Chemung CountyChemung CountyPerinatal Dental CoalitionPerinatal Dental Coalition During 2006,2007 & 2008 During 2006,2007 & 2008

Thomas R. Curran DDSThomas R. Curran DDS

Retired Oral Maxillofacial Retired Oral Maxillofacial SurgeonSurgeon

Thursday May 20, 2010Thursday May 20, 2010Community Health - Access to Oral Community Health - Access to Oral

HealthHealth

Oral HealthOral Health

DuringDuring

PregnancyPregnancy

AndAnd

Early ChildhoodEarly Childhood

Evidence Based GuidelnesEvidence Based Guidelnes

►New York State DOH August 2006New York State DOH August 2006

www.health.state.ny.us/publication/0824.pdfwww.health.state.ny.us/publication/0824.pdf

Oral Health Care during Pregnancy and Early Oral Health Care during Pregnancy and Early ChildhoodChildhood

► California Dental Foundation February 2010California Dental Foundation February 2010

www.cdafoundation.org/learn/perinatal_oral_hwww.cdafoundation.org/learn/perinatal_oral_healthealth

Oral Health During Pregnancy & Early Oral Health During Pregnancy & Early ChildhoodChildhood

Healthy Mothers, Healthy Babies Healthy Mothers, Healthy Babies CoalitionCoalition

“ “Oral health care during pregnancy is Oral health care during pregnancy is crucial and should be available to all crucial and should be available to all woman, regardless of income level. The woman, regardless of income level. The Coalition is committed to working with Coalition is committed to working with dental and other health care providers to dental and other health care providers to increase awareness of and support increase awareness of and support research on the research on the possible linkpossible link between between periodontal disease and preterm, low periodontal disease and preterm, low birth weight babies.” June, birth weight babies.” June, 20012001

Statistics Statistics

►USA: 4.12 million live birthsUSA: 4.12 million live births►NY State: 253,001 live birthsNY State: 253,001 live births

►Chemung County 1000 live birthsChemung County 1000 live births►Over 50% of the mothers are on MedicaidOver 50% of the mothers are on Medicaid►80 to 85 of the newborns are premature 80 to 85 of the newborns are premature

and/or have low birth weight (less than and/or have low birth weight (less than 37 weeks gestation and/or 2500 grams) 37 weeks gestation and/or 2500 grams)

Premature & Low weight Premature & Low weight birthsbirths

► Incidence unchanged in past 40 years Incidence unchanged in past 40 years ►Nationally PT 11% & LBW 7.7%Nationally PT 11% & LBW 7.7%►NY State ranks 20th for premature birthsNY State ranks 20th for premature births

►PT births = 75% of neonatal mortality and PT births = 75% of neonatal mortality and 50% of neurologic impairments in children50% of neurologic impairments in children

►PT births = 35% of money spent for infants PT births = 35% of money spent for infants and 10% of money spent for childrenand 10% of money spent for children

Systematic ReviewSystematic Review►28 (47) Studies on PT/LBW & Periodontitis 28 (47) Studies on PT/LBW & Periodontitis ►18 Studies suggested an association of 18 Studies suggested an association of

PT/LBW with Periodontal Disease.PT/LBW with Periodontal Disease.►1996 & 1998 1996 & 1998 Offenbacker et alOffenbacker et al nearly 8 nearly 8

times risk of PT/LBW with moderate to times risk of PT/LBW with moderate to severe periodontal disease of the mother.severe periodontal disease of the mother.

