June 3, :00 1:30 PM (Central)

Transcription

1 June 3, :00 1:30 PM (Central) Supported in part by Grant No. UC4MC21534 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. These slides and their content is not to be reproduced without permission from the AAP. 1

2 The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAP designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity is acceptable for a maximum of 1.50 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics. The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit from organizations accredited by ACCME. Physician assistants may receive a maximum of 1.50 hours of Category 1 credit for completing this program. This program is accredited for 1.50 NAPNAP CE contact hours of which 0 contain pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners (NAPNAP) Continuing Education Guidelines. 2

3 Jayanth Kumar, DDS, MPH Dr Kumar is the Director, Bureau of Dental Health, New York State Department of Health and Associate Professor at the School of Public Health, University at Albany. He also directs the New York State Dental Public Health Residency Program. Dr. Kumar is a board certified specialist in dental public health and a former director and president of The American Board of Dental Public Health. Renee Samelson, MD, MPH, FACOG - Dr Samelson is a Professor of Obstetrics and Gynecology at Albany Medical College in the Division of Maternal Fetal Medicine. She has board certification in OB-GYN and Preventive Medicine/Public Health with sub-specialty boards in Maternal-Fetal Medicine. She was the co-editor of Oral Health Care during Pregnancy and Early Childhood Clinical Practice Guidelines and served as a member of the Institute of Medicine Committee on Oral Health Access to Services which published Improving Access to Oral Health Care for Vulnerable and Underserved Populations, She participated in the panel that developed the national consensus statement. 3

4 Melissa Moore-Sanchez, CIC From Bothell, Washington, Melissa Sanchez began her professional liability insurance career as a medical malpractice claims representative; working with hospitals, medical professionals and defense attorneys. She then went to work for a prominent Pacific Northwest medical and dental malpractice carrier for 17 years as a senior marketing representative. Currently she is the Manager for Northwest Dentists Insurance Company, providing professional liability insurance and risk management services to dentists in the northwest. Russel Maier, MD From Yakima, Washington, Dr Maier is a family physician and program director of Central Washington Family Medicine Residency training doctors to practice in rural and underserved settings. He is a clinical professor in the Department of Family Medicine at the University of Washington, co-chair of Society for Teachers of Family Medicine s Group on Oral Health, and is immediate past chair of the board of Washington Dental Service Foundation. His interest and expertise in oral health come from leading a successful fluoridation campaign, implementing a novel national oral health curriculum for physicians in training, and working to integrate the oral and medical healthcare system in Washington and nationally. 4

5 All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities. *Commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Name / Role Relevant Financial Relationshi p (Please indicate Yes or No) Name of Commercial Interest(s)* Please list name(s) of entity AND Nature of Relevant Financial Relationship(s) (Please list: Research Grant, Speaker s Bureau, Stock/Bonds excluding mutual funds, Consultant, Other -iidentify) Disclosure of Off-Label (Unapproved)/Investigational Uses of Products AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or demonstrate pharmaceuticals and/or medical devices that are not approved by the FDA and/or medical or surgical procedures that involve an unapproved or off-label use of an approved device or pharmaceutical. (Do intend to discuss or Do not intend to discuss) Katrina Holt, RD/Plannig No N/A Do not intend to discuss Group Pamella Vodicka, No N/A Do not intend to discuss RD/Planning Group Rani Gereige, No N/A Do not intend to discuss MD/Planning Group Rose Tan, MD/Planning No N/A Do not intend to discuss Group Sheila Strock, No N/A Do not intend to discuss DMD/Planning Group Francisco Ramos-Gomez, No N/A Do not intend to discuss DDS, MS Ngozi Onyema/Staff No N/A Do not intend to discuss Lauren Barone/Staff No N/A Do not intend to discuss Renee Samelson, No N/A Do not intend to discuss MD/Faculty Melissa Moore-Sanchez, No N/A Do not intend to discuss CLC/Faculty Jayanth Kumar, No N/A Do not intend to discuss DDS/Faculty Russel Maier, MD/ Faculty No N/A Do intend to discuss fluoride varnish use.

