Introduction 1 4 5 6 7 9 10 13 14 An important oral condition affecting many pregnant women is periodontal disease. Periodontal disease is a destructive inflammatory condition of the gingiva and bone that supports teeth. It is most commonly associated with a gram-negative anaerobic infection of these structures. Fluid that bathes the tooth at the gingival margin, known as gingival crevicular fluid, often contains inflammatory mediators and oral pathogens associated with periodontal disease. 15 7 8 16 17 15 The second oral disease important to women of childbearing age because of its maternal-child health associations is dental caries. Dental caries is the pathologic process by which teeth “decay” and develop “cavities.” It occurs when acid is produced at the tooth surface by cariogenic bacteria in the dental plaque that metabolize dietary carbohydrates. Acquisition of these cariogenic bacteria, dietary practices that govern the caries process, use of fluorides that dampen the caries process, and utilization of dental care all link mothers’ and children's experience with tooth decay through biological, behavioral, and social pathways. Is maternal oral health linked to pregnancy outcome? Preterm birth 18 19 20 21 7 7 22 23 9 9 24 24 25 25 23 2 2 2 23 26 P 27 26 27 28 Other adverse pregnancy outcomes 29 29 30 P 31 2 α β 32 Is maternal oral health linked to children's experience with tooth decay? 10 mutans streptococci 11 33 33 34 Is preconception preventive oral health care the answer? It is intriguing to consider preconception, pregnancy, or intrapartum treatment of oral health conditions as a mechanism to improve women's oral and general health, pregnancy outcomes, and their children's dental health. Evidence is currently weakest for interventions that seek to reduce the incidence of preterm low birth weight through oral care. The mechanism of periodontal disease-associated adverse pregnancy outcomes is as yet unclear, and althoughit is hypothesized that if the ‘insult’ occurs early (either at conception or implantation) the risk is greater, no direct evidence to confirms that this is the case. However, given the strong relationship between oral health conditions and periodontal disease and general health and well-being, oral health care should be a goal in its own right for all individuals. If treatment of periodontal disease is going to impact pregnancy outcomes, then it is likely that the therapy will be of greatest benefit before or in very early pregnancy. 35 12 13 Access to oral health care during pregnancy 36 37 36 38 33 39 40 Independent of pregnancy, the presence and source of dental insurance coverage is an important predictor of dental care utilization with publicly insured adults experiencing higher levels of oral diseases but less access to dental care. Medicaid is particularly significant to dental care of pregnant women as this program covers approximately 1/3rd of births in the US. However, states vary widely in adult Medicaid dental coverage, and at present only 7 jurisdictions providing comprehensive care to eligible adults. In contrast, low income pregnant women seeking dental services find themselves with no coverage in 8 states, coverage for only relief of pain or infection in 18 states or eligible for a limited range of services in 18 states. Three states (UT, LA, CA) have recently expanded dental benefits specifically to pregnant women in anticipation of reduced rates of unfavorable pregnancy outcomes. Pregnancy may be the only time that some low-income woman can readily obtain dental care as some state Medicaid programs provide adult dental coverage only to pregnant women or enhanced coverage during pregnancy. Conclusions and future directions Data are emerging to support a role for maternal periodontal disease as an infectious risk factor for preterm birth and other adverse outcomes of pregnancy. The prevalence of periodontal disease and the possibility of preterm birth prevention by treatment of oral infection make this a novel approach to improve the health and well being of our mothers and their soon-to-be born children. Further studies to better understand the mechanism of periodontal disease-associated preterm birth will enable us to tailor treatment to those women who might benefit the most. Data on the relationship between maternal and child experience with dental caries is well established. Therefore, regardless of the potential for improved oral health to improve pregnancy outcomes, public policies that support comprehensive dental services for vulnerable women of childbearing age should be expanded, so not only their own oral and general health is safeguarded but also so that their children's risk of caries is reduced. Particularly if NIH trials confirm that treating pregnant women for periodontal disease reduces the incidence of unfavorable birth outcomes, the Centers for Medicare and Medicaid Services should build on its September 2004 coverage expansions for pregnant women by stimulating the states to similarly expand oral health services for pregnant women. The power of prevention needs to be brought to bear, as both periodontal disease and caries are overwhelmingly preventable through well recognized strategies including regular and effective home care for periodontal disease and use of fluorides and sealants for caries. To the degree that pregnancy provides a “teachable moment” in self-care and future child-care, prenatal education should universally adopt an oral health component. This educational intervention should prioritize those mothers who have suffered significantly from dental caries so that they can learn to effectively prevent transfer of this disease to their children. To be effective, oral health promotion must first seek to educate women and their health care providers about the importance of oral health and must promote an understanding of their ability to prevent and manage both periodontal disease and caries and to thereby limit the personal and intergenerational consequences of both conditions.