The Importance of Perinatal Oral Health P3

Here you have the opposite.  Don’t be fooled by the chart with little bars.  This graph starts at 80% of the population.  If you look at national data, you can see that in the childbearing age, 20 to 34, almost 85% of women have already had caries experience.  Once you pass 40, 90% of people have had cavities.  So, we all have Streptococcus mutans.

What about that childhood caries?  Again, we want to delay caries and not have caries if possible.  There’s probably some of you out there in the audience that have never had a cavity, but you’re definitely in the minority.  If you’re going to get cavities, the later the better because having caries in baby teeth is the highest risk factor for having caries in your permanent, leading to a lifetime of cavities.  Getting cavities in the baby teeth very young, again, leads to loss of function, failure to thrive, unequal expenditure because a lot of these cases have to be fixed in the hospital in the operating room, and there’s always morbidity associated with treatment or with not getting treatment.  Children have died both while being treated for dental caries because of the sedation or from not having treatment, resulting in abscesses as [30:11] over five years ago.

There are disparities in early childhood prevalence.  Let me decipher this slide for you.  Here, you can see, if you look at 2 to 4 year olds across the United States, percentage of 2 to 4 years olds that have untreated decay.  If you go from left to right, it’s basically 1 out of 5 Caucasian children, 1 out of 4 African-American children, and more than 1 out of 3 Mexican-American children in the United States, ages 2 to 4, already have untreated decay.  If you look at this NHANES survey, the latest one, caries rates actually improved in every other demographic group, seniors, adults, teenagers, elementary school children.  Only in the very youngest, 2 to 4, are the caries rates actually going up from the last survey that was done 10 years prior.

So, when you’re looking at the influence of children’s oral health, you can see that you need a tooth, some bacteria, and some sugar in order for you to get a cavity, but it’s really the whole community and your whole near biological components.  It’s the way, again, because it’s the lifestyle we use.  So, it’s the way that your family, your community, everything influences.

This is why mom becomes such a key component, on multiple levels, because if you have a mom that has high caries rates, you’re probably going to have a child that has high caries rates.  This ties into not just the bacterial piece of it.  Yes, there are genetic.  The genetics of some strains of Streptococcus mutans is more virulent than other strains, and again the transmissibility.  Again, because caries is a multifactorial lifestyle disease.  The influence of diet, what’s give, how it’s given, home care of the teeth, and just in terms of attitudes and beliefs of going to the dentist, the importance of primary teeth in oral health.  They are all really modulated by the primary treatment of the caregiver in the family.  That’s usually mom.

So, again, it makes it doubly important not just for mom’s own health but also for the child.  This is why pregnancy is so unique.  It provides a great opportunity to do a two-for-one.  It really introduces risk reduction and self-management strategies for both mom and the child as well as a chance to stabilize the mom’s periodontal status as well as impact the cycle of Streptococcus mutans transmission by eliminating, lowering Sreptococcus mutans count in the mom from getting treatment while pregnant.

Again, as I stated previously, especially for low income women and at risk populations, sometime when you’re pregnant, you’re going to be in contact with the health care delivery system more frequently than usual through the monthly perinatal.  At that time, the women may be more interested in oral health and how their oral health impacts and influences their babies’ oral health.  They may be more open to have education messages not just on their own oral health but how it’s going to impact the child and, at least here in California (every state is different), in California, that’s really the only time that a woman has more comprehensive dental insurance coverage through Medicaid, when she’s pregnant.  However, again, the flip side of that is in some places that’s actually the only time you can go to the dentist.

There’s research that pregnant women receive dental care less frequently than the general female population, interestingly, regardless of the insurance source.  So, we’re talking about both primary dental insurance and Medicaid populations.  Women will tend to go to the dentist less frequently when they’re pregnant than when they’re not pregnant.  So, again, that speaks to the education that probably needs to happen in the perinatal piece of it to get women to come over to the dental piece while they’re pregnant.

So, we found in all the work that we’ve done at the health center in my county where I work and other health centers throughout the United States that basically you have to have this loop of perinatal part of your organization educating women about the importance of dental care while pregnant.  We will refer them to a group of dentists that is willing to treat them while they’re pregnant, and it just goes around and around.  If you don’t have either piece, you’re not going to be able to make an impact.

So, here’s some resources on perinatal oral health.  Again, this is super [35:36].  The first one is the New York State guidelines that were published in 1996.  The second one is the California oral health perinatal guidelines that were published in 2010, which really gives you the fine clinical procedures that you can do both for the perinatal provider and from the dental, which is what you want to do when you want to treat pregnant women.