6 Following the Webinar the learner will: Know his/her role as it pertains to caring for a pregnant woman s oral health. Be able to identify community resources to help address pregnant women s oral health care. Be able to counsel a pregnant woman about her oral health care needs. Understand the importance of oral health during pregnancy. Understand that dental care during pregnancy is safe and necessary. Learn the key concepts around prevention, disease management, and treatment as well as how to work with other health care providers to care for pregnant women. 6

7 Jayanth Kumar, DDS, MPH Director, Bureau of Dental Health New York State Department of Health Associate Professor, School of Public Health University at Albany 7

8 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. 8

9 Recognize the importance of oral health during pregnancy and in early childhood Discuss management of dental care during pregnancy Describe the effect of maternal oral health on pregnancy outcomes Learn to incorporate oral health into prenatal care 9

10 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. 10

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12 Pregnancy may affect oral health Infants acquire caries causing bacteria from care givers Studies suggest an association between periodontal disease and adverse pregnancy outcomes 12

13 Pregnancy Gingivitis Pregnancy Epulis Increased Tooth Mobility Dental Caries Erosion Dental Problems in relation to Labor and Delivery 13

14 Selected Oral Health Indicators in the United States, Bruce A. Dye,; Xianfen Li, M.S.; and Eugenio D. Beltrán-Aguilar. NCHS Data Brief No. 96 May

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16 2 cm foot ulcer- smaller than the ulcerated epithelium within infected periodontal pockets Source: Douglass AB, Gonsalves W, Maier R, Silk H, Stevens N, Tysinger JW, Wrightson AS. Smiles for Life: A National Oral Health Curriculum for Family Medicine. Society of Teachers of Family Medicine

17 New York State excluding New York City,

18 New York State excluding New York City, 2006 and

19 Perception that dental care is not important Financial issues Availability of dentists Fear of dental treatment Concerns about harm to fetus Lack of practice guidelines 19

20 Erroneous perception of effect of dental x- rays Use of materials like mercury Use of medication Perception of patient discomfort 20

21 Medical concerns during pregnancy: Nausea & vomiting Hypertension Gestational diabetes Hypoxia Aspiration Heparin use for Thrombophilia Restrictions on medications 21

22 Provide emergency or acute care any time during pregnancy Develop a comprehensive plan Discuss benefits and risks of treatment and alternatives Consult as necessary Co-morbid conditions that may affect management Use of nitrous oxide, intravenous sedation or general anesthesia Use standard practice Keep patients comfortable in chair Keep head higher than feet Use x-rays appropriately Follow recommendations for medication 22

23 Renee Samelson, MD, MPH, FACOG Professor, Department of Obstetrics & Gynecology Albany Medical College 23

24 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. 24

25 Infection and inflammation etiology for 25% of preterm births Usually subclinical with histologic evidence of inflammation Muglia LJ, Katz M. Enigma of spontaneous preterm birth. N Engl J Med. 2010;362:6: Wikipedia. Accessed 6 May

26 Inflammation may reflect early activation of normal parturition OR Inflammation may indicate local or systemic infection caused by anaerobes, genital mycoplasmas, other low virulent organisms OR Preterm labor may be the result of a shift in the bacterial ecosystem of the vagina Novel mechanisms of chronic infection and host systemic responses that may resist antibiotics have been identified 26

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28 All studies reported that routine non-surgical periodontal therapy, dental care, including use of topical or local anesthesia, has NOT been associated with adverse pregnancy outcomes. Periodontal treatment during pregnancy did not significantly decrease rate of preterm delivery. MOTOR, OPT, PIPS 28

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32 Pregnancy is a unique period characterized by physiological changes, which may adversely affect oral health. Oral health is key to overall health and wellbeing. Preventive, diagnostic, and restorative dental treatment is safe throughout pregnancy. 32

