Dental Team's Role in Maternal and Child Oral Health During and After Pregnancy

Pregnancy and the subsequent postpartum/infancy period are critical times for establishing oral and systemic health habits for both mother and child that will allow for a lifetime of wellness. While the postpartum/infancy period can be a busy and stressful time, it is vital that oral and overall health is not neglected for either mother or baby. Given the high prevalence of dental caries in children and the high rates of both periodontal disease and dental caries in the adult population as well as the relatively low-cost, high-yield preventive measures that can be taken to improve outcomes for both children and adults, pregnancy can be a crucial time for intervention to allow for adoption of improved oral healthcare regimens for children and mothers alike.

Because dental care is both safe and effective during a healthy pregnancy,¹ ideally by the time of delivery the mother should have optimal oral health for herself and gained knowledge about her own oral health and that of her new infant in the early years. While the immediate period after delivery may not be ideal for the completion of any outstanding dental issues, some concerns, such as gingival changes or oral diseases that have not resolved postpartum, may necessitate that dental visits be scheduled when possible. For the infant, the first primary tooth will usually erupt around the age of 6 months, and this will provide a substrate for the oral ecosystem to begin to change. Plaque biofilm and debris will accumulate on the newly erupted hard surfaces, and cariogenic bacteria may be transmitted from parents and caregivers. With the introduction of solid foods, sugars and other simple carbohydrates become substrates for fermentation by the biofilm and the risk of caries is established.

The forming of good oral hygiene habits to remove plaque biofilm and establishing regular professional dental care are key factors for reducing the rates of caries in the primary dentition. Maintaining a healthy and caries-free primary dentition allows the child to reap lifelong benefits such as adequate space for eruption of the permanent dentition and an absence of pulpitis and consequent pain. Despite the well-known and long-term negative outcomes associated with childhood tooth decay, caries in early childhood is a significant public health problem, especially in children from families of low socioeconomic status (SES).^2,3

Early Childhood Caries as a Public Health Crisis

Early childhood caries (ECC) is characterized by one or more teeth with caries, tooth loss due to caries, or filled teeth surfaces in children less than 6 years of age. ECC is a "family disease," meaning that cariogenic bacteria can be passed through close contact with saliva; vertical and horizontal transmission within families is common and familial clustering of oral hygiene habits is also seen.⁴ ECC is a highly infectious and transmissible disease dependent on poor, sugar-laden dietary habits and parents/caregivers infecting their children with caries-causing bacteria.⁵ Maternal levels of oral bacteria are predictive for the prevalence and severity of ECC in the mother's offspring.^6,7 Despite current guidelines published by the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association's (ADA) patient's guide (MouthHealthy^™) that encourage the establishment of a dental home by age 12 months, national Medicaid data from 2008 revealed that only 9% of 1- to 2-year-olds have a preventive dental visit.^8-11 As the present authors have discussed in previous reports,^12-14 pregnancy is a unique opportunity for healthcare professionals to influence maternal behaviors and dental care during and beyond pregnancy and allows for maternal education that promotes optimal maternal and child oral health.

Poor oral health in children and mothers has been associated with a variety of factors, including those related to high-risk pregnancy.¹⁵ These factors may be clinical, social, and/or correlated to other areas of oral health. In particular, ECC has been associated with low SES and limited access to preventive professional oral care for both mother and child. Because of this association, interventions aimed at reducing ECC rates should especially target high-risk mothers and children. Many states consider a pregnant adolescent an "emancipated minor," a person capable of making health decisions. Up to two-thirds of adolescent pregnancies occur in teens aged 18 to 19 years old. Only 40% of teen mothers finish high school, and less than 2% finish college by age 30.¹⁶ The children of adolescent mothers are also at a greater risk for adverse pregnancy outcomes (eg, preterm birth, low birth weight).^17,18 Additionally, a teen pregnancy can have an increased psychosocial impact on the adolescent and the extended family.¹⁹ Children born to adolescent mothers have higher rates of socioeconomic, health, cognitive, and behavioral disadvantages,¹⁹ and teenage mothers have lower rates of healthcare utilization and decreased self-care habits compared with their cohorts who are not parents.²⁰

These circumstances can lead to future disparities in rates of chronic diseases and quality of life. A case-control study in Australia related presence of Streptococcus mutans, enamel hypoplasia, SES, sweetened drink consumption, dentist visits, visible plaque, reported child's tooth cleaning difficulty, maternal anxiety, and access to healthcare to an increased incidence of ECC.²¹ Additionally, a study of children from Detroit, Michigan, demonstrated maternal stress was associated with ECC.²² Given these findings, children of teenage mothers may have an increased risk of ECC and warrant targeted intervention and education to optimize oral health and wellness behaviors.