►1998 1998 DasanayakeDasanayake Odds Ratio 3 times Odds Ratio 3 times►2004 2004 DevineDevine Odds Ratio nearly 3 times Odds Ratio nearly 3 times ►2005 2005 KhaderKhader Odds Ratio 4 times Odds Ratio 4 times

Maternal Periodontitis and Maternal Periodontitis and Prematurity.Part 1Prematurity.Part 1Offenbacker et al. Ann Periodontology Offenbacker et al. Ann Periodontology Dec ‘01Dec ‘01► Very Premature and very low birth weightVery Premature and very low birth weight relative to periodontal healthrelative to periodontal health

Very Premature <28 wks Very LBW <1500gVery Premature <28 wks Very LBW <1500gHealthy 25% 1.1% 0%Healthy 25% 1.1% 0%Mild 69.5% 3.5% 6.1%Mild 69.5% 3.5% 6.1%M-S 5.5% 11% 11.4%____________M-S 5.5% 11% 11.4%____________

► The 5.5% M-S Perio = 9.6% Premature/LBWThe 5.5% M-S Perio = 9.6% Premature/LBWWhich is >37 wks and >2500gWhich is >37 wks and >2500g

Offenbacker et al. Part 1 Offenbacker et al. Part 1 continuedcontinued

The progression of periodontal disease The progression of periodontal disease during pregnancy (+2mm in 4 or more during pregnancy (+2mm in 4 or more sites) in seen in 28.8% of women.sites) in seen in 28.8% of women.

In this subset, there is a 14% increase of In this subset, there is a 14% increase of premature deliveriespremature deliveries

With Incidence/Progression 21% LBWWith Incidence/Progression 21% LBW

Without Progression 11% LBWWithout Progression 11% LBW

Biological ModelBiological ModelGram negative bacteriaGram negative bacteria

causescausesRising Prostaglandins, Interleukins and Rising Prostaglandins, Interleukins and

tumor necrosis factortumor necrosis factor + specific genotype+ specific genotype

Critical levels of the chemical mediatorsCritical levels of the chemical mediators

Endotoxins pass to the Fetal-Placental unit Endotoxins pass to the Fetal-Placental unit causing premature laborcausing premature labor

Periodontal Disease & PreeclampsiaPeriodontal Disease & Preeclampsia

►Women with severe periodontal disease at delivery Women with severe periodontal disease at delivery or progression of periodontal disease during or progression of periodontal disease during pregnancy had a higher risk of preeclampsia.pregnancy had a higher risk of preeclampsia.

► At delivery – odds ratio 2.4At delivery – odds ratio 2.4► Progression during pregnancy- odds ratio 2.1Progression during pregnancy- odds ratio 2.1

Boggess et al 2003 Boggess et al 2003

--------------------------------------------------------------------------------------------------------------------------------► Periodontal disease – odds ratio 3.47Periodontal disease – odds ratio 3.47

Canaki 2004Canaki 2004

Lopez et al in Santiago, ChileLopez et al in Santiago, Chile

Rx Chlorhexidine(11% alc) + Periodontal Rx Chlorhexidine(11% alc) + Periodontal care <28wk = rate of PT/LBW was 2.5%care <28wk = rate of PT/LBW was 2.5%

Same treatment only after delivery, the Same treatment only after delivery, the rate of PT/LBW was 8.6%rate of PT/LBW was 8.6%

Reported in J Perio Nov ‘05 with 400 Reported in J Perio Nov ‘05 with 400 women randomly assigned to one or women randomly assigned to one or other group other group

Jeffcoat et al in the USAJeffcoat et al in the USA

►Rx in second trimester = Premature Rx in second trimester = Premature birthsbirths

►Control group (no treatment) = 6.3%Control group (no treatment) = 6.3%

►Dental prophylaxis + placebo = 4.9%Dental prophylaxis + placebo = 4.9%►Periodontal Rx + antibiotics = 3.3%Periodontal Rx + antibiotics = 3.3%►Periodontal Rx + placebo = 0.8%Periodontal Rx + placebo = 0.8%

Reported J Perio 2003Reported J Perio 2003

Michalowicz et al. NE Journal of Med. Michalowicz et al. NE Journal of Med. Nov. ‘06Nov. ‘06

Multicenter (4) study in USAMulticenter (4) study in USA► Rx group 413 Control group 410Rx group 413 Control group 410► PT births 12% Control 12.8%PT births 12% Control 12.8%► Birth wt. 3239 gm. Control 3258 gm.Birth wt. 3239 gm. Control 3258 gm.

