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Primary Care Management of Oral Health in Pregnancy Goals for this Session • Show why oral health is a priority for primary care’s pregnancy management. • Review key structures of the mouth and the disease processes that affect them. • Outline a set of primary care actions shown to be effective in protecting and improving oral health and overall health. • Introduce a framework for incorporating oral health actions into primary care practice. 2 Oral Health Fits in Primary Care • Preventable infectious disease. • Common problem. • Serious health impact. • Patient and family behavior (self-care) is key. • Early recognition and treatment reduces the impact. 3 Oral Health As a Key Element of Pregnancy Management 4 Two Preventable Infectious Diseases • Caries: • Pain, abscess, tooth loss, and high costs. • Transmission to baby soon after delivery. • Periodontal disease: • • • • Premature birth. Pain, high costs, and tooth loss. Increases risk of diabetes. Accelerates cardiovascular disease. 5 Prevalence There are over six million pregnancies each year in the United States in women between the ages of 15 and 44. Active tooth decay • Nearly one in four women of reproductive age in the U.S. has active tooth decay. • Tooth decay is the single most common disease of childhood. Photo: Dr. Bea Gandara, Univ. of WA Periodontal disease • Can be detected in 37–46% of women of reproductive age and in up to 30% of pregnant women. Photo: Robert Henry, DMD, MPH 6 Caries: Maternal-Child Linkage Mothers/primary caregivers are the main source of the bacteria responsible for causing caries. How are the bacteria transmitted? • Normal essential behavior, including kissing and playing with baby. • Via saliva contact such as tasting food, licking spoons, or pacifiers. Mutans Streptococci Upstream prevention • If colonization is delayed until after two years of age, children have less dental decay. • Optimizing mothers’ oral health prevents caries in young children. 7 Current Unacceptable Outcomes • 30–40% of pregnant women have some form of periodontal disease. • > 50% of women receive no dental care (including cleaning) during pregnancy. • This is directly related to income level. • Hispanic and African-American women are only half as likely to get their teeth cleaned during pregnancy. 8 Barriers to Care Personal barriers Dental barriers • Finding a dentist. • Getting to a dentist. • Poor understanding of oral health importance. • Uncertainty that x-rays and dental treatments, e.g., fillings, lidocaine, and nitrous oxide, are safe. • Lack of dental training. • Past teaching to avoid dental care in pregnancy. • Unsubstantiated liability concerns. 9 ACOG Recommendations • Oral health assessment should be done at first prenatal visit. • Dental x-rays (with proper shielding) are safe during pregnancy. • Treatments, e.g., fillings, root canals, cleaning, and extractions, are safe. They may and should be done at any time during pregnancy. • Stomach acid can be neutralized by rinsing mouth with baking soda solution and using oral antacids. 10 The Overview • Goal: Dramatic reduction in caries and periodontal disease in pregnant women. • Strategy: Extend preventive care in partnership with dentistry with systematic primary care screening for: • Risk factors coupled with risk reduction action. • Oral disease coupled with referral for treatment. • Tactic: Oral Health Delivery Framework. 11 Extending the Reach of Oral Healthcare Pregnant Women Receiving Regular Prenatal Care Pregnant Women Receiving Regular Dental Care 12 Oral Health Delivery Framework Five actions primary care teams can take to protect and promote their patients’ oral health. Within the scope of practice for primary care, possible to implement in diverse practice settings. Preventive interventions: Fluoride therapy, dietary counseling to protect teeth and gums, oral hygiene training, therapy for substance use, medication changes to address dry mouth. Citation: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care. Seattle, WA: Qualis Health; June 2015 13 Primary Care’s Role in Oral Health The Oral Health Screening Assessment: Ask and Look Decide and Act • Identify risk factors: • • • • Adjust medication list. Fluoride for caries risk. Printed education material. Coaching. • Identify signs of disease: • Referral to dentistry. 