ECC impacts the child and his or her family and can be a burden on society due to direct treatment costs as well as indirect costs such as loss of parental wages in seeking care and/or reduced academic achievement. The impacts of unmanaged ECC include pain, swelling, and infection. Children suffering from dental pain do not eat or sleep properly and exhibit increased disruptive behavior.²² These changes increase familial stress, generating higher levels of parental concern for the child's well-being than that created by medical conditions such as asthma.²³ Long term, children with ECC have a higher prevalence of dental decay and malocclusion in their permanent dentition.^4,15 Affected primary teeth may lose significant tooth structure or require extraction, allowing the permanent teeth to drift into an unfavorable position, creating crowding or other malocclusions. Physically, children with ECC often have below-average weight that is consistent with poor nutrition and may impact neurological development.^24,25 These lower levels of nutrition and increased school absences may contribute to children with poor oral health being more likely to report poor school performance and perform at a lower level than children with good oral health.^26-28

Treatment of ECC is expensive to families and society in general, with 20% of children, mostly from lower SES families, accounting for more than 80% of cases.²⁹ Treatment often must occur under general anesthesia in an operating room. In 2012, more than 25% of Medicaid dollars spent treating caries in children under 6 years of age were spent on the 2% of patients who required this mode of treatment, and 50% to 80% of children undergoing caries treatment in the operating room have new cavities within 2 years.³⁰ It stands to reason that prevention of ECC reduces pain and suffering for the child, removes barriers to his or her future learning, lowers family stress levels, and reduces the need for expensive restorative care. Given the interconnection of maternal oral health and that of the mother's children, optimal oral health practices for both mother and child within the perinatal and infancy period are critical to promote overall oral wellness and develop lifelong habits that foster oral health.

Perinatal Oral Care for New Mothers

The postpartum and infancy period can be a stressful time. Up to 20% of all women (nearly 600,000 women annually in the United States) experience postpartum depression and/or anxiety.³¹ Parental stress is also a risk factor for ECC and is highly correlated with caries experience in the mother's offspring.³² It has been hypothesized that increased salivary cortisol levels may encourage dysbiosis (microbial imbalance) within the plaque biofilm and that high stress levels may lead to a decrease in health-promotion activities with long-term benefits, such as oral hygiene.³² Given the many stressors and the time constraints of caring for a newborn, it is unsurprising that many women tend to neglect their own healthcare during this demanding period in their lives, and this neglect may have significant implications on both their oral health and that of their children. Oral health is critical to a mother's overall health, and modeling healthy behaviors can result in improved health outcomes for children.^33,34

To maintain and optimize oral health after pregnancy, new mothers should be advised to adhere to a regular oral hygiene schedule, eat a balanced diet, and visit their dental and medical healthcare providers. Utilizing a regular oral hygiene regimen to reduce pathogenic oral bacteria and decrease rates of maternal caries and periodontal disease is critical to maintaining oral health and decreasing the rates of vertical bacterial transmission.^35,36 Decreasing intake of sugared foods and beverages and between-meal snacking^37-39 as well as increasing water and fiber intake can reduce the risk of dental caries during the perinatal period. Patients who regularly visit their dentist demonstrate a lower incidence of both periodontal disease and caries.^40,41 A patient-centered approach to behavior modification and counseling has been shown to be effective in achieving improved outcomes. The reader is referred to the second article in this series (Compendium, May 2018, pp. 286-290) for a review of motivational interviewing.¹³

Additionally, assessment of pregnancy-influenced gingival conditions, such as pregnancy gingivitis and pyogenic granuloma, and their postpartum resolution should be undertaken during the postpartum and infancy period. Non-emergent dental care that may have been deferred during the pregnancy should be completed at this time to ensure that oral health is maintained and dental disease does not worsen due to neglect. New mothers should be encouraged to facilitate childcare to allow for adequate time for these critical appointments so they may receive their needed and routine care. Maternal oral and overall health is critical during the perinatal period when sleep deprivation, hormonal changes, and caring for an infant may hinder the mother's personal emphasis on self-care. Table 1 offers suggestions for the maintenance of maternal oral and overall health during the perinatal period.

