The Safe and Effective Treatment of Pregnant Women and Infants. SC DHEC Division of Oral Health

Transcription

1 The Safe and Effective Treatment of Pregnant Women and Infants SC DHEC Division of Oral Health

2 Objectives: At the conclusion of this presentation, participants will be able to: Understand the impact of poor oral health on pregnancy, and Understand the role oral health plays in overall well-being of pregnant women and infants; Identify barriers to optimal oral health during pregnancy; Comprehend the oral health status of pregnant women in South Carolina; Understand the role that the medical and dental professional can play in supporting the oral health of pregnant women and infants; Identify current initiatives to address the needs of pregnant women.

3 The Importance of Oral Health During Pregnancy Oral health is an essential component of the overall health for pregnant women (women of reproductive age) and infants. Physiologic changes occurring during pregnancy can place a tremendous strain on a woman s body, including the mouth. Poor oral health of the mother during pregnancy has been linked to poor birth and pregnancy outcomes such as preterm birth and low birth-weight. When a mother has poor oral health her child is at a greater risk of having dental problems.

4 Oral health status of pregnant women in South Carolina Access to timely oral health care during the perinatal period is a contributing factor to the health and well -being of both women and their unborn children. The South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) report for on the dental experiences among South Carolina women during pregnancy reinforces the need to educate and connect women to dental care.

5 Key findings from the SC PRAMS ( ): Dental Care Utilization: only 46.7% of pregnant women in South Carolina reported receiving dental care. Prenatal Oral Health Counseling: 47.1% percent received prenatal oral health counseling. Dental Problem during Pregnancy: 21% reported having a dental problem during pregnancy, and 56.6% of this group did not seek dental care.

6 The link between periodontal disease and preterm/low birthweight babies Periodontal disease is a bacterial infection detectable in up to 40 percent of pregnant women that has been linked to premature delivery and low birth weight. Poor health outcomes resulting from premature delivery and low birth weights are significant contributors to infant mortality and long-term health complications among infants.

7 Oral Health for Women Pregnancy and Across the Lifespan The Effects of Periodontal Disease on Pregnancy Objective Apply the evidence for periodontitis affecting perinatal outcomes Image: Ken Hurst/Photos.com

8 Mechanisms for Preterm Birth 8 Chart courtesy of: Kumar J and Samelson R. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines. Albany, NY. New York State Department of Health P. 23; with permission

9 9 The Bottom Line Periodontal disease is associated with preterm birth and low birth weight Periodontal treatment during pregnancy has not been shown to improve birth outcomes Periodontal treatment does improves the women s oral health Periodontal treatment is safe during pregnancy Need additional research to determine if pre-pregnancy treatment would lower risk

10 Tooth Decay in Pregnant Women Tooth decay is a contagious bacterial disease that can affect all people across all age groups. Changes in the woman s diet and oral hygiene practices during pregnancy can result in an increase in tooth decay. Nausea and vomiting during pregnancy can cause extensive erosion of the tooth surface and lead to deteriorating oral health status.

11 11 The Maternal-Child Linkage Dental caries is a transmissible disease! Mothers are the main source of passing the bacteria responsible for causing caries to their infants Transmission occurs via saliva contact such as tasting food If mom s bacterial level is high, transmission is more likely If colonization is delayed (>age 2), child may have fewer caries Caregivers with caries also often pass on bad habits (high sugar intake, poor oral hygiene) Fathers can pass on bacteria, but this is less common Message is: BRUSH FOR TWO!

12 Oral Health for Women Pregnancy and Across the Lifespan Reduce the Risk of Caries Transmission from Mother to Child Objective Reduce the risk of caries transmission from mother to child Image: Jupiterimages/Photos.com

13 Decay Development Tooth Diet Plaque multifactorial

14 White Spot Lesions First appear as dull white bands, along the smooth surface of the tooth at the gum line followed by yellow or brown discoloration. Are first signs of decay. Important Points: Can be reversed with exposure to fluoride varnish and plaque removal. Patient is at very high risk of future decay Make a referral to a dental home as soon as possible.

