Health Disparities Oral Health Pilot Presentation Jay R. Anderson, DMD, MHSA Chief Dental Officer, Division of Clinical Quality Bureau of Primary Health Care Health Resources and Services Administration Mary E. Foley, RDH, MPH Project Director, Improving Perinatal and Infant Oral Health Children's Dental Health Project

HRSA Vision for Oral Health To improve the nation’s health by assuring access to comprehensive, culturally competent, quality oral health care for all, as an integral component of comprehensive health care.

The Surgeon General’s Report “Oral health is essential to the general health and well-being of all Americans and… improved oral health can be achieved by all Americans… Great progress has been made in reducing the extent and severity of common oral diseases …however, not everyone is experiencing the same degree of improvement.”

Current Trends Among Pregnant Women in Dental Service Utilization Generally poor dental service utilization Limited or lack of dental insurance Perceived need for services diminished Lack of medical and dental provider referral* Dental provider uncertainty due to gaps in evidence-based SOC* Tendency to postpone treatment

Goals Integrate oral health into primary health care services Expand the availability of dental care for pregnant women Increase awareness among the general public about the importance of oral health care for pregnant women, new mothers, infants and toddlers

What oral diseases affect [pregnant] women? Dental disease - tooth decay Periodontal disease Gingivitis Pregnancy Gingivitis Periodontitis Periodontosis

Dental Disease – Dental Caries NOT Synonymous with cavities Ongoing Disease PROCESS (similar to diabetes) Cavities: RESULT or Outcome of untreated dental caries Process: demineralization <-> remineralization Multifactorial Primary cariogenic organisms Strep mutans Lactobacilli

Dental Caries Management Microorganisms colonize Once organisms are established, ongoing infectious disease (process) must be managed by balancing risk factors with protective factors Dental caries can exist when no obvious cavities are present Only through continuous disease management can we prevent new cavities and the need for restorative (surgical) services Individual risk assessment is KEY! One size fits all protocols don’t work anymore!

Dental Caries Risk Factors High SM levels Frequent ingestion of fermentable carbohydrates Limited access to fluoride Compromised salivary flow Protective Factors Chlorhexidine* Access to fluoride* Fluoridation F Dentifrice 2x daily F Mouthrinse Xylitol Routine professional dental care Daily oral hygiene

This series of diagrams illustrates the progress of tooth decay. Moving from left to right we see how the tooth is attacked. Destruction involves the enamel first, then the dentin, and if unchecked finally the pulp tissue. Here the tooth has abscessed as a result of bacterial infection of the pulp. The end result of untreated caries is complete loss of the tooth.

How can dental caries in a new mother affect her young child? Dental caries is an infectious disease where SM microorganisms are passed from mother to child Infectivity potentially begins with eruption of the first tooth Therefore… Interventions should be aimed at minimizing the level of microorganisms in the mother and breaking the route of transmission to the child Oral health education and anticipatory guidance must include information on the need for ongoing balancing of risk and protective factors All primary care visits should include education and AG

Periodontal Disease Oral infection Caused by anaerobic bacteria in the plaque bio-film that forms on dental surfaces Gingivitis – Inflammation and infection of the gums Periodontitis- Inflammation and infection of gums and bone These bacteria have the potential to colonize sub-gingival plaque and generate by-products that directly injure tissue and elicit inflammatory or immune responses

Facts about Pre-term Birth and Low Birth Weight In the United States, 12% of newborns are born low birth weight LBW is defined as < 2500 g 25% of preterm low birth weight cases occur without any known risk factors PTB is defined as < 37 weeks gestation The number of low birth weight babies increased 6% between 1985 and 1993 Each year, more than $5 billion dollars are spent for the health care of low birth weight children Low birth weight is related to 60% of infant mortality

Facts about Pre-term Birth and Low Birth Weight While efforts to rescue low birth weight infants are excellent, efforts to prevent low birth weight or preterm births have generally been unsuccessful African American infants are twice as likely as infants of nearly all other ethnic/racial groups in America to be born low birth weight and to be born preterm

Risk Factors for Pre-term, Low Birth Weight Infants (PLBW) Age Low SES Hypertension GTI Diabetes Multiple pregnancies Inadequate prenatal care Drugs, alcohol and tobacco abuse African American ancestry 25% unknown

What’s the link? Researchers are focusing on the possibility that periodontal infections interfere with normal physiological regulation of labor and delivery Throughout pregnancy, levels of prostaglandins and cytokines steadily increase until a critical threshold level is reached inducing labor, cervical dilation and delivery Offenbacher, et al., Annals of Periodontology, 1998

What’s the link? The bacteria associated with periodontal disease are capable of stimulating excessive production of cytokines and prostaglandins, potentially initiating pre-term labor and delivery. Offenbacher, et al., Annals of Periodontology, 1998

Literature Review 1994-1995 Offenbacher (animal studies) 1996 Offenbacher (case control study) 1998 Offenbacher (case-control study) 1999 Offenbacher (case-control-laboratory) 2001 Jeffcoat (prospective study) 2002 Madianos meta analysis