Dental Care During Infancy

Oral disease, particularly dental caries, continues to be a global burden. In fact, the overall average decayed-missing-filled teeth (DMFT) index for 12-year-old children has increased from a median of 1.61 in 2004 to 1.86 in 2015.⁴² Achieving optimal oral health for the population requires a focus on the underlying etiological factors for dental caries, which is the most prevalent infectious disease in the United States, affecting 67% of children by age 17.⁴³

Dental caries and ECC are significantly more prevalent in low socioeconomic populations, which has been explained by a gap in access to care, income levels, oral health and overall education, and dental insurance status, resulting in more untreated disease and increased missing teeth.^44-46 Maternal education, oral hygiene practices, and oral health knowledge have been determined to be a predictor of caries development in the mother's offspring.^32-34 Furthermore, the perinatal period may allow an opportunity for intervention that results in more pronounced behavioral change than at other timepoints due to maternal focus on the health of themselves and their children.⁴⁷ Therefore, healthcare providers who are treating pregnant patients and infants should understand the importance of oral health and be able to direct pregnant patients and their offspring to resources that will allow them to develop lifelong habits to promote oral health.

Paralleling the American Academy of Pediatrics' model of the "medical home," the concept of the "dental home" addresses the oral health needs of young children and is the subject of a policy statement by the AAPD.^8-10 Healthcare provided in the medical or dental home has been shown to be more effective and less costly in comparison to care provided in emergency care facilities and hospitals.^10,30The AAPD suggests that every child have a dental home by age 12 months, similar to many other recommendations that a child's first dental visit should occur around the first birthday. The ADA joins with the AAPD in stating the first visit should take place after the first tooth appears but no later than the child's first birthday.^8-10

Essential features of the dental home include: care for children that is comprehensive, continuously accessible, family-centered, coordinated, compassionate, and culturally effective; comprehensive assessment of oral diseases and conditions; an individualized preventive dental health program that is based upon caries and periodontal risk assessment; anticipatory guidance regarding growth and development; and a plan for acute trauma. Children who have a dental home are more likely to receive routine oral health screenings, preventive care, and appropriate and timely interventions.¹⁰

Well-Baby Dental Visit

The well-baby dental visit (WBDV) is an initial dental appointment that allows the dentist to evaluate home hygiene and diet practices, assess the infant's dentition for early signs of problems, and, most importantly, create a plan empowering the parents to provide good day-to-day oral health practices for their child.⁴⁸ The AAPD recommends this first dental visit occur within 6 months of the eruption of the first tooth and by age 12 months.⁴⁸ This timing coincides with when parents often transition their infants from formula to other liquids and represents an optimal time to counsel parents to establish healthy choices and avoid caries-promoting behaviors.^49-51 As a member of the perinatal team, the dentist ideally will be in regular communication with the pediatric medical team to ensure there is clear understanding of this transition away from breast milk or formula and to emphasize the avoidance of excessive sugars. Such interprofessional alignment will help reinforce the message that the parent or caregiver should adhere to the instructions, with the goal being the prevention of unnecessary caries risk.

The most important element of the WBDV is the conversation between the dentist and the parent. Among the topics to be discussed in this conversation are the following risk factors.

Diet: Infants are typically weaned by 12 months. If they are not, parents should be encouraged to brush or wipe the child's mouth with a clean cloth after feedings. Parents who are transitioning their child to other drinks should be advised to avoid sugar-sweetened beverages (SSBs) such as juices and flavored milks. The 2015-2020 Dietary Guidelines for Americans include the recommendation to limit intake of added sugars to 10% of calories consumed.⁵¹ All-natural juices and other SSBs often have no nutritional value, and they add unnecessary calories to the diet. Dentists should instruct parents to avoid their regular use.⁵⁰ Infants should never sleep with access to beverages, and parents should not allow "grazing" feeding behaviors where children have on-demand access to any drink other than water. Nocturnal breastfeeding should be accompanied by mouth cleaning.

