Fields] AND “education”[All Fields]) OR “interprofessional education”[All Fields]) AND ((“oral health”[MeSH Terms] OR (“oral”[All Fields] AND “health”[All Fields]) OR “oral health”[All Fields]) AND (“promote”[All Fields] OR “promoted”[All Fields] OR “promotes”[All Fields] OR “promoting”[All Fields] OR “promotion”[All Fields] OR “promotional”[All Fields] OR “promotions”[All Fields] OR “promotive”[All Fields])) AND (“childhood”[All Fields] OR “childhoods”[All Fields])) AND ((y_10[Filter]) AND (english[Filter]))
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Detailed query 3:
((“Pregnant Women”[MeSH Terms] OR “Pregnancy”[MeSH Terms] OR “Expectant Mothers”[Title/Abstract]) AND (“Oral Health”[MeSH Terms] OR “Dental Health”[Title/Abstract] OR “Oral Hygiene”[MeSH Terms]) AND (“Knowledge”[MeSH Terms] OR “Attitude”[MeSH Terms] OR “Awareness”[Title/Abstract] OR “Perception”[Title/Abstract])) AND ((english[Filter]) AND (2014:2024[pdat]))
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Detailed query 4: ((“Maternal Health”[MeSH Terms] OR “Maternal Behavior”[MeSH Terms] OR “Mothers”[MeSH Terms] OR “Pregnancy”[MeSH Terms]) AND (“Child Development”[MeSH Terms] OR “Child Health”[MeSH Terms] OR “Infant Health”[MeSH Terms] OR “Pediatric Health”[Title/Abstract]) AND (“Health Behavior”[MeSH Terms] OR “Parental Influence”[Title/Abstract] OR “Risk Factors”[MeSH Terms]) AND (“english”[Language] AND 2014/01/01:2024/12/31[Date - Publication])) AND (english[Filter])
This review included English-language, peer-reviewed articles and gray literature published within the last 10 years. Eligible studies examined IPE approaches to oral health promotion in pregnancy and early childhood contexts. Articles that focused solely on clinical interventions without educational aspects or involved populations outside of pregnancy and early childhood were excluded. Additionally, we included studies on maternal general health and maternal knowledge of oral health and child health to ensure a comprehensive understanding of the topic from its foundations.
The research yielded 37 research articles that met the inclusion criteria. Titles and abstracts were independently screened by E.G. and M.A. for relevance. Relevant articles were included in this review, and reference lists were manually searched to identify sources not captured in the database search. The review process was conducted by E.G. and M.A. Conflicts and uncertainties related to study selection were resolved through discussion with the third reviewer (G.K.).
As this is a narrative review, no formal quality assessment tools were applied to evaluate the included studies. The review aimed to provide an overarching synthesis of the available literature, rather than assess the methodological rigor of each study.
Results
Effect of Maternal Health and Behaviors on Children
Some maternal habits could significantly affect the mother and her infant's general and oral health. For instance, smoking during pregnancy reported several general and dental adverse long-term outcomes for children born to smoking mothers. Some pregnant women consume heated tobacco products (HTP), a form of nicotine delivery, assuming they have less harmful effects than traditional cigarettes. Zaitsu et al found that HTP could increase the risk of gestational hypertension and low birth weight.[17] Akinkugbe et al assessed the association between prenatal smoking and the caries experience of offspring. The results showed that children born to smoking mothers had 1.42 (95% confidence interval [CI]: 1.08–1.86) the adjusted hazard ratio of the first caries experience compared to offspring of nonsmokers.[18]
In addition to smoking, overconsumption of alcohol during pregnancy may cause fetal alcohol syndrome (FAS), a developmental disorder that may cause several defects with lifelong consequences for a child. FAS symptoms include abnormal facial features and behavioral and dental abnormalities. Concerning dental problems, Blanck-Lubarsch et al examined 30 children prospectively diagnosed with FAS to investigate the associated dental anomalies and habits.[19] They found significant differences in mouth breathing, breastfeeding, DMFT (decayed, missing, filled teeth), and modified DDE (developmental defects of enamel) indexes as they were high compared to the control group.[19] Another recent study by Blanck-Lubarsch et al observed the relationship between FAS and dental malocclusion among 30 patients with FAS using the peer assessment rating (PAR) index.[20] The examination was done during the mixed dentition period. Compared to the healthy control group, there was a significant increase in malocclusion (crowding, spacing, crossbite, and edge-to-edge bite) in FAS patients, according to the PAR examination.[20] Therefore, early multidisciplinary assessment and treatment are required for children with FAS as it can prevent or mitigate further complications.