Conclusion: Improved Periodontal status but not Conclusion: Improved Periodontal status but not pregnancy outcomes (PT/LBW).pregnancy outcomes (PT/LBW).

NB. Less spontaneous abortions 5/14NB. Less spontaneous abortions 5/14 51 control patients received peiodontal 51 control patients received peiodontal

care because they showed progression care because they showed progression of periodontal disease (3mm inc. in of periodontal disease (3mm inc. in pocket)pocket)

Maternal Oral Health Resource Maternal Oral Health Resource GuideGuide

This booklet is available fromThis booklet is available fromNational Maternal and Child Oral Health National Maternal and Child Oral Health

Resource CenterResource CenterGeorgetown UniversityGeorgetown UniversityBox 571272Box 571272Washington, DC 20057-1272Washington, DC 20057-1272Phone 202 784-9771 orPhone 202 784-9771 orE-mail info@mchoralhealth.orgE-mail info@mchoralhealth.org

Practice GuidelinesPractice Guidelines

►Oral Health Care during Pregnancy and Oral Health Care during Pregnancy and Early ChildhoodEarly Childhood

NYS Department of HealthNYS Department of Health

August 2006August 2006►Oral Health During Pregnancy and Oral Health During Pregnancy and

Early ChildhoodEarly Childhood

California HealthCare FoundationCalifornia HealthCare Foundation

February 2010February 2010

How does PDC operate in Chemung How does PDC operate in Chemung County?County?

► Pregnant woman is seen in OB office or Pregnant woman is seen in OB office or OB agency - - - signs HIPA consent & is OB agency - - - signs HIPA consent & is referred to private dentist or dental clinicreferred to private dentist or dental clinic

► Dental hygienist does a standardized test Dental hygienist does a standardized test and periodontal care before delivery. and periodontal care before delivery. Referred for smoking cessation PRNReferred for smoking cessation PRN

► After delivery, the woman referred back After delivery, the woman referred back to DDS for PSR evaluation and to DDS for PSR evaluation and treatment. Hygienist advises on care of treatment. Hygienist advises on care of newborn. newborn.

What are the results after 1 yearWhat are the results after 1 year

►565 or 56.5% of the mothers referred for 565 or 56.5% of the mothers referred for periodontal care.periodontal care.

►23% of the 565 received periodontal care.23% of the 565 received periodontal care.►75 received care in the county dental clinic75 received care in the county dental clinic►50 received care at their private dentist.50 received care at their private dentist.►Starting in July 2007 mothers were seen Starting in July 2007 mothers were seen

postpartum and referred for periodontal Rxpostpartum and referred for periodontal Rx►Clinic patients were called after July, ’07.Clinic patients were called after July, ’07.

Oral & Dental Problems Associated Oral & Dental Problems Associated with Pregnancy (a teachable with Pregnancy (a teachable moment)moment)►Dental CariesDental Caries►ErosionErosion►Pregnancy Gingivitis(& oral Pregnancy Gingivitis(& oral

contraceptive)contraceptive)►EpulisEpulis►Tooth MobilityTooth Mobility►Dental Considerations in LaborDental Considerations in LaborAlready covered periodontal disease and Already covered periodontal disease and

the the possible link possible link to PT/LBW.to PT/LBW.

Dental Caries during pregnancyDental Caries during pregnancy

►““Calcium demand causes a loss of teeth Calcium demand causes a loss of teeth during pregnancy”. during pregnancy”. Not True.Not True.

► In reality, any increase in tooth decay In reality, any increase in tooth decay during pregnancy can be attributed to during pregnancy can be attributed to diet and poor oral hygienediet and poor oral hygiene

►A contributing factor can be the A contributing factor can be the repeated acid attacks with vomiting repeated acid attacks with vomiting early and regurgitation later in early and regurgitation later in pregnancypregnancy

Increased risks for tooth decay in Increased risks for tooth decay in pregnancypregnancy

►Food cravings during pregnancy.Food cravings during pregnancy.►High sugar snacks especially in 1High sugar snacks especially in 1stst

trimester in an attempt to prevent trimester in an attempt to prevent nausea.nausea.

