Access and use of dental services by pregnant women: an integrative literature review

The objective of this article is to identify the scientific productions on the access and use of dental services by pregnant women. A search was carried out on the BVS and MEDLINE/PubMed online databases to produce this integrative literature review. In the BVS database, the Portuguese descriptors were: “acesso aos serviços de saúde”, “saúde bucal” and “gestantes”, and in PubMed: “Health services accessibility”, “oral health” and “pregnant women”, all associated with each other by the Boolean operator “AND”. We identified five studies that met the inclusion and exclusion criteria and were systematized into two empirical and co-related categories: the significant number of pregnant women who do not perform prenatal dental care and the importance of educational measures that signal the need to receive dental care during prenatal visits. Further studies on the subject are required to support public health policies that consider this theme. Existing research shows low adherence to prenatal dental care and that the main factors hindering the access to and use of dental services were related to socioeconomic, cultural and educational aspects.


introduction
The gestational period is marked by several physical, hormonal and psychological transformations, and they require attention during prenatal care 1 . At this stage, approaches to health promotion become favorable 2 because pregnant women are receptive to acquiring information, changing their habits and improving their health practices for their benefit and also for their baby 1 .
During pregnancy, the woman's body undergoes several changes related to its functioning, causing changes in the estrogen and progesterone levels, which interfere in the oral cavity, with the aggravation of pathologies, such as periodontal diseases 3 . For populations with high preterm birth and low birth weight, periodontal treatment seems to reduce the risk of these adverse outcomes for gestation 4 .
In this context, women's need to receive dental care also during gestation 5 is clear. However, pregnant women seem to lack information on the relevance of prenatal dental visit or fear doing it, since they often believe that it may involve risks to their health and that of their child [6][7][8] . Also corroborating this fact is that there are professionals who consider delaying or even not performing clinical procedures in the gestational period due to lack of knowledge or fear of causing some harm to the health of the mother-baby binomial [6][7][8][9] .
Other factors also appear to be associated with lower access and use of dental services by pregnant women, such as socioeconomic level, lack of interest or time and need to rest due to hypertension, hindering travel to the clinic 3 . Regarding maternal educational level, regardless of the level, most of them refuse dental treatment in the gestational period, evidencing that the lack of information on the subject is not restricted to pregnant women with lower educational level 9 .
As a result, this study aims to identify the scientific productions developed on the access and use of dental services by pregnant women.

Methods
This is a qualitative study conducted through an integrative literature review, which allows the identification, synthesis and accomplishment of an extended literature review about a specific theme 10 .
To do so, the following steps were followed: definition of the theme and elaboration of the re-search question; elaboration of eligibility, inclusion and exclusion criteria of the studies; survey of publications in databases; categorization and analysis of the information found in the publications; evaluation of selected studies; presentation of results, including critical analysis of the findings and synthesis of the review 11 .
The following question was outlined to address this review: "What is the scientific knowledge produced in the literature about access and use of dental services by pregnant women?" For the construction of this work, the databases used were the BVS (Virtual Health Library) and MEDLINE/PubMed. The search for papers was conducted with an advanced form, considering Portuguese DeCS descriptors of the BVS database: "acesso aos serviços de saúde", "saúde bucal" and "gestantes". In the search on the MED-LINE/PubMed, we considered the indexed terms in the MeSH Database "health services accessibility", "oral health" and "pregnant women". All were associated with each other by the Boolean operator AND. The search was conducted in March 2017.
The inclusion criteria were listed as full-text papers available in the databases listed, with no restrictions as to the time of publication or language. Publications that did not respect the delimitation of the theme and the purpose of the study were excluded, as were those resulting from opinion papers, case studies or reflections, editorials, ministerial documents, book chapters, theses, and dissertations.
In the first phase, two trained reviewers (R1 and R2) independently read and evaluated the titles and abstracts of the papers identified in the electronic databases. According to the pre-established inclusion/exclusion criteria, they selected papers for full-text reading. Any disagreement among the reviewers about the inclusion of the studies and no consensus achieved required the opinion of a third reviewer (R3). In the second phase, when the papers were read in full, the opinion of a third reviewer (R3) was again requested when the reviewers R1 and R2 disagreed and did not achieve consensus as to the final inclusion of the papers.