Jeffcoat Study Design Three Treatment Groups Double blind, randomized assignment to one of three treatment groups Dental Prophylaxis + placebo pill Scaling and root planing + placebo pill Scaling and root planing + metronidazole 2002

Study Patient Population 22 weeks of gestation Signed informed consent Willing to participate in OB and dental portions of study No medical contraindication to participation Not participating in another clinical trial

Incidence of Preterm Births at Less Than 37 Weeks 13.7% Reference group with periodontitis 8.9% Prophylaxis + Placebo 4.0% Scaling and root planing + Placebo 12.5% Scaling and root planing + Metronidazole

Incidence of Preterm Birth Relative to the Reference Group (preterm birth at less than 37 weeks) Ref=Reference group with periodontitis; Pl=Placebo; Met=Metronidazole incidence relative to reference group

Results Periodontal treatment appeared to reduce the incidence of preterm birth in study subjects Scaling and root planing provided the greatest reduction in the incidence of preterm birth *This study represents a trend – a potential association which suggests the need for further research to prove causality

Additional Studies – Evidence Needed MOTOR and O??? Studies due for completion in 2006 Large study populations, multi-site

Clinical Considerations

Overview of Pregnancy Complex physiological and psychological changes Hormonal effects cause changes in nearly all organs and systems Oral cavity is no exception Numerous oral conditions and diseases Myths about oral conditions and Tx services Dental service utilization poor Clinical guidelines and policies sparse

Oral Conditions and Diseases Enamel Erosion Dental Caries* Pregnancy Gingivitis* Periodontal Disease*

Enamel Erosion Vomiting Palatal surfaces of maxillary teeth Thermal sensitivity Dentin exposure Recommended Therapy Avoid tooth brushing Use of neutral NaF mouthrinse

Dental Caries in Pregnant Women All pregnant women are at risk Risk is no greater than that of non-pregnant women Food cravings may increase desire for sugar-sweetened foods and beverages Risk Factors include: Frequent ingestion of fermentable carbohydrates Presence of SM Compromised salivary flow Limited fluoride

Pregnancy Gingivitis Inflammation of gums Redness, swelling, heat and pain Caused by plaque, bacteria on tooth surfaces adjacent the gum tissue Commonly observed in second trimester due to rise in estrogen levels in blood Preventable with 2x daily brushing with F tooth paste and flossing

Periodontal Disease All pregnant women are at risk Risk is no greater than for women who are not pregnant Gram-negative anaerobic bacteria Infection and inflammation of soft tissues >> gingivitis Progression to hard tissue: periodontitis Bone loss >>tooth mobility >>potential premature tooth loss

AHRQ Guidelines American Academy of Periodontology Parameter on systemic conditions affected by periodontal diseases. J Periodontol 2000 May;71(5 Suppl):880-3. [47 references]

AHRQ: Periodontal Treatment Consideration for Pregnant Women Diagnosis of the patient's periodontal condition. Consideration of consultation with patient's physician to advise of the presence of periodontal infection and proposed treatment. Consideration of gestational period; status of pregnancy; and risk factors for periodontitis which may influence pregnancy outcomes. Education of the patient regarding the possible impact of periodontal infection on pregnancy outcomes. Periodontal therapy and patient motivation to establish and maintain periodontal health.

AHRQ MAJOR RECOMMENDATIONS Diagnosis Patient Evaluation A comprehensive periodontal evaluation should be performed as described in the “Parameter on Comprehensive Periodontal Examination”. The medical history should be evaluated for existing systemic diseases or conditions, medications, and risk factors for systemic diseases. Other health care providers may be consulted as indicated by the patient's systemic health status, periodontal condition, and proposed treatment. Any consultation should be documented.

Therapeutic Goals The therapeutic goals are to diagnose periodontal infections which may impact on the patient's systemic health; to inform the patient of possible interactions between the patient's periodontal disease and systemic condition; and to establish periodontal health which may minimize potential negative influences of periodontal infections. Research and clinical experience indicate that periodontal infections may have an impact on the following diseases or conditions: Diabetes mellitus Pregnancy Cardiovascular diseases

Outcomes Assessment The desired outcome of therapy is to prevent adverse systemic consequences of existing periodontal infection via: Knowledge of the patient's medical history and systemic status, the periodontal condition, and the possible interactions between oral and systemic health or disease Reduction of clinically detectable plaque and periodontal pathogens to a level compatible with periodontal health. Reduction of clinical signs of gingival inflammation Reduction of probing depths Stabilization or gain of clinical attachment Control of acute periodontal infections Addressing the risk factors for periodontal disease as they affect the systemic condition.