The unnecessary use of medications during pregnancy is another factor that could negatively affect a mother and her child. For example, overuse and misuse of antibiotics cause antibiotic resistance among pathogenic bacteria and DDE.[21]
[22] Molar incisor hypomineralization (MIH) is a significant dental problem that could result from antibiotic overuse in pregnancy and early childhood.[23] MIH leads to many complications affecting a child's oral health and quality of life. Teeth discoloration is another negative effect of using antibiotics such as the tetracycline group during pregnancy.[24] Tetracycline has the ability to bind to calcium ions during tooth mineralization and calcification, resulting in discoloration of both primary and permanent dentitions. In some cases, medications with lower risk profile can be selected to limit dental adverse effects.
Knowledge and Attitude of Pregnant Women about Oral Health
Practicing good oral health care during pregnancy significantly impacts the general and oral health of expectant mothers and their babies. Liu et al evaluated the behaviors and information of pregnant women regarding oral health and dental visits.[16] The common theme among some study participants was avoiding dental visits during pregnancy would be better for their overall health.[16] Some patients thought nutrition supplements could help prevent dental problems.[16] A study by Togoo et al assessed the knowledge level of 251 pregnant women about pregnancy gingivitis.[25] They found most participants did not know about the condition, its cause, outcomes, and prevention measures.[25] Many women were also unaware of the effect of untreated pregnancy gingivitis on their newborns' oral health, and even when they had inflamed gum, they did not seek dental treatment.[25]
Wassihun et al assessed knowledge of 384 pregnant women at South Omo Zone public hospitals in Southern Ethiopia about oral health and related factors.[26] Most participants (n = 251, 65.9%) had a low level of knowledge of oral health.[26] One of the principal factors that impacted their dental knowledge during pregnancy was getting counseling and information on oral care at the prenatal clinic.[26] Therefore, exploring barriers to dental services among pregnant women, such as lack of knowledge, cost, fear, cultural issues, and other reported factors, is essential to address these barriers and work on improving dental care utilization during pregnancy.[27]
Raising awareness of oral health as part of prenatal care is necessary, especially since pregnant women are usually willing to develop good behaviors to improve their health and the infant's well-being. Implementing a prenatal oral health program as an educational intervention in dental and medical curricula and residency programs that see pregnant women regularly is a valuable step in health care. These programs would help standard clinical guidelines that support interprofessional collaboration between dental and medical health providers to deliver comprehensive clinical care to pregnant women.[28]
[29]
[30] Promoting and providing oral health information and dental services during the prenatal period positively impacts pregnant women's behaviors toward their own and their infants' oral and general health.[31]
Importance of Interprofessional Education and Interprofessional Practice in Oral Health Promotion
According to the WHO, the definition of IPE is “when two or more professions learn with, about and from each other to enable effective collaboration and improve health outcomes,” and it defines interprofessional collaborative practice as “when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, careers and communities to deliver the highest quality of care across settings.”[32] Enhancing multidisciplinary preventive oral health practice is necessary as oral health is integral to general health. IPE and collaboration would help achieve good oral health in pregnant women and young children.
Sheiham and Watt introduced the concept of the “common risk factor approach” in dentistry, where oral diseases share common risk factors with other noncommunicable diseases.[33] For example, smoking and sugary foods might not only cause dental decay but also cause obesity and cardiovascular diseases. Focusing on these common risk factors will significantly impact many diseases at a lower cost and with greater efficiency and effectiveness than disease-specific approaches. Hence, interprofessional collaboration is needed to tackle many risk factors at once and reduce the incidence of multiple diseases.