results
The search returned 17 publications in the BVS database and 46 publications in the MEDLINE/ PubMed database, totaling 63 publications. Duplicated abstracts within the same database, as well as those in both databases, were excluded. After reading the titles and abstracts with the application of the inclusion criteria, 20 papers remained, and they were read in full. After reading and final analysis of the manuscripts, only five papers were left out in the final selection ( Figure  1).
A collection instrument called the synoptic table, adapted from the one elaborated by other researchers 10 was used to systematize the data of these papers, which considered: title of the study, name of the authors, year of publication, indexing journal and database, language, country of origin, objectives, method employed and the primary results and conclusions regarding the access and use of dental services by pregnant women ( Table 1).
The papers included have been published in the last ten years. We observed that all of them are observational, four with a cross-sectional design and one case-control type. None of these studies analyzed the access and use of dental services by pregnant women, although their results showed data regarding this outcome ( Table 1).
The reading of the corpus of analysis allowed the systematization of the papers in two empirical categories that are complementary and directly related: expressive number of pregnant women not performing prenatal dental care 6,12,13 ; the relevance of educational measures that signal to pregnant women the need to receive dental care during prenatal care visits 6,14,15 (Table 1).

Discussion
This study aimed to verify the access to and use of dental services by pregnant women, a matter of high relevance, considering the consequences of not performing prenatal dental care for the  not pregnant with at least one child and non-pregnant women and without children. The results showed that the use of dental care, mainly preventive and restorative, by pregnant women and mothers was low and became even lower with time. In 2005, the last year studied, the rates of the use of dental services by low-income pregnant women and women with dependent children were only slightly higher than the rates for non-pregnant women without children who were covered only for dental emergencies. chart 1. Synoptic table, showing the summary of the primary data referring to the included publications, which focus on the access and use of dental services by pregnant women, 2017.
mother-baby binomial 16,17 , as well as the strong influence of mothers on their child concerning the transmission of oral health habits 18 . However, the scarcity of research on the subject in this specific population caused a stir. Due to the robust complementary nature and direct relationship of the empirical categories, which emerged from the reading of the papers included in this integrative review, we opted for the construction of an expanded discussion, considering both thematic axes in an interconnected way.
The evaluated studies identified that few pregnant women perform prenatal dental care. As researchers report, when assessing pregnant women in public maternity wards and in agreement with the Unified Health System (SUS) in the metropolitan region of Great Vitória, Espírito Santo, Brazil, where approximately 20% of pregnant women were assisted in pregnancy at a preventive dental care, and at curative level, the most frequently performed procedures were urgent visits 6 , when patients already feel pain, a fact that could be avoided with continuous dental monitoring.
It was observed that prenatal care is a crucial element in maternal health, which encompasses children's and women's health and family planning. They say that pregnant women should receive health care in the public system and may be referred to the nearest dental clinic for oral examinations and necessary treatments, regardless of socioeconomic status and geographical location. The oral health education sessions should aim to sensitize women to the importance of this during pregnancy and the care of the baby's oral health 13 . Throughout the context of pregnancy, it is usually a stage in which women are more willing to receive new knowledge that will improve their lives and that of their babies 19,20 .
One of the reasons for the low demand for the follow-up of a dental surgeon during the gestational period is due to the beliefs and myths that dental treatment may be harmful to the baby. Regardless of the region, studies agree that the expectation of physical pain and insecurity are determinant in the option of not performing prenatal dental care 6,21 . When interviewing 170 pregnant women, researchers found that 89% reported fear of dental treatment, 53% were afraid of losing their babies due to genital hemorrhage caused by dental treatment, and 32.6% believed that these treatments would cause harm to the baby. It was also observed that 22.4% of the respondents did not seek the dentist for the following reasons: "pregnant cannot go to the dentist", "the obstetrician doctor did not authorize", "the dental surgeon refused to attend". Thus, it is noted that even if dental treatment is required, pregnant women often avoid treatment in this period 9 due to beliefs and misinformation about the importance of oral health care.
Another reason why pregnant women do not perform dental care is that many dentists feel unsafe meeting them and end up postponing dental treatment until after the birth of the baby, and most of the time the problem can be solved during gestation 22 . It is known that provided that professionals are aware of the care in performing dental care on pregnant women, including their stance during care, types of recommended anesthetics, indication of radiographic exams and medication, there will be no problems for the mother-baby binomial [21][22][23] .
