1. 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

2. 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.

3. 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.”

4. 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

5. 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

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

8. 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

9. 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!

10. 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

11. 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.

12. 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

13. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

28. Clinical Considerations

29. 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

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

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

32. 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

33. 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

34. 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

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

36. 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.

37. 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.

38. 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

39. 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.

40. Indian Health Service Periodontal Disease Quick Screening Tool

42. Visual Clinical Assessment

43. Visual Clinical Assessment

44. Visual Clinical Assessment

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

46. Myths about Dental Care During Pregnancy of Dentists

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

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

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

50. 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

51. 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.

52. 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.

53. 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

54. Drugs that can be Prescribed and Those that are Contraindicated
During Pregnancy
Source:
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

55. 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

56. 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

57. 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)

58. 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):
Offenbacher et al., Ann Periodontol 1998:3(1)

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

60. Resources and References
Surgeon Generals Report on Oral Health -
Health Disparities Chronic Care Model
Periodontal Infection and Preterm Birth: Results of a Prospective Study . Obstetrical & Gynecological Survey. 57(1):5-6, January 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.

61. Resources and References
HRSA Programs
National Maternal and Child Health Resource Centers
Jay Anderson