14 Oral Health Screening in Primary Care Risk assessment Identifying high-risk patients: • Tobacco use • Diabetes • No recent dental care • Poor oral hygiene • High dietary sugar content • Frequent snacking • Inadequate fluoride • Meds affecting saliva Case finding Detecting signs of disease: • Gums • Gingival inflammation • Epulis • Periodontitis • Teeth • Loose teeth • Erosion • Caries Treatment: Referral, in-clinic therapy Treatment: Reduce risk 15 Oral Structures and Oral Disease 16 The Healthy Mouth Photo: UKCD, Robert Henry DMD, MPH • • • • • Saliva Teeth Gums Oral mucosa Tongue Photo: UKCD, Robert Henry DMD, MPH 17 The Primary Threat Is Bacterial Infection Teeth and/or gums Bacteria UKCD, Robert Henry DMD, MPH Substrate: carbohydrate Over time 18 Saliva • Secretion: Autonomic nerve stimulation • Components: • Antimicrobial proteins • High calcium concentration • Role: • Physical barrier, lubrication, and cleansing • pH buffer for acid: food, bacteria, and gastric reflux • Remineralization 19 The Salivary Glands 20 Saliva Repairs Enamel • Demineralization • Acid dissolves enamel. • pH drops with eating and drinking (except water). • Stimulation of bacterial growth by sugar. • Acid in food and beverages. • Remineralization • Saliva restores pH balance and remineralizes enamel between meals/snacks. • Time is required for remineralization. 21 Saliva: The Protective Balance Protective Factors Saliva Peptides (defensins) Oral hygiene Prudent diet Fluoride No Caries Pathologic Factors Acid-producing bacteria e.g., Strep mutans Frequent carbohydrates Reduced saliva Caries 22 Remineralization Takes Time Regular Meals Regular Meals Plus Frequent Snacks 23 Medications Causing Oral Dryness • • • • • • • • • Diuretics Antihistamines Antipsychotics Antidepressants ADD medications Anti-anxiety medications Anticholinergics Proton pump inhibitors Many others 24 Drugs That Cause Oral Dryness Caffeine Alcohol Amphetamines 25 Assessing for Oral Dryness • Ask • Dry mouth. • Not enough saliva. • Look • • • • Dry-appearing mucosa and tongue. Enlargement of the parotid glands. Tongue blade sticking to oral mucosa. Lack of saliva pooling under the tongue. 26 Loss of Protective Saliva • Patient’s experience: • Mouth feels dry • Difficulty: • Swallowing • Tasting food • Speaking Photo: Dr. Bea Gandara, Univ. of WA • Untreated, leads to infection: • • • • Tooth decay Periodontal disease Angular cheilitis Yeast infection of the tongue Photo: Dr. Bea Gandara, Univ. of WA 27 Consequences of Dry Mouth Dry mucosa Tooth loss Root caries Gum recession Photo: Dr. Bea Gandara, Univ. of WA 28 29 Managing Patients with Dry Mouth Avoid: • Medications causing dry mouth. • Alcohol, caffeine, and tobacco. • Sugary drinks and snacks. Suggest: • Frequent sips of water. • Sugar-free products with xylitol. • Saliva substitutes and stimulants. Saliva substitutes Saliva stimulants Sugar-free gum and mints Prevent infection: • Daily oral hygiene. • Protect teeth with fluoride. 29 Dry Mouth Leads to Caries • Plaque deposits build up on teeth. • Dietary acid and acid-producing bacteria erode enamel. • Caries-producing bacteria invade enamel. • Progression to dentin causes deep decay. • Progression to pulp causes tooth death: • Need for expensive root canal therapy and crown to save tooth, or • Tooth loss. • Bacteria spread to other teeth. 30 What Is Plaque? • Initially a film, which turns into hard deposit on the teeth. • Protein precipitate from saliva, food, and bacteria adheres to teeth. • Calcium deposits from saliva turn it into calculus. • Substrate for bacterial growth. • A place acid and bacteria have prolonged contact with enamel and roots. • Barrier to protective effects of saliva. 31 Anatomy of a Tooth Periodontal ligaments 32 Tooth Decay Progression 33 Assessing for Caries • Ask • Do you experience tooth pain or bleeding gums when you eat or brush your teeth? • Has anyone in the immediate family (including a caregiver) had tooth decay, or lost a tooth from tooth decay, in the past year? • Look • White discoloration of the enamel. • Dark discoloration of enamel or root. 34 The Spectrum of Caries Root caries Early caries Advanced caries Plaque setting the stage for caries Photo: Dr. Bea Gandara, Univ. of WA 35 Actions to Prevent Tooth Decay Remove bacteria daily. • Brush twice daily for two minutes with fluoridated toothpaste. • Floss daily, preferably at night. Limit sugar, and sweet, sticky, or sugary foods and drinks. Fluoride Toothpaste • Use xylitol (a natural sweetener). • Rinse with water after meals. Use fluoride. • Use fluoridated toothpaste. • Drink fluoridated water. • Apply fluoride varnish. Regular dental care. Fluoride Varnish 36 The Impact of Fluoride • Inhibits bacterial metabolism and limits pH drop associated with eating and drinking. • Makes enamel and dentin more resistant to demineralization and dissolution in acid. • Enhances remineralization by attracting calcium to demineralized enamel. 