1. Veronika N. Stiles University of Michigan School of Dentistry Department of Periodontics and Oral Medicine

2.  Depot Medroxyprogesterone Acetate (DMPA) (Depo Provera)=a progestin-only injectable contraceptive  administered every 3 months  used by 10% of women ages 15-40  Periodontal diseases (PD) are a spectrum of slow progressing chronic bacterial infections that can negatively affect the health of gingival tissues and periodontal supporting structures

3. Association of gingival infections with progression of  Stroke  Coronary heart disease  Low birthweight infants ! Link between oral and systemic health !

4.  Bone mineral density at the hip and spine of DMPA users decreases 0.5%-3.5% after one year use + A 2012 cross-sectional preliminary study (using NHANES data) suggested that DMPA use may be associated with PD  Its main limitation is the cross-sectional nature of the data … therefore…

5.  Therefore, we propose a pioneer prospective cohort study  Objective: to directly test the central hypothesis—>progestin-only contraceptive will increase the incidence of PD in women

6. Kent County Health Department Public Clinics 189 Females ages 15-35 New Depo Provera New Oral Contraceptive Diaphragm or condom user (exposed case)user (exposed case) user (control) (n=63)(n=63)(n=63) TIME Baseline 3mo 6mo 9mo 12mo 15mo 18mo 21mo 24mo Clinical exam Plaque Index Gingival Index *SAME VARIABLES COLLECTED AT EACH TIME POINT* GCF-AST * GCF-ALP* Questionnaire* *Gingival Crevicular Fluid (GCF); Aspartate Aminotransferase (AST) *Gingival Crevicular Fluid (GCF); Alkaline Phosphatase (ALP)

7. 1. To evaluate potential periodontal disease- associated confounders associated with women who select DMPA contraception compared to controls. Working hypothesis: The majority of DMPA users may be females of lower socioeconomic status with already existent risks for increased levels of periodontal diseases.

8. 2. To determine the prevalence and severity of periodontal conditions in women before and after they initiate DMPA hormonal contraception within the first 24 months of use, while controlling for identified confounders (1). Working hypotheses: Women who use DMPA: (a) will have the same baseline prevalence of PD as controls. If any differences are found, we hypothesize that they can be explained by known PD risk factors, and (b) have a greater risk of progression of periodontal disease than controls in the first 24 months of use who attend the Kent County Health Department in Grand Rapids, Michigan, after adjusting for other risk factors and confounding variables, including age, race, poverty income level, dental visit (<2 years), and smoking history.

9. 3. To estimate the prevalence of specific oral health behaviors, including dental care utilization patterns, among women who initiate DMPA use. Working hypothesis: Poor practices of oral health care, dental utilization and detrimental behaviors (e.g., smoking, high alcohol consumption) have a direct negative impact on women’s periodontal health status.

10.  We propose to use prospective cohort study design that will establish proper temporal sequence.  This contribution is significant because it is the first step in a continuum of research that is expected to lead to the determination of the prevalence and severity of PD in women after initiation of DMPA contraception and identification of confounders, as well as specific oral health behaviors that might have a direct negative impact on women’s periodontal health status.

11.  2012 cross-sectional study using NHANES data  Study sample= 4,460 non-pregnant, pre- menopausal females  15-44 years old  All statistical analyses were performed taking into account:  Complex sampling design  Incorporation of sampling weights

13.  65.6% white;  51.4% well-educated;  >57% not married;  27.2% never had a child;  4% DMPA users;  12.1% past users;  1/3-smokers;  59.5% -dental visit in the past 2 years

14.  All demographic factors differed significantly between the three DMPA user groups using a χ 2 test for association (P ≤ 0.003).  Total sample weighted percents in column format.

15. Published in Journal of Periodontology 2012;83:1008-1017. DOI: 10.1902/jop.2012.110534 © 2012 American Academy of Periodontology. All rights reserved. Figure 1. Females, aged 15 to 44 years, who reported ever using DMPA by age and race/ethnicity: 1999 to 2004 NHANES.

18.  P-values are not reported in Table 3

20.  P-values are not reported in Table 4  Once DMPA use and Smoking were defined as ever (current/past) and never  DMPA use X smoking interaction – significant  Summary of interaction term odds- Table 5 (no p-value!)

22. This is the first cross-sectional study to examine DMPA use and PD using multivariable modeling to control for potential confounders that provided additional evidence of an association

23. To better answer the question of association, prospective cohort study design will establish proper temporal sequence using multivariable modeling to control for potential confounders

24. THTH