►Gingival bleeding during pregnancy is Gingival bleeding during pregnancy is an excuse to decrease oral hygiene.an excuse to decrease oral hygiene.

►Erosion – vomiting (acid) in pregnancy Erosion – vomiting (acid) in pregnancy can cause dental erosion which makes can cause dental erosion which makes the teeth more subject to decay.the teeth more subject to decay.

Because pregnant women are at higher Because pregnant women are at higher risk for dental decay consider the risk for dental decay consider the

following:following: ►Brush teeth BID with Fluoride Brush teeth BID with Fluoride

toothpastetoothpaste►Floss once a dayFloss once a day►Use fluoridated water or fluoride rinse Use fluoridated water or fluoride rinse ►Chlorhexidene rinse BIDChlorhexidene rinse BID►Xylitol chewing gum after mealsXylitol chewing gum after meals►Complete restorations NOW. Use of Complete restorations NOW. Use of

amalgam, composites & glass-ionomer amalgam, composites & glass-ionomer OK Consider use of rubber dam OK Consider use of rubber dam removal of amalgam restorations.removal of amalgam restorations.

How to avoid dental erosion in How to avoid dental erosion in pregnancypregnancy

►After vomiting, rinse with 1 tsp of After vomiting, rinse with 1 tsp of baking soda in a cup of water.baking soda in a cup of water.

►Regular use of a neutral fluoride Regular use of a neutral fluoride mouthwash bid.mouthwash bid.

►Firm tooth brushing immediately after Firm tooth brushing immediately after vomiting should be avoided to reduce vomiting should be avoided to reduce the risk of dental abrasion. the risk of dental abrasion.

Pregnancy EpulisPregnancy Epulis

►Usually resolve after deliveryUsually resolve after delivery►Occasionally require excision after Occasionally require excision after

deliverydelivery

Dental problems in labor & deliveryDental problems in labor & delivery

►Severe periodontal problems may cause Severe periodontal problems may cause increased tooth mobility. This can be increased tooth mobility. This can be problem during anesthesia for a C-problem during anesthesia for a C-section.section.

►Loose fillings, unstable bridge work and Loose fillings, unstable bridge work and ill fitting removable partial dentures are ill fitting removable partial dentures are all candidates for aspiration.all candidates for aspiration.

►All of these are good reasons for the All of these are good reasons for the pregnant woman to seek dental care. pregnant woman to seek dental care.

Dental Care During PregnancyDental Care During Pregnancy

►Dental Care is safe and appropriate Dental Care is safe and appropriate during pregnancy.during pregnancy.

►Needed dental treatment can be Needed dental treatment can be provided throughout pregnancy. The provided throughout pregnancy. The ideal time is between 14ideal time is between 14thth to 20 to 20thth weeks. weeks.

►Even necessary dental x-rays can be Even necessary dental x-rays can be taken using the proper abdominal and taken using the proper abdominal and neck shield.neck shield.

►Extensive elective dental care can be Extensive elective dental care can be deferred. deferred.

Antepartum Dental Radiography and Antepartum Dental Radiography and Infant Low Birth Weight JAMA April Infant Low Birth Weight JAMA April

28, 200428, 2004 Exposure >0.4 mGy to central thyroid glandExposure >0.4 mGy to central thyroid gland

Mother Infant # >0.4 mGy No XraysMother Infant # >0.4 mGy No Xrays

1,117 LBW1,117 LBW 21 or 1.9% 89% 21 or 1.9% 89%

336 TLBW 10 or 3% 85%336 TLBW 10 or 3% 85%

4500 NBW4500 NBW 45 or 1% 45 or 1% 89% 89%

Conclusion: Dental Xrays during Conclusion: Dental Xrays during pregnancy are associated with LBW pregnancy are associated with LBW specifically TLBW.specifically TLBW.

