1 Smiles for Life A National Oral Health Curriculum for Family Medicine STFM Group on Oral Health Module 5 Oral Health and the Pregnant Patient

2 Funders

3 Overall Curriculum  Educational objectives  Four core PowerPoint lecture modules  The relationship of oral to systemic health  Child oral health  Adult oral health  Dental emergencies  Supplementary PowerPoint lecture modules  Oral Health and the Pregnant Patient  Topical fluoride  Test questions  Resources for further learning

4 Acknowledgements  The materials in this module were originally developed in part by:  Washington Interdisciplinary Oral Health Project  Physician Oral Health Education in Kentucky  University of Connecticut  Consultants  OB/GYN- Laura Silk, M.D.  Dentistry- Joanna Douglass, B.D.S., D.D.S.  Steering group editors for Module 5:  Hugh Silk, M.D.  Alan Douglass, M.D.

5 Objectives  Review basic oral anatomy, terminology and performance of oral examination  Understand the effects of oral disease on pregnancy  Identify common oral conditions in the pregnant patient  Understand the effects of common dental interventions such as medications and x-rays in pregnancy  Promote oral health in pregnant women and unborn children

6 Why is Oral Health Important During Pregnancy?

7 Impact of Oral Health on Pregnancy  Associations between periodontal disease, preterm labor and other antenatal conditions  Treatment may reduce this risk, however only  34% of pregnant women visit the dentist  50% of pregnant woman with a dental problem visit the dentist

8 Oral Anatomy, Terminology and Examination

9 Anatomy of a Tooth

10 Gingivitis  Mildest form of periodontal disease  Mild gum swelling, tenderness, erythema  Gums bleed during brushing  30-75% of pregnant women  Reversible  Etiologies  Plaque  Local disease  Pregnancy  Hormonal changes  Gum trauma

11 Periodontal Disease  Etiology:  Chronic plaque at gumline Plus  Bacterial infection Plus  Host inflammatory response  Causes destruction of supporting bone and eventual tooth loss

12 Caries  A bacterial disease of teeth  Bacteria metabolize dietary sugars to produce acid which de-mineralizes and eventually destroys teeth

13 Oral Disease Risk Factors  Low socioeconomic status  Poor oral hygiene habits  History of cavities  Lack of routine dental visits  Poor access to dental and/or medical care  Non-fluoridated community water  High sugar-containing diet  Medications that contain sugar or cause xerostomia (antidepressants, antihistamines, asthma inhalers, syrups)  Emotional or physical disabilities

14 Adult Oral Examination  Observation  Teeth  Soft and hard tissues  External structures  Lateral borders and undersurface of tongue  Posterior pharynx  Palpation  Floor of mouth  Neck

15 Effects of Oral Disease on Pregnancy

16 Periodontal Disease and Preterm Labor  Maternal periodontal disease is associated with increased risk of preterm labor  Anaerobic oral gram- negative bacteria cause inflammatory response  Inflammatory response stimulates prostaglandin and cytokine production to stimulate labor

17 Management of Periodontal Disease in Pregnancy  Small studies demonstrate that deep root scaling reduces PTL  These studies account for confounding variables  One study that added metronidazole found a reversal of the benefit of cleaning

18 Periodontal Disease and Low Birth Weight  Periodontal disease is associated with low birth weight  Evidence is not conclusive as most studies explored PTL concurrently  Biochemical mechanism similar cascade as in preterm labor leading to placental blood flow restriction and necrosis

19 Periodontal Disease and Preeclampsia  Emerging data  Mechanism unclear  Proposed mechanism:  Periodontal infection leads to inflammatory vascular damage  Triggers cell damage in placenta

20 Maternal Caries Increases Newborn Caries Risk  No direct in utero transmission  Mothers with high bacteria counts transmit bacteria to children:  Kissing babies on mouth  Tasting food/licking spoon  Moms should be dentally healthy before delivery  Parents also pass on poor hygiene habits

21 Other Common Oral Conditions in Pregnancy

22 Candidiasis  AKA Thrush  Wipes off  Usually asymptomatic, but may burn  Treatment topical or systemic antifungals

23 Pregnancy Granuloma  5% of pregnant women  Rapidly growing mass  Triggers: bacteria, irritants, hormones  Erythematous, non- painful, smooth or lobulated; bleeds easily  Common on gingiva  Management:  Reassurance, observation  Excision  Can recur

