Perinatal Oral Health Irene V Hilton DDS MPH

Perinatal Oral Health Irene V. Hilton, DDS, MPH San Francisco Dept. Public Health La Clinica de la Raza UCSF School of Medicine UCSF School of Dentistry

Objectives • Understand the effect of maternal oral health status on families • Describe why pregnancy provides a unique opportunity to provide oral health interventions for women • Learn the elements of clinical prevention and treatment guidelines for pregnant women • Learn how to leverage medical-dental integration in the CHC setting to improve perinatal oral health

Impact of Maternal Oral Health on Families

Periodontal Disease • Two main disease categories with different causative bacterial agents – Gingivitis • Reversible, no bone loss, aerobic – Periodontitis • Irreversible, loss of supporting bone, anaerobic • Inflammatory process

Disease Response to Bacterial Plaque Low Fatty acids FMLP LPS IL-8 IL-10 TGFb IL 1 ra TIMP s High TNFα IL-6 IL-1β IFN-g PGE 2 MMPs

Epi: Moderate periodontal disease prevalence (1+ sites with Loss of Periodontal Attachment (LPA) 4+ mm) Source: NHANES 3 (1989 -94), US Population

Epi: Attachment loss > 6 mm by race/ethnicity Source: NHANES III (1989 -94), US Population

Periodontitis & Pregnancy Mechanisms • Circulating periodontal bacteria induce activation of maternal immune responses leading to cytokine production and release of prostaglandins, which may directly or indirectly interfere with fetal growth and delivery (Offenbacher 1998) • Periodontal bacteria & toxins can cross the placental barrier • Pregnant women with periodontitis had higher Creactive protein (C-RP) levels than periodontally healthy counterparts (Pitiphat et al, 2006)

OPT Results • Nov. 2006 NEJM • 410 control, 413 Tx group @ 4 US sites • No significant difference between Tx and control groups in number of pre-term births (<37 weeks) • Periodontal treatment while pregnant is safe, but does not improve birth outcomes • Await MOTOR results – 1, 800 subjects

Aetna/ Columbia University College of Dental Medicine • Women who received dental care before or during their pregnancy had a lower risk of adverse birth outcome • The preterm birth rate was 11. 0 percent for those not receiving dental treatment, and 6. 4 percent for those receiving treatment • 29, 000 pregnant women who each had medical and dental coverage with Aetna

Thoughts • There is an association • We don’t know if it’s causal – Mechanism not clear • Periodontitis is still a disease/pathological state • Treatment of periodontitis is safe during pregnancy • Time will tell!

Dental Caries • Dental caries, once acquired, is a chronic, ongoing disease PROCESS that must be managed throughout the life cycle • Cavities are the RESULT or final disease endpoint of the dental caries process • Multifactorial disease • Primary cariogenic organisms – Strep mutans – Lactobacilli

Epi: Prevalence of Coronal Caries Among Dentate Adults NHANES 1999 - 2002

Etiology: Maternal Transmission • Maternal transmission of strep mutans during normal activities (Berkowitz et al 1981, 1985, 2003, 2006. Caufield et al 1993, 1995, 2000, 2003, 2005) • Can occur with other primary caretakers or siblings but highest fidelity with mother • 0 -36 month window of infectivity

Strep Mutans Transmission

Early Childhood Caries Disparities % 2 -5 y/o Untreated Decay Data Source: NHANES IV, 1999 -2000, NCHS/CDC.

Maternal Influence • Diet • Level of home care • Importance of teeth & oral health • Along with genetic & transmissibility components

Pregnancy Presents an Opportunity • Stabilize periodontal status • Break the chain of s. mutans transmission • Introduce risk reduction & self management strategies for two life cycles

Opportunity… • At risk populations in contact with medical care delivery system more frequently than usual • Pregnant women may be interested in their oral health & open to health education messages • May be only time have any type of dental insurance coverage

Oral Conditions Unique to Pregnancy • Pregnancy Gingivitis • Pregnancy Epulis • Erosion from morning sickness

Dental Visits: 2002 PRAMS Pregnancy Risk Monitoring System (CDC)

Clinical Interventions

Medical- Dental Integration is Key!!!!! Perinatal educating pregnant women Dentists willing to treat pregnant women

NY State Guidelines • Physician section: Importance of oral health to pregnancy, responses to common concerns by dentists • Dentist section: Evidence based recommendations and protocols for clinical treatment of pregnant women

“Because pain was so great she took ‘excessive doses’ (Tylenol) resulting in toxicity to her and her baby. At the time she was approximately 29 weeks pregnant. The baby died from liver toxicity. My patient suffered acute liver failure and was flown to Pittsburgh expecting a liver transplant. ”

Medical Side Action Steps • Ask and advise- “any problems? ” • Encourage pregnant women to schedule an oral health examination and why completing recommended treatment is important • Facilitate treatment by providing written medical clearance • Inform dental care is safe and effective • Delay in treatment could result in adverse effects

Management of Caries & Periodontal Disease • Risk Assessment • Surgical intervention/treatment appropriate to level of disease process to reduce bacterial levels • Chemotherapeutics to maintain low bacterial levels/suppress • Risk reduction self-management strategies for changes in home care/diet • Recall