Teeth cleaning and fluoride use: Oral hygiene should begin even before tooth eruption, with the wiping of the infant's mouth and gums. Dental home care of teeth should start as soon as they erupt. A soft-bristled infant brush should be used two times daily to clean the teeth and gums. A mild-flavored fluoride-containing toothpaste or one that has been formulated for infants and toddlers should be used. For children under 36 months, no more than a "smear" or "grain of rice" of fluoride toothpaste should be applied to the brush. Children 3 to 6 years should use an amount of fluoride toothpaste no larger than the size of a small pea. Once children can reliably expectorate, they may use alcohol-free fluoride mouthrinse.⁸

Tooth eruption: Mild discomfort is a normal part of tooth eruption. Over-the-counter benzocaine teething gels and ointments should be avoided due to a rare but serious reaction, methemoglobinemia, that can occur. Methemoglobinemia is a blood disorder in which an abnormal amount of methemoglobin is produced, impairing the red blood cells' ability to carry and distribute oxygen to the body.⁵² This condition can be life-threatening. Teething symptoms such as fever and irritability may be present for 24 hours and can be treated with cold teething rings or antipyretic medicines, such as acetaminophen and ibuprofen in appropriate dosages as recommended by a dentist or pediatrician. Symptoms persisting beyond 24 hours are likely unrelated to teething.

Injury: Because children under 6 years old may be at higher risk for dental trauma, parents need to be informed on what to do if an injury occurs and how to manage these injuries in conjunction with the dental practitioner at the child's dental home.

Non-nutritive sucking: Pacifier and digital sucking are considered normal developmental behaviors at this age, and they often self-correct within 24 to 36 months. Persistent non-nutritive sucking habits may need to be addressed later in life, but not at the time of the WBDV. Social and familial norms regarding this issue may stress young parents; therefore, dentists should offer encouragement that there is no need to worry about it at this time.⁴⁹

Parental health practices: Counseling about the transmissibility of caries should also be provided to parents and caregivers. They should be instructed to avoid the transfer of saliva and the bacteria it contains through the sharing of eating utensils, and a pacifier should not be "cleaned" in the adult's mouth. Additionally, the benefits of excellent oral health of the adult caregivers as they relate to the child should be discussed. For example, lower quantities of oral bacteria and a less pathogenic bacteria reduce the risk of transmission of cariogenic bacteria to offspring from caregivers through sharing food/drinks, kissing, and other methods of salivary transfer.

Infant dental examinations often occur in the parent's lap. The dentist and parent sit in a "knee-to-knee" position facing each other with their knees touching. The infant sits in the parent's lap with the legs around the parent's waist and the head laid back into the dentist's lap. This allows the dentist to fully visualize the child's mouth (Figure 1). The dentist then examines eruption sequence, enamel quality, and soft tissue. While significant variation occurs in the timing of eruption, the sequence of central incisor, lateral incisor, first molar, canine, and then second molar remains consistent across all children, and the examination should verify this sequence. The quality of the enamel, especially at the gingival margin, should be evaluated for white spots indicative of early demineralization.

Because ECC often begins on the palatal surfaces of the maxillary incisors, a mirror should be used to readily assess this surface. Soft-tissue anomalies are rare. Occasionally, an infant may have a short labial or lingual frenum that interferes with his or her ability to properly feed, but this issue will have presented within the first weeks of life and be resolved at the time of the WBDV. Once the examination is completed, a topical fluoride agent may be applied to all teeth two to four times per year depending on caries risk assessment. An optional additional step is to use a standard infant toothbrush to clean the teeth. The primary purpose of the cleaning is to teach the parent proper brushing technique, not to provide a professional prophylaxis.