In a study conducted in the United States, more than 80% of dentistry training courses devote only two hours on the unfavorable outcomes in pregnancy related to the periodontal condition of pregnant woman in their curricula, which indeed generates insecurity for professionals in the field 24 . The result of pregnant women care program in Brazil reported that dental students, although previously prepared, have difficulties regarding drug administration, performing invasive clinical procedures and knowledge about baby care 21 . Thus, there is little knowledge of dentistry professionals in this field, and they end up reproducing common-sense beliefs, causing insecurity and fear in pregnant women who postpone dental appointments 1 .
Scientific literature has evidenced that the access to and use of dental services by pregnant women may be related to issues linked to the place of residence 13 , while even if care programs for vulnerable populations are established, they often do not achieve the targeted results 13 . As most of the studies 6,12,13 are performed with pregnant women attending public health services, it was not possible to gauge differences with the private service.
During gestation, women are more susceptible and determined to acquire new knowledge and modify some habits that can intervene in the health and development of the baby. Thus, pregnant women become a strategic group for health education, and it is essential that these guidelines be carried out in a multidisciplinary way, aiming to ensure the introduction of healthy habits from the beginning of gestation [25][26][27] . Therefore, this is an appropriate time to demystify apprehensions and beliefs about dental treatment 28 .
Medical professionals, mainly gynecologists and obstetricians, play a fundamental role in guiding pregnant women to perform prenatal dental care. About 78% of the pregnant women attended at the private practice or through covenants, and 50% of those assisted at the SUS reported that they had not received counseling from the gynecologist about oral health 22 . In a previous study, it was verified that only 5% of the pregnant women received some information about oral health during the prenatal period 28 . In another study, it was observed that the knowledge about dental care, passed on to pregnant women in the Family Health Program (PSF), the current Family Health Strategy (ESF) by health professionals, was low for most of the oral health promotion and prevention items 29 .
Ideally, women should be referred to the dental surgeon as soon as they discover the pregnancy 25 . It is even a recommendation of the Ministry of Health, and the Pregnant Women's Booklet states that they can and should undergo dental treatment during pregnancy 30 .
Dental caries 12,31 and gingival and periodontal diseases 32 are highly prevalent among pregnant women, showing biological mechanisms that may affect pregnancy, and are risk factors for preeclampsia and the birth of preterm and low-weight babies 33 . These data reinforce the relevance that pregnant women should consult the dental surgeon for the prevention and treatment of these diseases. Another critical factor is that the maintenance of the oral health of pregnant women brings good oral health habits for the future baby 1,34 and an improvement in the quality of life of women during the gestational period 27,35 .
According to the guidelines of the Unified Health System (SUS) 36 , women in the gestational period are a priority in health services and are a target group for the implementation of oral health education programs 34 . However, as explained previously, this population is still often lacking care.
We found that most of the papers selected in this integrative review did not mainly aim to evaluate access to and use of dental services by pregnant women, which was considered a secondary outcome, but assess other outcomes related to the oral health of pregnant women. Almost all works were cross-sectional studies, not allowing the establishment of the cause-effect relationship; moreover, they were based on information reported by research participants, so there may be a bias related to the reliability of the reports. Therefore, these limitations must be considered when interpreting the results. It is suggested that other research, explicitly focused on this topic, with appropriate methodology, be conducted so that results can support public health measures aimed at oral health care during pregnancy.

Final considerations
Few studies on the access to and use of dental services by pregnant women are available. These show low adherence to prenatal dental care and that the main complicating factors of access to and use of these services were related to socioeconomic, cultural and educational aspects.
Despite the progress of the scientific-technological knowledge and the development of dentistry, in an attempt to improve the quality of life of the human being, the oral health of pregnant women still requires attention. The available literature evidenced the relevance of educational measures that signal to pregnant women the need to receive dental care during prenatal care visits and their safety, contributing to the well-being of the mother-baby binomial. collaborations CC Silva, CM Savian, BP Prevedello, C Zamberlan, DM Dalpian e BZ Santos: substancial contributions to the conceptions, design of the work, analysis and interpretation of the data for the work; drafting the work, revising it critically; final approval of the version to be published.