All of this is based on >0.4 mGy to the All of this is based on >0.4 mGy to the central portion of the thyroid gland.central portion of the thyroid gland.

RememberRemember►1 periapical is 0.08 mGy1 periapical is 0.08 mGy►4 bitewings are 0.22 mGy4 bitewings are 0.22 mGy►1 Panorex is 0.12 mGy1 Panorex is 0.12 mGy

Questions about dental care?Questions about dental care?

►Periodontal care should be priority.Periodontal care should be priority.►Pain & swelling should be resolved.Pain & swelling should be resolved.►Dental x-rays with shielding can be doneDental x-rays with shielding can be done►Local anesthesia with epinephrine is safeLocal anesthesia with epinephrine is safe►Dental restorations are appropriateDental restorations are appropriate►The pregnant woman should lean or be The pregnant woman should lean or be

propped toward her left side and in a propped toward her left side and in a semi sitting position. It allows for venous semi sitting position. It allows for venous return.return.

Drugs during pregnancyDrugs during pregnancy

UseableUseable ► Antibiotics - Penicillin, Amoxicillin, Antibiotics - Penicillin, Amoxicillin,

Cephalosporin, Clindomycin, chlorhexidine Cephalosporin, Clindomycin, chlorhexidine mouthwashmouthwash

► Analgesics – Acetaminophen, Codeine, Analgesics – Acetaminophen, Codeine, Hydrocodone, Morphine Hydrocodone, Morphine

UnacceptableUnacceptable► Antibiotics – Tetracyclines, Quinolones, Antibiotics – Tetracyclines, Quinolones,

ClarithomycinClarithomycin► Analgesic – Aspirin & NSAIDS (Ibuprofen)Analgesic – Aspirin & NSAIDS (Ibuprofen)►Hypnotics – Valium or Versed and barbituratesHypnotics – Valium or Versed and barbiturates

Postpartum dental care of mother & Postpartum dental care of mother & infantinfant

► In the Perinatal Dental Coalition, the last In the Perinatal Dental Coalition, the last visit of the mother is the 1visit of the mother is the 1stst for the infant. for the infant.

►Who is responsible for advice on the oral Who is responsible for advice on the oral care of the infant 0 – 3 years?care of the infant 0 – 3 years?

►The average infant has 11 well-child visits.The average infant has 11 well-child visits.►28% of children 2-5 yrs. of age have decay28% of children 2-5 yrs. of age have decay► In NYS each yr. 2900 children <6 years old In NYS each yr. 2900 children <6 years old

require hospital care for dental cariesrequire hospital care for dental caries

Early childhood dental careEarly childhood dental care

►ECC or Early Childhood Caries is a ECC or Early Childhood Caries is a virulent form of decay caused by Strep virulent form of decay caused by Strep mutans mutans from an adult.from an adult. Bottles or sippy Bottles or sippy cups provide the substrate. Use only cups provide the substrate. Use only H2O.H2O.

►Saliva sharing habits should be avoided.Saliva sharing habits should be avoided.►Wipe infants teeth after eating with soft Wipe infants teeth after eating with soft

cloth or toothbrush up to age 2.cloth or toothbrush up to age 2.►Young children 2-6 need supervised Young children 2-6 need supervised

tooth brushing. Fluoride toothpaste = to tooth brushing. Fluoride toothpaste = to the size of pinky nail. the size of pinky nail.