33 Retrospective cohort study of 23,441 women enrolled in Aetna delivered Compared rates of LBW and PTB among 5 groups with respect to timing and type of dental treatment. Women who received preventive dental care had better birth outcomes than did those who received no treatment (p<.001). No evidence of increased odds of adverse birth outcomes from dental or periodontal treatment. Am J Public Health. 33

34 Ob-gyns largely recognize the importance of receiving routine dental care during pregnancy and agree that treatment of periodontal disease has a positive impact on pregnancy outcome. Despite this, the majority does not ask about oral health, does not provide patients with information about oral care, does not advise all pregnant patients to receive routine dental care, and does not ask pregnant patients if they have seen a dentist in the past 12 months. Many Ob-gyns had not previously thought about advising patients to see a dentist. This suggests that encouraging Ob-gyns to advise patients about the importance of oral health during pregnancy might be well received. Morgan et al. J Matern Fetal Neonatal Med

35 Delivered a live birth in 2009 Included both Medicaid Managed Care (MMC) and Fee For Service (FFS) Medicaid Sample: MMC FFS- 123 Information source: prenatal/postpartum care records 10 months prior to and 6 weeks post delivery NYSDOH data Includes data from multiple prenatal providers for a pregnancy where available 35

36 Performance Category % 51-75% 0 50% Percent

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38 Assess pregnant women s oral health status. Advise pregnant women about oral health care. Work in collaboration with oral health professionals. Provide support services (case management) to pregnant women. Improve health services in the community. 38

39 Assess Pregnant Women s Oral Health Status Take oral health history. Check mouth for problems (eg, swollen or bleeding gums, untreated dental decay, mucosal lesions, signs of infection, or trauma). Document findings in the medical record. 39

40 Advise Pregnant Women About Oral Health Care Reassure women that oral health care is safe throughout pregnancy. Advise women about scheduling appointment with a dentist. Provide referral, if needed. Encourage women to seek oral health care, practice good oral hygiene, eat healthy foods, and attend prenatal classes during pregnancy. Counsel women to follow oral health professionals recommendations. 40

41 Work in Collaboration with Oral Health Professionals Establish relationships with oral health professionals in the community Develop a formal referral process Share pertinent information about pregnant women Coordinate care 41

42 Provide Support Services (Case Management) to Pregnant Women Help pregnant women complete applications for insurance and other coverage, social services, or other needs. If woman does not have a dental home, explain importance of oral health during pregnancy and help her obtain care. 42

43 Improve Health Services in the Community Include questions about oral heath on the prenatal patient-intake form. Establish partnerships with community-based programs. Provide a referral to a nutrition professional if counseling would help. Integrate oral health topics into prenatal classes. Provide culturally and linguistically appropriate care. 43

44 Tips for Good Oral Health During Pregnancy and After the Baby Is Born Get oral health care. Practice good oral hygiene. Eat healthy foods. Practice other healthy behaviors. Take care of her mouth and her baby s mouth after the baby is born. 44

45 This patient may have routine dental evaluation and care, including but not limited to: Oral health examination Dental x-ray with abdominal and neck lead shield Dental prophylaxis Local anesthetic with epinephrine Scaling and root planing Root canal Extraction Restorations (amalgam or composite) filling cavities Patient may have: (Check all that apply) Acetaminophen with codeine for pain control Alternative pain control medication: (Specify) Penicillin Amoxicillin Clindamycin Cephalosporins Erythromycin (Not estolate form) 45

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47 American College of Obstetrics and Gynecology (ACOG) to publish committee opinion: Oral Health During Pregnancy and Beyond Written by the Committee on Obstetric Practice and Committee on Health Care for Underserved Women 47

48 Health Resources and Service Administration (HRSA) primary Federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable is developing inter-professional oral health core clinical competencies Incorporation of oral health into programs to improve outcomes. Healthy Babies are Worth the Weight - Kentucky State of Michigan s Infant Mortality Reduction Plan 48