Infants cannot be expected to understand the need to hold their head still or follow the instruction to open their mouth. Dentists will likely need to stabilize the infant's head gently between their hands and manually open the infant's lips with their fingers. Crying during the examination should be considered normal behavior typical of an infant experiencing something new. The dentist should talk to the child (and parent) in a calm, soothing voice. While infants may not comprehend the words being spoken, they can understand a tone that conveys care and compassion. The parent typically will observe the interactions between the dental team and the infant and make judgments on not only the clinical skills of the dental professional but also on his or her understanding of social and behavioral competence with young patients.

The AAPD provides simple and easy-to-use resources for assessing caries risk and determining protocols for caries management.^8-10 Success or failure in halting the progression of caries in a high- or moderate-risk infant largely depends on the family's ability to limit dietary sugars and practice good home care. Dentists can assist by offering more frequent visits for application of topical fluoride treatments on a risk basis. A child with carious lesions may require treatment, which could range from operative elimination of the carious lesions, to extraction of hopeless teeth, to non-invasive therapy with silver diamine fluoride (SDF), depending on the severity of the lesions, the risk for disease progression, and/or the timeline to exfoliate the teeth in question. If a child is found to have white-spot demineralization, enamel hypoplasia, or other indications of high caries risk, care should include a diet that avoids access to SSBs and other sugar-containing snacks, twice-daily home hygiene that includes brushing with fluoride toothpaste, and dental office visits for professional application of topical fluorides every 3 months. Children with risk factors of high SSB exposure and poor home hygiene but who have no signs of active disease should be identified, and effective behavior modification methods should be instituted with both the children and caregivers to attempt to alter their diet. These high-risk children also may be seen at least every 6 months for topical fluoride application (SDF or varnish). Many infants will present with no dietary or hygiene risk factors, excellent enamel, and overall low caries risk. These infants can be scheduled for follow-up in 12 months.⁵¹

Summary

The perinatal and infancy period presents numerous challenges for the maintenance of ideal oral health for mothers/caregivers and their children. Yet, it also allows an opportunity to emphasize maternal oral health and hygiene habits for mothers/caregivers and to reinforce ideal practices for good oral hygiene, avoidance of caries risk, and regular professional dental care for infants. It is imperative, therefore, for primary care providers, pediatricians, perinatal maternal healthcare providers, and dental healthcare providers to leverage their opportunities during the perinatal and infancy period, through a high level of interprofessional collaboration, to emphasize oral and overall health to help patients establish ideal habits as a foundation for a lifetime of good dental health.

About the Authors

Maria L. Geisinger, DDS, MS

Associate Professor, Director, Advanced Education Program in Periodontology, University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama

David C. Alexander, BDS, MSc, DDPH

Adjunct Professor, Epidemiology and Health Promotion, New York University,
New York, New York; Principal, Appolonia Global Health Sciences LLC,
Green Brook, New Jersey

Irina F. Dragan, DDS, MS

Assistant Professor, Department of Periodontology, Tufts University School of
Dental Medicine, Boston, Massachusetts

Stephen C. Mitchell, DMD, MS

Associate Professor, Director, Predoctoral Pediatric Dentistry, University of
Alabama at Birmingham School of Dentistry, Birmingham, Alabama

Queries to the author regarding this course may be submitted to authorqueries@aegiscomm.com

References

1. Oral Health Care During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy: A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center; 2012.

2. Gaur S, Nayak R. Underweight in low socioeconomic status preschool children with severe early childhood caries. J Indian Soc Pedod Prev Dent. 2011;29(4):305-309.

3. Ramos-Gomez FJ, Weintraub JA, Gansky SA, et al. Bacterial, behavioral and environmental factors associated with early childhood caries. J Clin Pediatr Dent. 2002;26(2):165-173.

4. Berkowitz RJ. Mutans streptococci: acquisition and transmission. Pediatr Dent. 2006;28(2):106-109.

5. Douglass JM, Clark MB. Integrating oral health into overall health care to prevent early childhood caries: need, evidence, and solutions. Pediatr Dent. 2015;37(3):266-274.

6. Köhler B and Andréen I. Influence of caries-preventive measures in mothers on cariogenic bacteria and caries experience in their children. Arch Oral Biol. 1994;39(10):907-911.

7. Chaffee BW, Gansky SA, Weintraub JA, et al. Maternal oral bacterial levels predict early childhood caries development. J Dent Res. 2014;93(3):238-244.