15 Early Childhood Caries Mild Photo: AAPD Smiles for Tomorrow

16 Early Childhood Caries Severe Photo: AAPD Smiles for Tomorrow

17 Reducing the Risk 17 Untreated caries can lead to: Infections Pain Poor self-esteem Missed school/work Nutritional deficiencies Sleep disruption Caregivers can decrease their own caries levels by: Receiving regular comprehensive dental care, including during pregnancy Limiting the frequency of sugar in the diet Maintaining excellent oral hygiene Photo: ICOHP

18 18 Postpartum Interventions Promote breast feeding Breast fed children are less likely to develop caries American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life and continuing until at least age 12 months Consider xylitol gum or brief chlorhexidine rinse programs for mothers until child is age 2 Child care: Ensure children are not put to bed with a bottle Teeth are at highest risk overnight when saliva levels are low. Clean infants' teeth twice daily with a smear of toothpaste (AAP and AAPD recommendation) Recommend children see a dentist at 12 months of age

19 Sleep Time Habits

20 Early Oral Hygiene Begins with infants After feeding, an infant's teeth and gums should be wiped with a moist cloth or gum cleaner to remove any remaining liquid that coats the teeth and gums

21 Oral Hygiene Habits Photo: AAPD Smiles for Tomorrow

22 Toothbrushing and Toothpaste As soon as teeth appear, parents & caregivers should begin brushing children s teeth with fluoride toothpaste 2 times a day. Under 3 years of age, use smear amount. Over 3 years, use pea sized amount American Dental Association Council on Scientific Affairs (2014) Fluoride toothpaste use for young children. Journal of the American Dental Association. 145(2):

23 Fluoride Varnish An effective way to prevent and in some cases stop tooth decay Recent studies report fluoride varnish application in primary teeth resulted in a 37% reduction in tooth decay Provides a thin coating of fluoride that stays on the tooth surface and releases fluoride over time Available in a choice of flavors, colors and varying package sizes

24 Positioning The positioning of the child is based on the age and size of the child. Knee to Knee position: Place the child on the parent s lap with the child s head on the parent s knees and the child s legs around the parent s waist. The provider or assistant positions themselves knee-to-knee with the parent and treat the child from behind the head.

25 First Dental Exam The American Academy of Pediatric Dentistry recommends a dental consultation by the eruption of the first primary tooth.

26 Regular Dental Exams

27 Nutritional Recommendations Food guidance for dental health often mirrors food guidance for obesity prevention. Encourage: healthy foods such as fruits and vegetables or whole grain snacks. Discourage: sticky foods such as raisins, fruit leather, and hard candies. Discourage: grazing behavior where the child is eating and drinking very frequently throughout the day.

28 ALERT!!! AAP Guidelines Say Children Under One Year Old Should Not Be Given Fruit Juice The AAP has toughened its stance against juice, recommending that the drink be banned entirely from a baby s diet during the first year. Meanwhile, The new report, published online in...pediatrics, also advised restricting fruit juice to four ounces daily for 1- to 3-year-olds, and six ounces a day for 4- to 6-year-olds.

29 Regular Meals Meals plus Sweet Snacks

30 Misuse of Sippy Cups Used continuously throughout the day. Filled with sugary beverages. Used a as pacifier to calm and appease. Not discarded every 6 months.

31 Non-Nutritive Sucking Habits Pacifier dipped in sweetened liquid? Determine Frequency of use and Sugar content of liquid Photo: AAPD Smiles for Tomorrow

32 Treating tooth decay in pregnant women Improves the overall health of the mother Decreases the transmission of dental caries causing bacteria from the mother to the infant. (Kumar J, Samelson R, eds., 2006). Reduces caries risk. Children whose mothers have poor oral health and high levels of oral bacteria are at greater risk for developing dental caries (tooth decay), as compared with children whose mothers have good oral health and lower levels of oral bacteria (Ramos-Gomez, Weintraub, Gansky, Hoover, and Featherstone, 2002). Even though tooth decay (dental caries) is largely preventable, it remains one of the most common chronic disease of childhood, affecting children, adolescents and adults.