Dentist’s Concerns for Surgical Intervention/treatment • • Potential harm from x-rays Use of materials such as amalgam Local anesthesia Use of medications Nitrous oxide Timing of procedures Perception of patient discomfort

X-rays • Standard of care is as needed for proper diagnosis and treatment • Less of an issue with digital imaging • Current x-ray systems very low emissions

Amalgam Restorations • No evidence of harmful effect in population based studies and reviews (CDC, NCI) • Restorative options also non-optimal

Drugs in Pregnancy • • • Category B (non-controlled studies) Lidocaine Acetaminophen Pen, amox, clindamycin, nystatin Chlorhexidine rinse Haas DA, Pynn BR, Sands TD. Drug use for the pregnant or lactating patient. Gen Dent. 2000 Jan-Feb; 48(1): 54 -60.

Nitrous Oxide • The use of nitrous oxide should be limited to cases where topical and local anesthetics are inadequate • Cost-benefit analysis • Pregnant women require lower levels of nitrous oxide to achieve sedation

Clinical Considerations • Position head higher than feet • Upper arch treatment early in pregnancy before lower arch • IVC pressure- 3 rd trimester • Morning or afternoon appointment preference

Use of Chemotherapeutics • No universal standards or guidelines for regimens • Individual studies have looked at specific interventions • International studies (Sweden, Italy) • Common sense should prevail

Chemotherapeutics Safe • Chlorhexidine (CHX) • Fluoride • Xylitol • No over the counter mouth rinses with alcohol (Listerine 20% alcohol)

Caries Featherstone et al.

Chlorhexidine • Controls/suppresses s. mutans & periodontal pathogens • Staining of teeth a side effect • Dosage and timing of application for most effective suppression? • Original 30 month study showing delayed s. mutans colonization in children after intervention with the mother during last 3 months of pregnancy (Brambilla et al. JADA 1998)

Suggested Regimen to Reduce s. mutans Transmission • Category B- At minimum should have in dental clinic and have patient rinse prior to appointment during pregnancy • After birth- 1 week of CHX followed by 3 weeks of OTC Fl rinse- ACT, Fluorigard, generics 0. 05% Na. F (Spolsky et al. CDA Journal 2007) • Cost/insurance coverage

Xylitol • Naturally occurring sugar derived from bark of the birch tree • Suppresses s. mutans (Hildebrandt 2000) • Studies show decreases transmission s. mutans (Soderling et al, 2000)

Dosage • Optimum 6 -10 mg/day (Milgrom 2006) • 4 -6 times/day • OTC products have variable levels of xylitol - if not first ingredient not useful • The only way to insure therapeutic dose is to dispense • Gum, mints

Combination Therapy • Triad- Fl/CHX/xylitol – Brush 2 x/day w/Prevident – 4 x/day Xylitol – CHX 1 x/day separated from Prevident by 30 min • Best 2/3 – Xylitol & Prevident • Fl varnish for Mom @ 3/6/9/12 well baby visits along w/child (once has teeth) Featherstone 2008

Self Management Goals Based on Risk Assessment • Maintaining reductions in maternal levels of s. mutans and/or bacteria that cause gingivitis or periodontitis • Reducing other risk factors (diet, smoking) • Appropriately cleaning the teeth and gums • Use of topical agents as recommended

Patient Education Materials • Review for reading level and cultural appropriateness • Be selective and keep materials brief. Include materials with larger print • Coordinate patient education with national standards (i. e. Anticipatory Guidance) or organization's care guidelines

Motivational Interviewing • • • Get Mothers to talk/you listen Give choices (key, key) Acceptance facilitates change Pressure to change facilitates resistance Receiving same message from all health care providers will increase acceptance

Strategies for Implementing Perinatal Oral Health Care

Medical- Dental Integration is Key (again)!!!!! Perinatal educating pregnant women Dentists willing to treat pregnant women

Clinical Information Systems • Develop database of pregnant women Clear tracking processes Standardized language in daily processes and documentation Integrated health record and scheduling system (ideally electronic)

Decision Support Education and training for medical and dental staff about the oral health needs of pregnant women Develop referral process from medical for pregnant women Educate and train dental staff in the treatment of pregnant women Facilitate consults/ communication

Delivery System Design Oral health considerations integrated into every appropriate medical visit Fast track pregnant women Utilize maximum expanded duties Establish a dental liaison or patient navigator to interface with medical staff and patients

Self Management (SM) Support Utilize effective SM techniques and tools Train team members on motivational interviewing techniques, SM goal setting and follow-up Consistency of oral health education provided by team members Co-located patient education materials

Organization of Health Care Organizational commitment to see and treat pregnant women Co-location of services Respect and understanding of roles and contributions of medical and dental staff Integrated case management

Community Raise community awareness of importance of oral health for pregnant women Partner with community organizations that provide services to pregnant women and community OB providers • Educate other dental providers about enhancing oral health access and outcomes for pregnant women

Conclusion • Paradigm shift for both dental and medical professionals • Long-term commitment • We have models • Perinatal Oral Health is the right thing to champion

Our Goal