37 Periodontal Disease 38 The Pathway to Periodontal Disease and Tooth Loss 39 Early Periodontal Disease Gingivitis Redness Bleeding Puffiness Photo: Dr. Bea Gandara, Univ. of WA 40 Advanced Periodontal Disease • Gum retraction • Bone loss • Spaces between teeth • Loose teeth • Tooth loss Gum puffiness masking spaces between teeth and bone loss Gum recession Photo: Dr. Bea Gandara, Univ. of WA 41 Periodontitis Accelerators • Poor oral hygiene • Medication side effects • Malnutrition • Eating disorders • Alcohol • Tobacco • Chemical dependency • Hormonal effects of pregnancy • Diabetes 42 Periodontal Treatment Reduces Medical Costs for People with Chronic Conditions Lower Annual Medical Costs Reduced Hospital Admissions $1,090 (10.7%) $2,840 (40.2%) 21.2% $2,433 28.6% (73.7%) $5,681 39.4% (40.9%) Diabetes Stroke Heart Disease Pregnancy 43 Assessing for Periodontal Disease • Ask: • Find out if patient experiences tooth pain or bleeding gums when eating or brushing. • Look: • Gum inflammation, bleeding, gum recession. • Root exposure. • Decide/Act: • Refer to dentist for intensive treatment. • Address the accelerators. • Apply fluoride to protect roots. 44 How is Oral Health Different in Pregnancy? 45 Endocrine Changes • Estrogen increases 10-fold. • Capillary permeability and gingival hyperplasia. • Progesterone increases 30-fold. • Reduced inflammatory response: numbers of neutrophils and antibody response. • Increased bacterial growth. • Gram negative bacteria in gums: periodontitis. • Strep mutans and lactobacillus: caries. • Fusobacterium nucleatum: pre-term delivery. 46 Pregnancy Gingivitis Clinical characteristics: • 30‒80% of women. • 2nd‒8th months, anterior areas. • Changes in gingival vascularity result in greater bleeding. • Preexisting gingivitis may predispose to pregnancy gingivitis. • Treatment is safe. Photo: Dr. Robert Johnson, Univ of WA 47 Pregnancy Granuloma (Epulis or Pregnancy Tumor) Photo: Dr. Robert Johnson, Univ of WA Clinical characteristics: • Occurs in up to 5% of women. • Starts in the 2nd or 3rd month. • Single, tumor-like growth (up to 2 cm) in an area of gingivitis or recurrent irritation (usually maxillary buccal anterior). • Usually regresses spontaneously after delivery. 48 Pre-term Births and Periodontitis • Severe periodontitis leads to high levels of prostaglandins in the blood. • High levels of prostaglandins are associated with early uterine contractions, early birth, and low birth weight. 49 Preeclampsia and Periodontitis • Periodontal disease may be associated with preeclampsia. • PGE2, IL-1, and TNF- levels from gingival cervicular fluid are higher in women with preeclampsia. • Oral pathogens have been found in placentas of women with preeclampsia. This implies a possible contribution of periopathogenic bacteria to the pathogenesis of this syndrome. 50 Increased Exposure to Acid • Vomiting. • Gastroesophageal reflux (GERD). • Craving acidic foods. 51 Gastric Reflux • Pressure on the stomach from fetus. • Lower esophageal sphincter pressure falls 33%–50%. • Progesterone affects GI smooth muscle (decreased motility and prolonged intestinal transit time). 52 Erosion of Tooth Enamel Photo: Dr. Bea Gandara, Univ. of WA 53 Tooth Mobility • Transient increase in tooth mobility. • Gingivitis and ligament relaxation not correlated with hormone changes. Photo: Dr. Bea Gandara, University of WA Note: pregnancy does not result in demineralization of teeth because of fetal calcium needs. Women don’t lose a tooth for each pregnancy. 54 Primary Care Oral Health Interventions • Oral hygiene coaching: • Brushing with fluoride twice daily • Flossing once daily • • • • • Dietary counseling Topical fluoride Medication review Antacids Referral 55 Case 1 • A 36-year-old female comes in for her 16-week prenatal visit. • She has been suffering from hyperemesis since her sixth week, and while it has begun to get better, she still vomits three to four times a day. • Her nausea is helped a bit by sipping on Coke and sucking on ginger candies. She has not been to the dentist in the past year, and she has not been able to regularly brush her teeth since the onset of hyperemesis, since the toothbrush in her mouth triggers vomiting. • She reports pain when drinking hot tea or cold ice cream. 