33 Prevention is Key Most chronic diseases are preventable Most can be controlled by modifying health behaviors

34 34 The Dental Disconnect Women frequently do not see a dentist when pregnant Only 26-34% of all pregnant women visit the dentist Percentage is even lower for Hispanic women, low SES, and those not aware of oral-systemic linkages Only 50% of pregnant woman with a dental problem visit a dentist Even among women with dental insurance, dental care rated decline during pregnancy

35 35 Reasons pregnant women don t obtain dental care Obstetrical and primary care providers do not routinely refer patients for dental care Uncertainty about safety of dental interventions Lack of training Competing health demands limits focus on this topic Dentists may be reluctant to manage the pregnant patient Lack of practical training Dentists may fear malpractice repercussions Patients have competing health demands and may receive conflicting or unclear information about the importance of having a dental visit during pregnancy

36 Oral Health for Women Pregnancy and Across the Lifespan Other Oral Conditions in Pregnancy Objective Manage other common oral conditions in pregnancy Image: Leah-Anne Thompson /Photos.com

37 Pregnancy Gingivitis

38 38 Pregnancy Granuloma Symptoms Occur in 5% of pregnant women Erythematous, non-painful, smooth or lobulated mass Bleeds easily when touched Usually develops on the gingiva Etiology Develops as a response to local irritation such as poor hygiene or trauma and hormonal changes Treatment Photo: Brad Neville, DDS Observe unless lesions are bleeding excessively, interfere with eating, or do not resolve spontaneously after delivery

39 39 Hyperemesis Gravidarum Gastroesophageal reflux and excessive vomiting (Hyperemesis gravidarum) are both common in pregnancy and can cause enamel erosion Management Rinse with water bicarbonate to reduce acid in mouth immediately after vomiting Avoid brushing too firmly or just following vomiting Photo: John McDowell, DDS

40 Oral Health for Women Pregnancy and Across the Lifespan Dental Treatment in Pregnancy is Safe Objective Counsel patients about the safety of common dental interventions in pregnancy Image: Vicki Reid/Photos.com

41 Treatment Guidelines 41 American Congress of Obstetricians and Gynecologists (ACOG) states A dental checkup early in pregnancy will help ensure that your mouth stays healthy. Pregnant women are at an increased risk for cavities and gum disease

42 42 Dental Treatment Tips First Trimester Care should begin early especially if extensive care is needed Schedule visits in the afternoon to avoid morning sickness Second Trimester Ideal time for dental care The fetus is not large, making it easier for mothers to recline in the dental chair for prolonged periods Organogenesis is complete, reducing fear of harm to the baby (even though dental procedures are safe throughout pregnancy) Third Trimester Position woman slightly on left side with a towel prop to avoid vena cava compression Encourage standing and walking periodically Elevating the head helps avoid shortness of breath

43 43 Dental Radiographs Risks Radiation exposure to the fetus from dental x-rays is so low, it cannot be measured by conventional techniques Procedures X-ray as necessary to make diagnosis Proper radiographic techniques to minimize radiation exposure Utilize lead apron shielding Avoid retakes when possible Use a long cone to focus radiation only on mouth Newer digital X-rays (80% less radiation) Photo: ICOHP

44 Safe Administration of Drugs during the Perinatal Period Dental professionals need to be fully informed about the safe administration of drugs for pregnant women. The FDA developed a classification system to provide therapeutic guidance for use of drugs during pregnancy. Most medications prescribed for common diseases can be used with relative safety (with a few notable exceptions like thalidomide and aspirin) because there have been few adverse drug reports. Refer to the Oral Health for Pregnant Women guidelines for the latest recommendations.

45 45 Common Antibiotics The following antibiotics are appropriate to use during pregnancy: Penicillin Amoxicillin Cephalexin Erythromycin base * Clindamycin * Metronidazole; do not use in first trimester * Appropriate alternative for non-type I penicillin allergic patients

46 46 Common Analgesics The following analgesics are appropriate to use during pregnancy: Acetaminophen Ibuprofen # Oxycodone, Hydocodone & Codeine * # Caution in 1 st trimester; Avoid after 30 weeks * Weigh risk/benefit especially if prolonged use; neonatal withdrawal

47 47 Common Anesthetics The following anesthetics are appropriate for use during pregnancy at standard dental doses: Lidocaine with or without epinephrine Procaine Nitrous Oxide Controversy based on studies of chronic exposure in operating room nurses leading to B12 deficiency before the advent of scavenger systems Dental use of nitrous oxide delivers much smaller, shorter exposures which have not been associated with these problems

