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rev port estomatol med dent cir maxilofac . 2026;67(1):2-10 3

Ethical approval was granted by the Ethics Committee for
Introduction
Health of the Faculty of Dental Medicine, University of Porto
Oral health in Portugal remains a significant public health (Ref. 26/2023), and the University of Porto Data Protection Of-
challenge. In 2019, according to Statistics Portugal (Instituto fice (Ref. A-11/2024).
Nacional de Estatística, INE), 15.9% of the population rated The study took place across Portuguese Local Health Units
their oral health status as poor or very poor, with worse out- (Unidades Locais de Saúde, ULSs). After project approval, the
comes among women and those with lower levels of educa- SNS Executive Directorate (Direção Executiva do SNS) sent an
1
tion. By 2023, Portugal had the third-highest level of unmet endorsement email to all ULSs, followed immediately by direct
dental care needs in the European Union, affecting 8.7% of the emails from the research team. Eleven units completed their
total population and 19.3% of low-income groups, with finan- internal ethics procedures and agreed to participate: São João,
2
cial hardship cited as the primary barrier. These figures high- Médio Tejo, Guarda, Algarve, Póvoa de Varzim/Vila do Conde,
light how direct out-of-pocket costs, within a system where Estuário do Tejo, Lezíria, São José, Litoral Alentejano, Oeste, and
most care is delivered privately, continue to exacerbate social Entre Douro e Vouga. Participating units were asked to display
and economic inequities. 1-5 the study poster in patient-visible areas and, when possible,
The consequences of limited access to oral care extend identify a person of contact, such as a chief nurse. Despite
beyond the mouth, as untreated oral disease is linked to sys- follow-up reminders, the remaining units and three contacted
temic conditions, increased healthcare expenditures, and a private hospitals did not respond.
reduced quality of life. During pregnancy, these effects are Eligible participants were pregnant women at any gesta-
3,6
significant. Pregnant women face compounded challenges in tional stage or women attending a consultation within 60 days
accessing oral health care, primarily due to cost-related bar- postpartum. Ineligible individuals were automatically prevent-
riers, insufficient health literacy, including prevalent miscon- ed from completing the survey through embedded screening
ceptions regarding the safety of dental treatments during in the online form.
pregnancy, and a general lack of awareness concerning the Data were collected using a 31-item web-based question-
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oral-systemic health connections. The implications of these naire developed by the research team and deployed through
access barriers are clinically significant; for example, mater- Google Forms under a University of Porto license. The ques-
nal periodontitis has been linked to higher risk of adverse tionnaire covered demographics, socioeconomic character-
pregnancy outcomes, including preterm birth, low birth istics, oral health practices, perceived importance of oral
weight, and preeclampsia. 8-10 health, and awareness and use of the Dental Voucher pro-
In response to some of these disparities, Portugal’s Na- gram for pregnant women (Appendix 1) . A pilot test with 15
tional Oral Health Promotion Program (PNSPSO) created pregnant women confirmed clarity and feasibility, with a
the Dental Voucher (in Portuguese, Cheque-Dentista) pro- completion time under 10 minutes. All items were manda-
gram in 2008. This program provides pregnant women tory, ensuring complete datasets; internal consistency anal-
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with up to three annual dental vouchers, which cover pre- ysis was not yet performed due to the preliminary nature of
ventive care and curative treatments, paying the dentist at this report.
a rate of 45€ per voucher. Vouchers are issued by Portu- Program utilization data were obtained from two national
guese National Health Service (SNS) primary care units, sources: the SNS Transparency Portal (Portal da Transparência
and beneficiaries can select any dentist who has signed a do SNS), which provided records of voucher issuance and re-
contract with the state to participate in the program. These demption from 2008 to 2024, and the INE, which supplied an-
dentists are required to conduct an initial assessment, cre- nual live birth statistics for the same period.
ate a treatment plan within the established three-voucher Descriptive statistics for questionnaire responses were
framework, and prioritize the control of oral disease with- generated using IBM SPSS Statistics 29. Administrative data on
in this allowance. 11 voucher issuance, redemption, and live births were analyzed
Although dental voucher usage has improved, it still re- in Microsoft Excel to describe temporal patterns in program
mains below expectations, and routine data on barriers and performance. Two indicators were calculated. The utilization
determinants are lacking. This evidence gap constrains poli- rate was defined as the proportion of vouchers redeemed rel-
cymakers’ capacity to optimize program delivery. Therefore, ative to those issued each year:
this study aims to assess how pregnant women in Portugal
perceive the significance of oral health, quantify their utiliza- Utilization rate = (Vouchers redeemed / Vouchers issued) × 100
tion rate of the Dental Voucher program, and identify opera-
tional limitations of the program. Coverage was defined as the proportion of live births for
which at least one voucher was used:

Material and Methods Coverage = (Vouchers redeemed / 3) / Live births × 100

This cross-sectional study was conducted between October The division by three accounts for the allocation of three
2024 and September 2025 to assess oral health practices, vouchers per pregnancy. For years with missing birth data,
awareness, and utilization regarding the Dental Voucher pro- coverage estimates were not calculated. These methods al-
gram among pregnant women in Portugal. The study followed lowed for consistent year-by-year comparisons and assess-
STROBE guidelines for cross-sectional research. ment of temporal trends in program uptake.