8. American Academy of Pediatric Dentistry. Perinatal and infant oral health care. Pediatr Dent. 2017;39(6):208-212.

9. American Dental Association. Your baby's first dental visit. Mouth Healthy website. https://www.mouthhealthy.org/en/babies-and-kids/first-dental-visit?fbclid=IwAR1dNBmb_nzgF9c-IwwwWRn-Z0IWV8XaZdnmuOy6DUtGWC9RGBToa5rdRpI. Accessed December 20, 2018.

10. American Academy of Pediatric Dentistry. Caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2017;39(6):197-204.

11. Bouchery E. Utilization of dental services among Medicaid-enrolled children. Medicare Medicaid Res Rev. 2013;3(3).

12. Dragan IF, Veglia V, Geisinger ML, Alexander DC. Dental care as a safe and essential part of a healthy pregnancy. Compend Contin Educ Dent. 2018;39(2):86-91.

13. Geisinger ML, Dragan IF, Alexander DC. Healthy pregnancy: a patient-centered approach to counseling and behavioral change. Compend Contin Educ Dent. 2018;39(5):286-290.

14. Alexander DC, Geisinger ML, Shenoy S, Dragan IF. Collaborating with the perinatal team for optimal oral health before, during, and after a healthy pregnancy. Compend Contin Educ Dent. 2018;39(10):678-684.

15. Bernabe E, MacRitchie H, Longbottom C, et al. Birth weight, breastfeeding, maternal smoking and caries trajectories. J Dent Res. 2017;96(2):171-178.

16. National Conference of State Legislatures. Postcard: Teen pregnancy affects graduation rates. NCSL website. June 17, 2013. http://www.ncsl.org/research/health/teen-pregnancy-affects-graduation-rates-postcard.aspx. Accessed December 20, 2018.

17. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, et al. Maternal age and risk of labor and delivery complications. Matern Child Health J. 2015;19(6):1202-1211.

18. Suellentrop K. The Costs and Consequences of Teen Childbearing. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy; August 17, 2010. https://www.cdc.gov/nchs/ppt/nchs2010/29_suellentrop.pdf. Accessed December 20, 2018.

19. Mollborn S, Lawrence E, James-Hawkins L, Fomby P. How resource dynamics explain accumulating developmental and health disparities for teen parents' children. Demography. 2014;51(4):1199-1224.

20. Hanna B. Negotiating motherhood: the struggles of teenage mothers. J Adv Nurs. 2001;34(4):456-464.

21. Uribe S. Early childhood caries-risk factors. Evid Based Dent. 2009;10
(2):37-38.

22. Finlayson TL, Seifert K, Ismail AI, Sohn W. Psychosocial factors and early childhood caries among low-income African-American children in Detroit. Community Dent Oral Epidemiol. 2007;35(6):439-448.

23. Thikkurissy S, Glazer K, Amini H, et al. The comparative morbidities of acute dental pain and acute asthma on quality of life in children. Pediatr Dent. 2012;34(4):e77-e80.

24. Williamson R, Oueis H, Casamassimo PS, Thukkurissy S. Association between early childhood caries and behavior as measured by the child behavior checklist. Pediatr Dent. 2008;30(6):505-509.

25. Acs G, Lodolini G, Kaminsky S, Cisneros GJ. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent. 1992;14(5):302-305.

26. Blumenshine SL, Vann WF Jr, Gizlice Z, Lee JY. Children's school performance: impact of general and oral health. J Public Health Dent. 2008;68(2):82-87.

27. Jackson SL, Vann WF Jr, Kotch JB, et al. Impact of poor oral health on children's school attendance and performance. Am J Public Health. 2011;101(10):1900-1906.

28. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies. Pediatr Dent. 2017;39(6)59-61.

29. Kanellis MJ, Damiano PC, Momany ET. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. J Public Health Dent. 2000;60(1):28-32.

30. Centers for Medicare & Medicaid Services. Reducing Early Childhood Tooth Decay: Approaches in Medicaid. May 27, 2015. https://www.medicaid.gov/medicaid/benefits/downloads/learninglabslides12.pdf. Accessed December 28, 2018.