Fluoride for children Fluoride for children

►Best source – municipal water at 1 ppmBest source – municipal water at 1 ppm►Only if necessary – Fluoride supplementsOnly if necessary – Fluoride supplementsTest H2O = <0.3 ppm then 0 up to 6 mo, Test H2O = <0.3 ppm then 0 up to 6 mo,

then .25 mg to age 3, then .50 mg to age then .25 mg to age 3, then .50 mg to age 66

and 1 mg from age 6 to 16.and 1 mg from age 6 to 16.If water 0.3 to 0.6 ppm it is 0 up to age 3, If water 0.3 to 0.6 ppm it is 0 up to age 3, .25 mg to age 6 and 0.5 mg from 6-16 years.25 mg to age 6 and 0.5 mg from 6-16 yearsNo F supplements if H20 > 0.6 ppmNo F supplements if H20 > 0.6 ppm

Daily Fluoride IntakeDaily Fluoride Intake

► Age Adequate Intake Tolerable IntakeAge Adequate Intake Tolerable Intake

0-6 months 0.01 mg/day 0.7 mg/day 0-6 months 0.01 mg/day 0.7 mg/day

7-12 months 0.5 mg/day 0.9 mg/day7-12 months 0.5 mg/day 0.9 mg/day

Using 1 ppm of fluoridated water for dilutionUsing 1 ppm of fluoridated water for dilution

Age Liquid Formula Powdered Age Liquid Formula Powdered FormulaFormula

0-6 months 0.5 mg/day 1 mg/day0-6 months 0.5 mg/day 1 mg/day

7-12 months 0.5 mg/day 1 mg/day7-12 months 0.5 mg/day 1 mg/day

Do You Have Any Questions?Do You Have Any Questions?

AcknowledgementsAcknowledgements►Jayanth Kumar, DDS, MPHJayanth Kumar, DDS, MPH

NYSDOH Bureau of Dental HealthNYSDOH Bureau of Dental Health

Director of Surveillance & Director of Surveillance & ResearchResearch

►Sangeeta Gajendra, DDS, MPHSangeeta Gajendra, DDS, MPH

U of R Eastman Dental CenterU of R Eastman Dental Center

Spontaneous Abortion or Spontaneous Abortion or MiscarriageMiscarriage

►15 to 25% of pregnancies lost < 20 15 to 25% of pregnancies lost < 20 wks.wks.

►Not really preventableNot really preventable►No evidence that is related to dental No evidence that is related to dental

procedures done in the first trimesterprocedures done in the first trimester

►Pregnancy is NOT pathological. It is a Pregnancy is NOT pathological. It is a normal physiologic statenormal physiologic state

Preterm Birth 11% in USAPreterm Birth 11% in USA

►No improvement in the past 40 yearsNo improvement in the past 40 years►Associated with gram neg. infectionsAssociated with gram neg. infections►33% of cases have premature rupture 33% of cases have premature rupture

of the membranesof the membranes►Periodontal Rx safe but no reduction in Periodontal Rx safe but no reduction in

Preterm births as note by Micholowicz Preterm births as note by Micholowicz in Nov. 2006, Offenbacker in Sept. in Nov. 2006, Offenbacker in Sept. 2009 and Jeffcoat later in 20092009 and Jeffcoat later in 2009

PreeclampsiaPreeclampsia

►Bl. Press. >140/90 plus proteinurea. Bl. Press. >140/90 plus proteinurea. Seen after 20 weeks in 3-7% of Seen after 20 weeks in 3-7% of pregnancies pregnancies

►Cause unknown. Higher prevalence with Cause unknown. Higher prevalence with peridontitis. Tolerate dental careperidontitis. Tolerate dental care

►SEVERE PREECLAMPSIA BP >160/110 & SEVERE PREECLAMPSIA BP >160/110 & >5gm of protienurea in 24 hrs. HELLP >5gm of protienurea in 24 hrs. HELLP Treatment is delivery with careful Treatment is delivery with careful management. management.

GDM or Gestational Diabetes GDM or Gestational Diabetes MellitusMellitus

►3-7% of all pregnancies. Associated with 3-7% of all pregnancies. Associated with obesity. Results in Macrosomia. More C-obesity. Results in Macrosomia. More C-sectionssections

►Do they test their blood sugar?Do they test their blood sugar?►Like all diabetics - - - make sure they Like all diabetics - - - make sure they

cover their insulin or insulin stimulating cover their insulin or insulin stimulating medication. Timing is important.medication. Timing is important.