Download Oral Health Issues for Hispanics

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
IL1ra
TIMP
s
High
TNFα
IL-6
IL-1β
IFN-g
PGE2
MMPs
Epi: Moderate periodontal disease prevalence
(1+ sites with Loss of Periodontal Attachment (LPA) 4+ mm)
60
50
40
% 30
20
10
0
18-24
25-34
35-44
45-54
Age
Source: NHANES 3 (1989-94), US Population
55-64
65-74
Epi: Attachment loss > 6mm by
race/ethnicity
40
35
30
25
NHW
NHB
MA
20
15
10
5
0
18-24
25-34
35-44
45-54
Source: NHANES III (1989-94), US Population
44-64
54-74
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
96
94
92
20-39
40-59
60 & up
90
88
86
84
82
20-39
40-59
60 & up
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
35
31.5
30
24.6
Percent
25
20
19.3
15
10
5
0
2-5 years
NHANES 1999-2000
Non-Hispanic White
Data Source: NHANES IV, 1999-2000, NCHS/CDC.
Non-Hispanic Black
Mexican American
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)
60
50
40
30
20
10
k
Bl
ac
hi
te
W
M
ed
ic
ai
d
no
nM
ed
ica
id
A
ll
Pr
eg
0
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- 3rd
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)
The Caries Balance
Pathological Factors
• Acid-producing bacteria
• Sub-normal saliva flow
and/or function
• Frequent eating/drinking
of fermentable carbohydrate
Caries
Caries
Protective Factors
Protective
Factors
• Saliva
flow and
components
• Fluoride, calcium, phosphate
•Antibacterials: - chlorhexidine,
iodine?, xylitol, new?
No 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% NaF (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 2x/day w/Prevident
– 4x/day Xylitol
– CHX 1x/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, 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