There’s actually going to be, probably in about a month, there’s going to be a national consensus statement on perinatal oral health that is going to be released, and this has been three years in the making, a collaboration between HRSA, Bureau of Maternal and Child Health, ACOG, and the American Dental Association.  This is going to be a statement paraphrasing what we are saying today which is that oral health during pregnancy is important and say that your perinatal provider should refer one for dental care, and the dentist should provide dental care while pregnant.  Hopefully that will be the end of any reluctance on either side to rethink that we now improve women and children’s oral health because this is the goal of everything that we’re trying to do and have people be healthy and happy.

So, thank you.



Great, thank you so much.  Thank you so much Dr. Hilton.  We are now going to turn the presentation over to Amy Gagliardi, and Amy?


Amy Gagliardi:

Hi, Jenn. I can hear just fine.  So, welcome everyone.  Morning, afternoon, or evening, depending on your time zone.

So, I’d like to give you just an overview of what we’re going to cover today.  We’re going to look at how periodontal disease might be related to adverse birth outcomes, how maternal oral health is connected to the oral health of their children.  We’re going to look at oral health utilization studies and barriers to care among pregnant women.  Then, I’m going to share an oral health uptake study that we’ve conducted in our workplace, and then, I’ll follow that with recommendations.

I work at Community Health Center, which is a federally qualified health center in Connecticut, and we serve the largest population of Medicaid throughout our state.  We are an NCQA level III health center, and we have multiple interventions, which you can read on the bottom left hand side of our screen.   The medical home status that we have is really pertinent to the type of prenatal care that we deliver, and I just want that as a backdrop to the study that we do.  We have integration of primary medical care, prenatal care, general care, and behavioral health care under one roof.  So, it’s a very interesting place to work and exciting.

So, the American Academy of Pediatric Dentistry has come out with really strong and clear guidelines for mothers and children around oral health care.  They say that all pregnant women should receive oral health care and counseling during pregnancy and that infants should have oral health care and an oral health risk assessment before their first birthday. I know in Connecticut, we have a program called Home by One, and that’s really to capture that second piece of recommendation.

So, periodontal disease and adverse birth outcomes.  There are multiple studies supporting the theory that there is a relationship between periodontal disease during pregnancy and birth outcomes.  However, it’s important to note that the presence of maternal periodontal disease does not always result in adverse birth outcomes.

Now, there was a large randomized control study that suggested that the treatment of periodontal disease did not prevent preterm birth.  However, Dr. Steven Offenbacher who’s done a lot of research in this area strongly suggested that there is a relationship between periodontal disease and poor pregnancy outcomes but that we need to learn to treat the disease better in women before we can understand the systemic implications.  He suggests that perhaps the more intensive treatment approach will impact birth outcomes or perhaps periodontal disease is not a treatable cause of poor birth outcomes or perhaps preterm birth and periodontal disease share an underlying commonality such as an exaggerated inflammatory response.  However, his suggestion was that pregnant women continue to receive exams and treatment.

So, as you can see from the information and research out there, we still have more questions than answers.  So, Jeffcoat’s another researcher.  He’s done a lot of work in this field, and he’s done a lot of studies that suggest that there is a relationship but the relationship between periodontal disease and birth outcomes is a relational one rather than a causal relationship.

There’s some very good studies that suggest that we need some additional studies to explore how that relationship really interacts.  Is it the severity of periodontal disease and the relation of it, and is there a risk not just for preterm birth but for preeclampsia, gestational diabetes, early and late term miscarriage?  So, there’s strong evidence to suggest that the severity and progression of maternal periodontal disease during pregnancy is related to the more severe birth outcomes.

Now, the relationship between maternal and child oral health is more clear cut.  We do know the vertical transmission of Streptococcus mutans between mother and infant.   There is a vertical transmission.  Mothers with high levels of Streptococcus mutans in their saliva is associated with an earlier establishment of bacteria in their children, and that’s important because this early colonization of the bacteria places children at risk for early childhood caries.  So, we know that the prevention of early childhood caries in children begins with the oral health and health education of their moms.  All of us in maternal health care are aware that you can’t really separate the [43:26] from everything that we do in maternal child health.

So, what do we know about oral health utilization during pregnancy?  My colleagues who presented before me both noted that pregnancy is a portal for the health care system and may be the only time in a long time that women have health insurance.  So, even with having health insurance, we know that utilization of oral health during pregnancy is low, and it is especially low for at risk women.

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