56 Case 2 • A 28-year-old woman comes in for her 32-week prenatal visit. • She was recently diagnosed with gestational diabetes so is trying to change her diet, but was previously eating a lot of carbohydrates and sugary snacks. • She reports bleeding while brushing her teeth and pain while eating, as well as a feeling that a few of her teeth are “wiggling.” • She has not been to the dentist in a few years and intended to go when the bleeding started a few months ago, but a friend told her it wasn’t safe to get a cleaning when pregnant. 57 Group Discussion • Who will ask the questions that give you this information? • Who will look in the mouth and look for the key findings? • Who will order preventive actions? • Who will deliver preventive actions? • How will you set up the referral? 58 Addressing Oral Health for Pregnancy in an Already Busy Primary Care Practice 59 Building Oral Health into the Process • Structure visits and use the entire team to ensure oral health isn’t overlooked. • Use health IT to organize information so that risk factors are easily identifiable and education interventions are automated. • Share the care among team members and let the clinician focus on the reason for the visit. • Used structured referrals to dentistry. 60 Teamwork to Share the Care • Identify target population patients before visit. • Ask about symptoms while rooming patient. • Set up orders for the clinician to sign. • Arrange for oral health protocol at the end of the visit. 61 Prevention Through Counseling Most important topics: • Oral hygiene best practices: • Brush twice daily for two minutes with fluoride toothpaste. • Floss at least once daily. • Diet: • Reduce sugar and carbohydrates, rinse with water. • Allow sufficient intervals between snacks. • Recognize dry mouth as a sign of trouble: • Teach patients to ask about medication side effects. 62 Prevention Through Counseling Technique depends on team resources: • Synergy with general health messages: • Teach-back • Motivational interviewing • Patient education: • Handouts • Videos • Peer support 63 Summary • Oral health in pregnancy is a major unmet need. • Maternal oral health directly benefits the baby. • Primary care strengths: • Risk factor identification and reduction through behavior change. • Case finding and referral. • Pathophysiology of caries and periodontal disease are familiar to primary care. • Integration into primary care workflow works using the Oral Health Delivery Framework. 64 Source: Developed by Qualis Health for the Washington Dental Service Foundation “Oral Health Preventive Services in Primary Care Project.” 1st ed. Seattle, WA. November 2014. 65 About the Oral Health Integration in Primary Care Project The Organized, Evidence-Based Care Supplement: Oral Health Integration joins the Safety Net Medical Home Initiative Implementation Guide Series. The goal of the Oral Health Integration in Primary Care Project was to prepare primary care teams to address oral health and to improve referrals to dentistry through the development and testing of a framework and toolset. The project was administered by Qualis Health and built upon the learnings from 19 field-testing sites in Washington, Oregon, Kansas, Missouri, and Massachusetts, who received implementation support from their primary care association. Organized, Evidence-Based Care Supplement: Oral Health Integration built upon the Oral Health Delivery Framework published in Oral Health: An Essential Component of Primary Care, and was informed by the field-testing sites’ work, experiences, and feedback. Field-testing sites in Kansas, Massachusetts, and Oregon also received technical assistance from their state’s primary care association. The Oral Health Integration in Primary Care Project was sponsored by the National Interprofessional Initiative on Oral Health, a consortium of funders and health professionals who share a vision that dental disease can be eradicated, and funded by the DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation. For more information about the project sponsors and funders, refer to: • National Interprofessional Initiative on Oral Health: www.niioh.org. • DentaQuest Foundation: www.dentaquestfoundation.org. • REACH Healthcare Foundation: www.reachhealth.org. • Washington Dental Service Foundation: www.deltadentalwa.com/foundation. The guide has been added to a series published by the Safety Net Medical Home Initiative, which was sponsored by The Commonwealth Fund, supported by local and regional foundations, and administered by Qualis Health in partnership with the MacColl Center for Health Care Innovation. For more information about the Safety Net Medical Home Initiative, refer to www.safetynetmedicalhome.org. 66