49 Oral health and dental treatment during pregnancy and early childhood is important. Oral diseases may adversely affect pregnancy. Early childhood caries is a preventable infectious disease. Oral health should be incorporated into prenatal care and well child visits. 49

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51 KJ was a 17 year old AA G1 who came for scheduled prenatal visit at 14 weeks gestation. She told her OB provider that two of her teeth were loose and she wondered whether that was because of the pregnancy. The OB provider arranged for her to be seen at the dental clinic that day. The OB provider received a call from the dentist; she explained that the loose teeth were the result of trauma, something that the OB provider had not considered. On further questioning, KJ revealed that she was the victim of DV at the hands of her boyfriend. The dentist referred her to the domestic violence hotline after providing appropriate dental care. In addition, the OB provider agreed to administer appropriate tetanus prophylaxis. 51

52 Melissa Moore Sanchez, CIC 52

53 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. 53

54 Which is correct? a) Dental care performed during pregnancy should be limited to routine care only; invasive, restorative or elective procedures should be avoided. b) Non-emergency dental treatment should only be given in the second trimester of pregnancy. c) If a pregnant patient requires treatment, it should be postponed until either after the second trimester or after the baby is born. 54

55 Pregnancy is not a reason to defer routine dental care or treatment of oral health problems. Oral Health Care During Pregnancy: A National Consensus Statement, 2012 CDAF Evidence-Based Guidelines,

56 If a dentist is deferring care because the patient is pregnant, they may be setting themselves up for a greater risk of exposure to a malpractice claim than if they had simply treated the patient. 56

57 If a dentist defers care because of pregnancy: Patient care may be delayed Patient may receive no treatment Existing issues go untreated potentially exacerbating the problem 57

58 Dental malpractice claim: Pregnancy is not a disease The standard of care is to treat Pregnancy will not make a good defense for deferring care 58

59 Historically there have been very few, if any, meritorious professional liability claims made due to dental treatment rendered during pregnancy. 59

60 Evidence Based Guidelines: Women can and should be treated during all phases of pregnancy Invasive, elective, restorative procedures are permissible during all trimesters We recommend avoiding extraction of nonproblematic 3 rd molars during 1 st and 3 rd trimester High risk patients coordinate care with prenatal care provider Oral Health Care During Pregnancy: A National Consensus Statement, 2012 CDAF Evidence-Based Guidelines,

61 The standard of care applies to you too! Oral health history Oral exam Refer Coordinate care with dentist Document!!! Oral Health Care During Pregnancy: A National Consensus Statement, 2012 CDAF Evidence-Based Guidelines,

62 Patient symptoms could be oral health related when diagnosing Discuss any high-risk concerns with the dentist Patients planning pregnancy should already be seeing a dentist Document your discussion Oral Health Care During Pregnancy: A National Consensus Statement, 2012 CDAF Evidence-Based Guidelines,

63 Should informed written consent be obtained from all pregnant women prior to any dental treatment? 63

64 The provider has the responsibility to inform and educate a patient of proposed treatment and obtain consent from the patient for that treatment 64

65 Procedure to be performed Alternatives to the procedure including no treatment at all Risks involved with the treatment, and/or delaying or avoiding treatment Questions opportunity to answer any that a patient may have 65

66 P-A-R-Q Procedure, Alternatives, Risks, Questions Use procedure-specific forms Document consent process and educational materials given to patient If possible, have a staff member present 66

67 The provider has an obligation to advise the patient of the ideal treatment plan, not just the ones the patient can afford or is covered by insurance or managed care contract If patient rejects treatment plan because of cost, chart it with quotation if possible 67