Lacking interprofessional cooperation is a significant problem in health care settings. The common barriers to effective communication between health care professionals were lack of experience and confidence, accessibility to patients' electronic health records, personal values and expectations, no formal communication between health care teams, and time restrictions.[34]
Integrating IPE into the academic curriculum and training is essential to improving dental care. These learning opportunities encourage students to work with colleagues in other health professions and improve their knowledge and skills to work effectively and collaboratively.[35] Haresaku et al conducted a study in a Japanese nursing school to examine the effect of oral assessment educational programs in the academic curriculum on first-year nursing students.[36] The course includes lectures and training on the importance of interprofessional health care and how to perform oral assessment.[36] The study found that students' attitudes, confidence, and performance in oral assessment improved after the program compared to baseline.[36] Similarly, Khanbodaghi et al tested the influence of oral health educational programs on pediatric nurse practitioners' dental knowledge and behaviors at Northeastern University, United States.[37] After the test, the authors reported significant improvement in all participants' understanding of dental issues, confidence, and behavior scores.[37]
Collaboration between health care teams has improved patient-centered care, decreased complications, and increased patient satisfaction.[35] Several educational programs have been developed to support IPE and collaborative practice between dental and medical teams. One of the critical programs in pediatric dentistry is the Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry (SPICE-PD) program 2015–2020 at the UCLA School of Dentistry.[38] As a young child could visit primary care centers several times a year, this program aimed to improve knowledge, confidence, and skills in oral health care among primary health care providers.[38] In addition, the program aimed to encourage primary health care providers to perform early management and intervention of oral health problems by applying some preventive measures for children, such as fluoride varnish.[38] Ramos-Gomez et al found that the SPICE-PD program has significantly helped most dental, medical, and pediatric nurse participants work effectively with their colleagues and enhance their clinical performance.[38]
Good investments from dental grant programs in supporting oral health education and practice in medical schools improve oral health promotion and drive positive health outcomes among the population. It also builds good communication between medical and oral health care professionals. The College of Medicine-Phoenix and Delta Dental of Arizona at the University of Arizona announced the creation of the Oral Health in Medicine Initiative (OHMI) program. The OHMI program is designed to offer oral health knowledge and hands-on training for medical students, providing real experience with patients in a clinical dental setting. This cooperation was made through a valued investment by the Delta Dental of Arizona Foundation.[39]
IP Conceptual Model
The conceptual model ([Fig. 1]) is derived from the authors' perspectives on the role of interprofessional collaboration in oral health promotion. The anticipated outcomes are to increase awareness of the importance of oral health, enhance understanding of each other's roles, and improve the oral health status and general health of pregnant women and children.
Fig. 1 Conceptual framework of the role of interprofessional collaboration in oral health promotion.
Role of Health Care Professionals and Policymakers in Oral Health Promotion
Prevention is critical to good oral health. Dental diseases such as tooth decay are widespread, yet easily preventable if proper oral hygiene care and regular dental checkups are maintained. Health care professionals, especially those who usually counsel pregnant women and young children, should improve basic oral health knowledge among their patients and perform routine oral examinations. Teamwork and effective communication between health care members can ensure optimal care for patients.
Obstetrician gynecologists and midwives can significantly establish good oral health care behaviors in expectant mothers. This can be achieved by offering oral health education and counseling visits to pregnant women before and after childbirth in collaboration with dentists. Oral screening and risk assessment are essential to identify at-risk cases for early referral and dental management. George et al presented the great impact of midwives' oral health interventions (education, screening, dental access, and referrals) on pregnant women attending antenatal clinics in Sydney, Australia.[40] Interestingly, there was a remarkable improvement in oral health status, including teeth and gum conditions, among the group who accessed dental services. All groups reported significant changes in oral health knowledge after the study intervention.[40] Maternal health care providers can also advise women about breastfeeding's positive effect on the baby's oral health. It was found that breastfeeding for more than 9 months decreased the prevalence of malocclusion among preterm infants, compared to the less than 3 months breastfed group.[41] Additionally, it is vital to provide informative free resources to help pregnant women learn how to practice proper oral hygiene and the importance of dental care for mothers and their children.
Pediatricians and pediatric nurses' knowledge and skills concerning oral health play a major role in managing children's oral health problems. Incorporating proper oral examination steps in the routine child wellness assessment would enhance the prevention and early detection of caries and other oral conditions during infancy and early childhood. They can also apply some preventive measures for children, such as fluoride varnish. Reddy et al investigated the role of 200 pediatricians in oral health in the Hyderabad district, India.[42] Most participants (>85%) believed they should do oral screening and early referrals to dentists, although less than 50% of participants had performed oral health screening.[42] A study conducted among pediatricians in Southern Saudi Arabia showed that more than 90% of the participants were aware of dental caries and its adverse effect on teeth.[43] They also agreed about their significant role in oral health promotion and prevention in young children.[43] However, almost half of the study respondents disagreed with the information that bacteria causing caries can be transmitted from a mother to her child.[43] This highlights opportunities to improve basic oral health among primary physicians. Encouraging oral health education/practice among pediatric health professionals is required since they see children regularly.