48 48 Amalgam Safety Amalgam, the silver colored restoration material used to fill cavities, has received attention as it contains small amounts of mercury Mercury is bound in a stable matrix and the amount released is minimal According to the FDA, the level is "not high enough to cause harm in patients" Studies of amalgam exposure during pregnancy have not documented toxicity, including birth defects, spontaneous abortions, or reductions in fertility Photo: Ellen Eisenberg, DMD

49 49 Preventive Agents The following are appropriate for use during pregnancy at standard dental doses: Fluoride o Inhibits bacteria growth and strengthens enamel o Used topically to prevent dental caries Xylitol Gum o Decreases level of bacteria in saliva and plaque o Selects for less virulent strains of mutans streptococci Chlorhexidine o Used as mouthwash to decrease bacteria o Reduces gingivitis and plaque

50 The Challenge health professionals often do not provide oral health care to pregnant women. At the same time, pregnant women, including some with obvious signs of oral disease, often do not seek or receive care. In many cases, neither pregnant women nor health professionals understand that oral health care is an important component of a healthy pregnancy. (2012)

51 Oral Health for Women Pregnancy and Across the Lifespan What Can We Do? Objectives Promote oral health in pregnant women and newborns Improve dental care access for pregnant women through interprofessional collaboration Image: Image Source/Punchstock

52 The Role of the Dental Professional Assess Oral Health Status Health History Determine Weeks of Gestation Topics to cover: (National Consensus Statement) When and where was your last dental visit? Do you have swollen or bleeding gums, mouth pain, problems eating or chewing, or any other problems in your mouth? Do you have any questions or concerns about getting dental care while you are pregnant? Since becoming pregnant, have you vomited? How often? Have you received prenatal care? If not, do you need help getting an appointment for prenatal care? How many weeks pregnant are you?

53 The Role of the Health Professional Prepare women for healthy pregnancies Provide oral health education and counseling Link women to dental care during the perinatal period Pregnancy is a teachable moment when women are motivated to adopt healthy behavior. (ACOG, Committee Opinion Number 569) Health Professionals include: Family physicians, Obstetricians, Pediatricians Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses Physician Assistants Certified Registered Nurse Midwives Health Educators Women, Infants and Children Program (WIC) Counselors and Nutritionists Early Head Start Health Coordinators Healthy Start Staff Community Health Outreach Workers, Dentists, dental hygienists and dental assistants

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55 55 Providing Optimal Care Screening Evaluate oral health risk history Perform an oral exam Document findings in prenatal record and share with dentist Anticipatory Guidance Brush with soft toothbrush twice daily with fluoride toothpaste Floss daily Limit sugary snacks and drinks to meal times only Chew xylitol gum four to five times per day after eating Establish a dental home for the family Regular dental visits q 6 months (or at dental discretion) Reassure regarding safety of dental treatment during pregnancy

56 Oral Assessment For adults there are a number of factors that contribute to caries risk such as: Visible cavities Many multi surface restorations Exposed root surfaces Deep pits/fissures on teeth Radiographic lesions Visible heavy plaque on teeth Saliva reducing factors (medications/radiation/systemic) Dietary history that includes frequent exposures to carbohydrates and frequent snacking and acidic beverages such as soda. Drug and alcohol abuse (Featherstone, 2007)

57 ADVISE Pregnant Women on the Need for Oral Health Care If the last dental visit took place more than six months ago or if any oral problems (e.g. toothache, bleeding gums) are identified, tell women to schedule an appointment with a dentist as soon as possible. Encourage women to improve or maintain good oral health during pregnancy and to attend prenatal classes. Counsel women to adhere to their dentist s recommendations for treatment or follow-up.

58 Providing Optimal Care 58 Standardize Office Processes Modify prenatal flowchart to include dental screening, advice, and referral Develop a role for office staff in taking risk history, offering advice, and providing referral information Maintain an up-to-date list of local dental providers that see pregnant patients, accept all insurances Use a referral form to improve communication Follow up to ensure dental care occurred Include oral handouts in prenatal packets

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60 Table 1: Strategies for the Medical Professional to Improve Access to Dental Care during Pregnancy (Kumar & Iida, 2008) Strategy Prenatal Classes Health Literacy Activity Integrate a component on oral hygiene and dental care in prenatal classes. Develop oral health education materials at appropriate reading levels. Patient Intake Forms Include an oral health assessment that identifies problems and offers recommendations on patient intake forms. Referral to Dentist Transportation: Counseling Make a referral to a dentist (sample form in Appendix) Assist women in securing transportation for dental care. Assist women in making decisions about dental care.