68 Inform patient of risks and consequences Document the chart Require the patient to sign informed refusal form 68

69 CA Evidence-Based Guidelines, 2010: Prevention, diagnosis and treatment of oral diseases, including needed dental radiographs and use of local anesthesia, are highly beneficial and can be undertaken during pregnancy with no additional fetal or maternal risk when compared to the risk of not providing care. CDAF Evidence-Based Guidelines,

70 Melissa Moore Sanchez, CIC 503/ Northwest Dentists Insurance Company (NORDIC) 70

71 Russel Maier, MD 71

72 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do intend to discuss an unapproved/investigative use of a commercial product/device (fluoride varnish for caries prevention) in my presentation. 72

73 A 23 year old female presents with nausea, breast tenderness, fatigue, and two missed periods. Her initial exam is fairly unremarkable, except for slightly swollen gums and a brown spot on her top right canine tooth. Her laboratory studies confirm her pregnancy. What do you do next? 73

74 Conduct an oral exam Provide patient education Advise patient to practice good oral hygiene (brush, floss) Encourage her to eat healthy foods low in sugar and carbohydrates drink fluoridated water instead of sugary beverages Discourage frequent snacking Address bacteria transmission between mother and baby; relationship of mother s oral health to baby s 74

75 Counsel patient about importance and safety of dental care during pregnancy Reassure that dental treatment radiographs, pain medication, and anesthesia is safe throughout pregnancy Answer questions, alleviate concerns Apply fluoride varnish Refer to dental care Refer to dentist who treats pregnant patients and sees them in a timely manner Provide patient with dentist s contact information, discuss insurance status/medicaid coverage if it includes dental Assist her in making an appointment if necessary 75

76 32 year old G3 P1 at 26 weeks is seen for an acute visit. She's been running a low grade temperature and noted increased Braxton-hicks contractions. Other than feeling poorly, with intermittent, irregular contractions, she complains of facial pain. On exam her vitals are unremarkable, as is her exam, except for being gravid with size consistent with dates, her left cheek is obviously swollen, slightly erythematous, with a grossly swollen gum and an abnormal looking tooth. What do you do next? 76

77 Counsel patient about the importance of treating an acute infection during pregnancy Explain that infections of the mouth or body can pose significant risk to baby and must be treated Reassure that dental treatment radiographs, pain medication, and anesthesia is safe throughout pregnancy Answer questions, alleviate concerns Refer to dental care for urgent treatment Refer to dentist who treats pregnant patients and sees them in a timely manner Provide patient with dentist s contact information, discuss insurance status/medicaid coverage if it includes dental Assist her in making a same day or next day appointment 77

78 Consult with dentist Call dentist to discuss observed symptoms, pertinent health information, and treatment options If needed, consult about medications, anesthesia, other Follow up with dentist and patient after dental visit to insure infection resolved 78

79 A Baby! Vertically Transmitted Infectious Disease Early Childhood caries Best Nutrition Breastfeeding First Visit by Age 1 Establishment of a dental home 79

80 Smiles for Life Curriculum Oral Health and the Pregnant Patient (Module 5): Washington Dental Service Foundation: /Prenatal.aspx National Maternal and Child Oral Health Resource Center New York State Department of Health Oral Health Care During Pregnancy and Early Childhood Guidelines ly_childhood.htm CA Dental Association Foundation 2010 Evidence-Based Guidelines for Health Professionals: Oral Health During Pregnancy and Early Childhood 80

81 OUR MISSION: To improve the health trajectory of every woman, fetus and child by engaging providers to deliver comprehensive and essential preventive oral health services during pregnancy.

82 ACOG, ADA, MCHB s National Consensus Statement: Fs/Oralhealthpregnancycons ensusmeetingsummary.pdf Single or multiple print copies are available at no charge and can be ordered online at org/order. For pregnant women tips for good oral health: /OralHealthPregnancyHandou t.pdf 82

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84 For additional information on the topics discussed in this webinar: Visit Following the Webinar you will receive an with a link to the post-survey. You must complete this survey to be eligible for continuing education credit. 84