Factors Associated to the Search for Dental Care in High-Risk Pregnancy
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Introduction: Conducting dental consultations during pregnancy is considered an important challenge in the context of Maternal and Child Health Policies. In this sense, it is important to identify barriers and facilitators to the search for dental assistance in this period, in order to support strategies that make this practice feasible.
Objective: To analyze the search for dental care during high-risk pregnancies, according to sociodemographic, gestational and health characteristics.
Methods: observational study with a cross-sectional design, carried out with high-risk pregnant women referred to a teaching hospital in southern Brazil, from January to May 2018. Pearson's chi-square association test and Fisher's exact test were used.
Results: The finally sample was composed for 190 pregnant. Advanced maternal age (p = 0.000) and history of premature birth in previous pregnancies (p = 0.047) were factors associated with a lower frequency of seeking dental care in the current pregnancy. On the other hand, the habit of dental consultation prior to the gestational period (p = 0.001), the knowledge about the importance of this monitoring (p = 0.050), as well as the safety (p = 0.000) in performing dental prenatal care, were related positively to the search during pregnancy.
Conclusion: Specific incentive strategies and access to dental prenatal care are necessary to neutralize barriers that may compromise the search for oral health services during pregnancy.
Keywords: Dental Care, Prenatal care, Pregnancy, High Risk
According to the Brazilian Ministry of Health, high gestational risk is one that encompasses pregnancies in which the life or health of the mother-child binomial has a greater chance of complications, when compared to the average of pregnancies . Is mainly related to maternal age , hypertension  and diabetes , conditions that, in isolation or associated with other factors, can cause the development of oral diseases such as decreased salivary flow  and greater occurrence of periodontal disease .
In this sense, there is also a possible relationship between maternal periodontal disease and adverse problems during pregnancy, such as the occurrence of premature birth, identified in recent systematic reviews [7-9], but which still lacks conclusive evidence that can confirm it . Aware that dentists' approach to high-risk pregnant women is a relevant theme for the consolidation of public maternal and child health policies, the objective of the study is to relate the search for dental care during high-risk pregnancy with sociodemographic characteristics, gestational and dental.
Cross-sectional observational, quantitative study carried out with high-risk pregnant women over 18 years old, in the 3rd trimester phase, referred to a teaching hospital in southern Brazil. The research was approved by the Research Ethics Committee with human beings of the State University of Ponta Grossa (opinion number 2,364,648; CAAE: 78544717.4.0000.0105). The dependent variable listed was 'Search for Dental Care during Pregnancy' (in current pregnancy), and as independent variables sociodemographic characteristics, gestational and dental. The significance level of 5% was considered and the association test used was Pearson's chi-square test and Fisher's exact test.
The sample was composed for 190 pregnant women, and the sociodemographic characteristics of the pregnant women were associated to the ‘Search for dental care during pregnancy’, with age being the only factor significantly associated. Pregnant women over the age of 35 were less likely to seek dental care when compared to the younger age (p <0.005). It is known that maternal age has a strong influence on the perinatal medical condition of pregnant women and their babies, with a higher risk of low birth weight for children of very young mothers or mothers between 35 and 39 years old [11,12] and with a higher risk of mortality for mothers over 40 years of age [13,14].
In the context of oral health, the relationship found between older pregnant women and lower frequency of seeking dental care suggests advanced maternal age also as a risk marker for the maintenance or aggravation of oral diseases. The contact with the dental surgeon during high-risk pregnancy becomes even more relevant, since preexisting oral conditions can be exacerbated during the gestational period  and are related to systemic diseases [16-18].
Regarding to the investigated gestational variables, there was a statistically significant association only between pregnant women who did not seek dental care and a history of premature birth (p = 0.047). Women with no history of preterm birth in a previous pregnancy sought the dental surgeon in the current pregnancy more frequently, which may suggest a positive habit of dental consultation during pregnancy by these women, and consequently the treatment and prevention of periodontal disease, or even suggest a greater importance they attach to oral health care during pregnancy.
Among the oral health characteristics analyzed, pregnant women who claimed to have the habit of consulting the dental surgeon before pregnancy and pregnant women who were instructed to seek this professional during pregnancy were associated with the search for dental care during pregnancy (p = 0.001 and 0000, respectively).
Another finding of the study was the positive association between the habit prior to pregnancy to seek the dentist and the maintenance of this practice during the gestational period. In this sense, access strategies that enable dental care in the pre-conception period are fundamental, since the lack of routine dental care in the pre-pregnancy period is pointed out as the most significant predictor of non-receipt of this care during pregnancy .
Although the demand for dental services during pregnancy has traditionally been low [20,21] and is mainly related to episodes of dental pain , behavior experts say that behaviors that help in promoting and maintaining health are generally developed during childhood and adolescence, and maintained in adulthood . In the specific case of pregnant women, barriers imposed by beliefs and myths that dental treatment should be postponed during pregnancy , coupled with feelings of professional insecurity  act as agents against the search for dental care by pregnant women.
On the other hand, the results showed that the guidance given to pregnant women, in the search for dental care, showed a positive relationship with the frequency with the dentist, which is relevant to the performance of the health team during the prenatal period and the insertion of oral health professionals in an interdisciplinary team. A similar result was found in a study with pregnant women of habitual risk, in which the incentive to seek dental care and the referral of the pregnant woman to the dental surgeon during prenatal care were key factors for the pregnant woman's decision to seek dental care in pregnancy .
Thus, the insertion of the dental surgeon in prenatal care and the exploration of characteristics of high-risk pregnant women become essential to control, prevent and treat perinatal health problems. The early identification of intraoral changes allows the treatment and prevention of clinical conditions that can impact the quality of life of the pregnant woman and the baby, and that can act as risk factors for unfavorable obstetric outcomes .
In conclusion, specific incentive strategies and access to dental prenatal care are necessary to neutralize barriers that may compromise the search for oral health services during pregnancy. For this reason, identifying the facilitators and hinders to the dental service is essential for planning effective actions related to prenatal care. It is also concluded that the inclusion of actions aimed at women during the prenatal period in oral health services, with an emphasis on health guidance, is of great importance to promote the quality of life of pregnant women.
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