61 Oral Health for Women Pregnancy and Across the Lifespan Oral Health Issues Across the Life Span for Women Objective Promote and address oral health issues across the life span for women Image: Image Source/Punchstock

62 62 Hormonal Changes and the Mouth Onset of puberty, menses, and oral contraceptives: Can all lead to gingivitis, bleeding gums and discomfort Treatment: Proper hygiene and regular dental visits including cleanings Menopause Gingival atrophy; increased dry mouth; altered taste HRT may improve symptoms, but is not an indication for HRT Image: Simone van den Berg/Photos.com Treatment: Maintain oral hygiene, saliva substitutes, routine dental visits (every 6 months)

63 63 Mouth Pain Oral pain can result from causes other than caries and periodontitis Burning Mouth Syndrome (more prevalent in women) Causes: medications (ACE inhibitors), candidiasis, B12 deficiency, dry mouth Screen for underlying conditions and correct Tricyclic antidepressants and gabapentin can ease symptoms Image: Jaimie Duplass/Photos.com Tooth Erosion GERD and eating disorders should be considered and addressed Temporomandibular Joint (TMJ) pain Consider dental referral for evaluation. Oral Trauma: Screen for domestic violence with tooth/lip trauma

64 HPV Infection Can Cause Cancer Site Male Female Both Sexes Likely Caused by any HPV Type Anus 1,600 3,200 4,800 91% Cervix 0 10,600 10,600 91% Oropharynx 9,600 2,000 11,600 70% Penis % Rectum % Vagina % Vulva 0 2,500 2,500 69% Total 12,100 19,400 31,500 31,500 people a year in U.S. diagnosed with a cancer caused by HPV.

65 Cancer Incidence Rates, SC Site Number of Cases Rate Oral Cavity and Pharynx 3, Anus Rectum 2, Cervix Vagina 79.5 Vulva Penis Total 8,714 Source: DHEC Cancer Registry

66 SC Cancer Mortality Rates, Site Rate Count Oral Cavity and Pharynx Rectum Anus.3 80 Cervix Vagina.3 39 Vulva.5 69 Penis ~ 15 Source: DHEC Cancer Registry

67 Oral Health for Women Pregnancy and Across the Lifespan Take Home Messages Periodontal disease is associated with preterm birth and low birth weight Decreased levels of cariogenic bacteria in mothers is associated with improved child oral health Periodontal therapy during pregnancy does not improve pregnancy outcomes, but is safe in pregnancy Routine dental interventions are safe during pregnancy Health professionals should promote good oral health during pregnancy and throughout the life cycle as oral health affects overall health

68 Current Initiatives Perinatal Infant Oral Health Quality Improvement Statewide evidence-based framework for the integration of oral health assessment and services into existing early childhood and perinatal care systems DHEC Health Regions Expand and strengthen the oral health network Oral Health for Pregnant Women Guidelines State-level recommendations and practice guidelines for medical and dental professionals on the treatment of pregnant women

69 Conclusion Oral health is an essential component of the overall health status for pregnant women and for women across the lifespan. The intent of the Oral Health for Pregnant Women guidelines is to increase the comfort level of health professionals and dental professionals in the oral health care of pregnant women. Pregnant women need to be encouraged to go to the dentist and dental professionals need to make every effort to attend to the unique needs of pregnant patients. It is essential that medical and dental professionals recognize oral health care as a need and a priority area for women who are pregnant or who plan to become pregnant.

70 Photo: Burton Edelstein, DMD

71 Oral Health for Women Pregnancy and Across the Lifespan Questions? Image: Stockebyte/Photos.com

72 Thank you! Contact us with questions and ideas to help us improve oral health in South Carolina! Dr. Ray Lala, Director Division of Oral Health Mary Kenyon Jones, Education and Outreach Specialist