31. Menon I, Nagarajappa R, Ramesh G, Tak M. Parental stress as a predictor of early childhood caries among preschool children in India. Int J Paediatr Dent. 2013;23(3):160-165.

32. Albert D, Barracks SZ, Bruzelius E, Ward A. Impact of a web-based intervention on maternal caries transmission and prevention knowledge, and oral health attitudes. Matern Child Health J. 2014;18(7):1765-1771.

33. Azevedo MS, Romano AR, Dos Santos Ida S, Cenci MS. Knowledge and beliefs concerning early childhood caries from mothers of children ages zero to 12 months. Pediatr Dent. 2014;36(3):95-99.

34. Begzati A, Bytyci A, Meqa K, et al. Mothers' behaviours and knowledge related to caries experience of their children. Oral Health Prev Dent. 2014;12(2):133-140.

35. Van der Weijden GA, Timmerman MF, Nijboer A, et al. A comparative study of electric toothbrushes for the effectiveness of plaque removal in relation to toothbrushing duration. Timerstudy. J Clin Periodontol. 1993;20(7):476-481.

36. American Dental Association. Oral health topics. ADA website. Updated August 3, 2018. https://www.ada.org/homecare. Accessed December 20, 2018.

37. Southam JD, Soames JV. Dental caries. In: Oral Pathology. Oxford, UK: Oxford University Press; 1993:chap 2.

38. Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134(6):1224-1229.

39. Roberts-Thomson K, Stewart JF. Risk indicators of caries experience among young adults. Aust Dent J. 2008;53(2):122-127.

40. Ramfjord SP, Morrison EC, Burgett FG, et al. Oral hygiene and maintenance of periodontal support. J Periodontol. 1982;53(1):26-30.

41. Morrison EC, Ramfjord SP, Burgett FG, et al. The significance of gingivitis during the maintenance phase of periodontal treatment. J Periodontol. 1982;53(1):31-34.

42. Oral Health Database. Global DMFT for 12-year-olds: 2011. Malmö University website. https://www.mah.se/CAPP/Country-Oral-Health-Profiles/According-to-Alphabetical/Global-DMFT-for-12-year-olds-20111/. Accessed December 20, 2018.

43. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11. 2007;(248):1-92.

44. Reid BC, Hyman JJ, Macek MD. Race/ethnicity and untreated dental caries: the impact of material and behavioral factors. Community Dent Oral Epidemiol. 2004;32(5):329-336.

45. Sabbah W, Tsakos G, Sheiham A, Watt RG. The effects of income and education on ethnic differences in oral health: a study in US adults. J Epidemiol Community Health. 2009;63(7):516-520.

46. Wu B, Liang J, Plassman BL, et al. Oral health among white, black, and Mexican-American elders: an examination of edentulism and dental caries. J Public Health Dent. 2011;71(4):308-317.

47. Geisinger ML, Robinson M, Kaur M, et al. Individualized oral health education improves oral hygiene compliance and clinical outcomes in pregnant women with gingivitis. J Oral Hyg Health. 2013;1:111. doi:10.4172/2332-0702.1000111.

48. American Academy of Pediatric Dentistry. Establishing the Dental Well-Baby Visit. http://www.aapd.org/assets/news/upload/2005/791.pdf. Accessed December 28, 2018.

49. Devaney B, Ziegler P, Pac S, et al. FITS Feeding Infants and Toddlers Study, A Gerber Initiative IDEAS Working Paper Series from RePEc. 2002.

50. Heyman MB, Abrams SA, et al. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):1-8.

51. US Dept of Health and Human Services and US Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 8th ed. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/. Accessed December 20, 2018.

52. Rodriguez LF, Smolik LM, Zbehlik AJ. Benzocaine-induced methemoglobinemia: report of a severe reaction and review of the literature. Ann Pharmacother. 1994;28(5):643-649.

This is the final article in a four-part series. For the first three articles, please follow these links.
Dental Care as a Safe and Essential Part of a Healthy Pregnancy
Healthy Pregnancy: A Patient-Centered Approach to Counseling and Behavioral Change
Collaborating With the Perinatal Team for Optimal Oral Health Before, During, and After a Healthy Pregnancy