24 Other Oral Conditions in Pregnancy  Dry mouth  Excessive salivation  Tooth erosions associated with severe GERD or hyperemesis

25 Pregnancy Myths  “A mother loses a tooth for every baby”  No evidence that aphthous ulcers are any more common in pregnancy

26 Dental Treatment in Pregnancy

27 Dental Procedures  No U.S. guidelines for treatment in pregnancy  Routine cleaning is safe in any trimester  Delay intensive treatments requiring anesthetics, medications until second trimester  If treatment is indicated – abscess, trauma, extraction, endodontics - proceed  Care may be easier to complete before delivery

28 Treatment Timing  First Trimester  Spontaneous miscarriages naturally occur more often in 1st trimester  Avoid elective treatment that can be delayed  Offer anticipatory guidance  Second Trimester  The optimal time for dental treatment  Organogenesis complete, fetus not large  Easier to prevent than treat established disease  Third Trimester  Late in term very uncomfortable (short visits)  Position slightly on left side

29 Risks of Dental X-Rays  X-ray only if necessary (i.e. root canal therapy, trauma)  When x-rays are indicated, radiation exposure is extremely low  Exposure can be limited by:  Lead apron shielding  Modern fast film  Avoiding retakes

30 Medication Safety in Pregnancy  A = Controlled Studies in women fail to demonstrate a risk to the fetus in the first trimester and the possibility of fetal harm appears remote  B = Animal studies show no risk, or if risk shown in animals, controlled trials in women showed no risk  C = Studies in animals with adverse effects and no human studies, OR no animal or human studies, but benefits of use may outweigh potential harms  D = There is evidence of human fetal risk, but benefits may outweigh risks  X = Contraindicated

31 Common Antibiotics  To treat oral abscess or cellulitis  Penicillin (B)  Amoxicillin (B)  Cephalexin (B)  Erythromycin base* (B)  Clindamycin (B)

32 Common Analgesics  Acetaminophen (B)  Ibuprofen (B/D*)  Oxycodone (B/D*)  Hydrocodone and codeine (C/D*) *avoid in third trimester

33 Common Anesthetics  Lidocaine (B)  Procaine (C)  Nitrous Oxide  No rating, use is controversial  Possible increased rate of spontaneous miscarriage

34 Common Preventives  Fluoride  No increased risk during pregnancy  Xylitol  No studies; no harm reported  Chlorhexidine  No increased risk during pregnancy

35 What You Can Do …

36 Screening  Evaluate oral health risk history  Perform a screening oral exam  Counsel patients to have caries and periodontal disease treated before they become pregnant

37 Referral  Encourage all prenatal patients to see their dentist early in pregnancy  Refer those at high risk or with oral lesions, caries, or periodontal disease  Deep periodontal cleaning and scaling may reduce the risk of pre-term labor and low birth weight

38 Anticipatory Guidance  Promote good daily oral hygiene:  Brush with soft toothbrush twice daily with fluoridated toothpaste  Floss daily  Regular dental visits  Limit sugary snacks and drinks

39 Benefits for Child  Promoting good oral hygiene in mother reduces caries risk for child  Improved maternal oral hygiene habits may be passed to child  Getting mother a dentist establishes a “dental home” for the family

40 Postpartum Interventions  Remind mother to discuss oral health with her child’s doctor  Recommend brushing once child’s first tooth erupts at 4-6 months  Recommend holding infant during feeds  Promote “breast is best” for teeth too  High risk moms – make dental referral. Consider xylitol gum postpartum

41 Take Home Messages  Periodontal disease is associated with worsened pregnancy outcomes  Periodontal therapy is associated with improved pregnancy outcomes  Decreasing maternal caries is associated with improved child oral health  Routine dental visits are safe during pregnancy and should be recommended  Physicians should promote oral health before, during, and after pregnancy

42 Questions?

43 Photo Credits  Brad Neville, D.D.S.  Robert C. Henry, D.M.D., M.P.H.  Joanna Douglass, B.D.S., D.D.S.  Physician Oral Health Education in Kentucky  American Academy of Family Physicians Home Study Program  Hugh Silk, M.D.