Indian Health Service Periodontal Disease Quick Screening Tool

Visual Clinical Assessment

Visual Clinical Assessment

Visual Clinical Assessment

Oral Health Myths of Pregnant Women Unborn child robs the mother of her calcium Osteoporosis Tooth loss for every pregnancy

Myths about Dental Care During Pregnancy of Dentists

Patient Management Considerations First Trimester Most fetal organ development occurs at this time Increased fatigue Syncope Postural hypotension Nausea and vomiting

Patient Management Considerations Second Trimester Symptoms dissipate Moderate comfort level Development of fetal dentition Susceptibility to tetracycline

Patient Management Considerations Third Trimester Increased fatigue Increased physical discomfort Mild depression

Professional Dental Care Regular dental visits should be continued throughout pregnancy A complete health and dental history should be taken to determine the general health of the pregnant woman Minimal health assessments at each visit should include: Blood Pressure Pulse Respiration

Timetable for the Management of Oral Health during Pregnancy 1st Trimester: Treatment may need to be limited due to morning sickness. Considerations for first trimester should be observed. Dental care may include Phase 1 dental care services. Dental providers and pregnant women should consult prenatal care providers about the use of anesthetics and medications. 2nd Trimester: Traditionally dental care is administered during this time. Considerations for second trimester should be observed. Dental care may include Phase 1 dental care services. Dental providers and pregnant women should consult prenatal care providers about the use of antibiotic, anesthetics and other medications. 3rd Trimester: Considerations for third trimester should be observed. Dental care may include Phase 1 dental care services. Dental providers and pregnant women should consult prenatal care providers about the use of antibiotic, anesthetics and other medications.Treatment may be impeded due to increased physical discomfort.

NUTRITION Effect on fetal tooth development Primary tooth development begins between the second and third month of pregnancy, and permanent teeth begin to form several months before birth.  A well-balanced diet with enough protein, calcium, phosphorus, and vitamins (especially A, C, and D) is recommended. Vitamin A helps to develop the tooth enamel Vitamin C is important in the formation of dentin Vitamin D aids in the absorption of calcium and phosphorus.  A very low intake of these nutrients can result in malformation of the mouth and in the development of teeth that are more likely to decay.

Use of Radiographs No established professional clinical guidelines ADA: Decision of the examining dentist based on individual patient risk assessment Only when essential Observe safety: High speed films Filtration Collimation Lead aprons* Routine radiographs (BWX and FMX) should be avoided

Drugs that can be Prescribed and Those that are Contraindicated During Pregnancy Source: www.agd.org/consumer/topics/pregnancy/main.html Drugs that can be prescribed during pregnancy Drugs that are Contraindicated during pregnancy Antibiotics: Penecillin, Cephalosporins, Amoxicillin, Clindamycin, Erythtomycin (except estole form) Tetracyclines, Doxycyclines, Erythromycin estolate form Analgesics: Acetaminophen, Acetaminophen with codeine (in small doses) Aspirin, Difunisl, Etodolac

Take Home Message Pregnant women should establish and maintain oral health for own benefit and for the oral health of her child; Dental caries should be managed during pregnancy; Restorative treatment can be safely performed on pregnant women There is no known downside risk of addressing inflammatory periodontal disease in pregnant women There is a potential upside benefit to acting on the association And the upside benefit can significantly prevent ECC in children

A Framework for Action Targets National, State, Local Partnerships Federal agencies States Grantmakers Professions Academics Business Public Strategies Change Perceptions of Oral Health Accelerate Building and Use of Science Build Effective Health Infrastructure Remove Barriers to Oral Health Services

Policy Development Develop policies to incorporate oral health screening into Ob-Gyn visits Develop programs to train non-dental and dental providers on important issues for pregnant women State Medicaid coverage to include dental services for pregnant women: examination dental prophylaxis; scaling and root planing CHX and fluoride therapies (prevention services)

References Gaffield et al., Trends 2002 Jeffcoat et al., JADA 2001:131 Jeffcoat, et al., J Periodontol 2003 Krejci et al., Clinical Practice 2002 Madianos et al., Obstetics, 58:7 Madianos et al., J Periodontology Supplement, 29:3, 2002 McGaw, JCDA 2002 Offenbacher, et al., J Periodontol 1996: 67(Suppl):1103-13. Offenbacher et al., Ann Periodontol 1998:3(1)233-50.

Resources and References American Academy of Periodontology. Parameter on periodontitis associated with systemic conditions. J Periodontol 2000 May;71(5 Suppl):876-9. http://www.ngc.gov/ AHRQ National Guideline Clearinghouse Oral Health and Pregnancy: A Review, JKumar, SGajendra, NYSDJ, January 2004

Resources and References Surgeon Generals Report on Oral Health - http://www.nidr.nih.gov/sgr/oralhealth.asp Health Disparities Chronic Care Model http://www.healthdisparities.net/about_chronic.html Periodontal Infection and Preterm Birth: Results of a Prospective Study . Obstetrical & Gynecological Survey. 57(1):5-6, January 2002. Jeffcoat, Marjorie K.; Geurs, Nico C.; Reddy, Michael S.; Cliver, Suzanne P.; Goldenberg, Robert L.; Hauth, John C. Offenbacher S, Katz V, Fertik G, et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103–1113.

Resources and References HRSA Programs http://www.hrsa.gov National Maternal and Child Health Resource Centers http://www.mchoralhealth.org Jay Anderson JAnderson@HRSA.GOV