As family members worldwide could visit primary care centers multiple times, family physicians and pediatric primary care providers can play an expanded role in oral health care, especially for infants and young children. Primary care practitioners can discuss and check oral health before, during, and after pregnancy. They can encourage pregnant women to do regular dental cleaning and checkups throughout pregnancy and after childbirth. For newborns, they may recognize congenital abnormalities in the mouth, such as cleft lips and cleft palate, and do referrals when required.[44] They can also screen young children's dentition status, discuss and reinforce proper dental care and food habits with their families, and do early referrals when needed.[45] Since primary health care providers significantly impact early childhood health and antibiotic prescription, it is imperative to be cautious when prescribing antibiotics and counsel parents about their improper use and their consequences on a child's dental and overall health. Early and frequent use of antibiotics has been reported among the critical risk factors of MIH.[46] MIH strongly negatively affects children's oral health–related quality of life (OHRQoL).[47]
Oral health professionals are in an ideal position to increase awareness of the importance of dental care and its positive consequences on maternal and infant health. In the Eastern province of Saudi Arabia, Albasry et al recruited pregnant women from hospitals and health care centers to assess dental care utilization during pregnancy and related factors.[48] From the results of 270 collected questionnaires, 52.6% of the study sample avoided dental treatment during pregnancy and thought it unsafe, while 43.7% visited a dental clinic when they had dental problems only.[48] In collaboration with their colleagues in maternal and primary care clinics, dentists can assure pregnant women about the safety of most dental procedures during pregnancy and how they improve oral health.[48] They can also encourage mothers and young children to practice proper oral health care and train them to do it efficiently. Interprofessional communication between dental and medical health care providers in oral health will reduce the number of pregnant women and young children without dental care.
Oral health is a critical aspect of overall well-being. According to the WHO Global Oral Health Status Report in 2022, oral diseases affect almost 3.5 billion persons worldwide.[49] Effective oral health promotion among the community targeting all age groups, particularly young children, requires cooperation between policymakers, health organizations, health care professionals, and society. It is critical to ensure the availability of resources that support and foster oral health care in the community, such as early and easy access to dental services, water fluoridation, and preventive oral procedures like pit and fissure sealant and topical fluoride.[50] In addition, integrating oral health education and activities in primary schools would motivate children to gain good oral care habits and have long-lasting benefits.[51] Supporting dental coverage for all population levels would reduce dental disparities and improve oral health behaviors and outcomes.[52] Zivkovic et al investigated the marginal effects (ME) of having dental insurance among 42,553 individuals aged ≥12 years in Ontario, Canada.[52] They found dental coverage positively affected the proportion of people who visited the dentist (56.6–79.4%; ME: 22.8) and those who reported good to excellent oral health (48.3–7.9%, ME: 9.6).[52] The authors suggested establishing universal dental coverage to eliminate financial barriers to dental care. Moreover, providing financial support to health care professionals and individuals in the health sector who can play a vital role in oral health promotion is required. It would ensure effective expansion and delivery of oral health awareness and preventive care among the population.
Role of Parents and Community in Oral Health Promotion
Parents can play a fundamental role in preventing oral diseases in children and affecting their oral health habits by establishing good dental hygiene routines early in their lives. Parents are the primary role models for their kids; it is imperative to model good oral health behaviors and attitudes in front of them as children learn by observation and active participation. Pregnant women, in particular, should pay careful attention to prenatal and postnatal oral care, which is essential for promoting good oral health and overall well-being for the mother and baby. Daily practices to avoid dental diseases include brushing the teeth regularly, flossing, maintaining a healthy diet, limiting sugary food and drinks, and having regular dental checkups with the application of fluoride varnish. Public health is critical in providing educational programs to promote oral health in communities. Implementing school-based oral hygiene programs starting from preschools is a significant way to increase oral health awareness.[53] These programs teach children about oral health and its association with general health and provide preventive oral health services, such as screening, cleaning, simple treatments, and fluoride application.[53] In addition, parental engagement in oral health promotion programs should be encouraged to produce better oral health outcomes.[54]
[55] Besides the education these programs offer, they can serve as a platform for open discussion and exchange of ideas between families guided by teachers and health professionals. This healthy communication helps improve awareness and understanding of each other's oral health needs and tackle barriers to dental care services. Since prevention is always better than cure, it is very important to invest in oral health education for parents and children in their early life years to improve general oral health in future generations.
