Transcript Primary Care Management of Oral Health in Pregnancy

Primary Care Management of
Oral Health in Pregnancy
Goals for this Session
• Show why oral health is a priority for primary
care’s pregnancy management.
• Review key structures of the mouth and the
disease processes that affect them.
• Outline a set of primary care actions shown to be
effective in protecting and improving oral health
and overall health.
• Introduce a framework for incorporating oral
health actions into primary care practice.
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Oral Health Fits in Primary Care
• Preventable infectious disease.
• Common problem.
• Serious health impact.
• Patient and family behavior (self-care) is key.
• Early recognition and treatment reduces
the impact.
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Oral Health As a Key
Element of Pregnancy
Management
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Two Preventable Infectious Diseases
• Caries:
• Pain, abscess, tooth loss, and high costs.
• Transmission to baby soon after delivery.
• Periodontal disease:
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Premature birth.
Pain, high costs, and tooth loss.
Increases risk of diabetes.
Accelerates cardiovascular disease.
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Prevalence
There are over six million
pregnancies each year in the United
States in women between the ages
of 15 and 44.
Active tooth decay
• Nearly one in four women of reproductive
age in the U.S. has active tooth decay.
• Tooth decay is the single most common
disease of childhood.
Photo: Dr. Bea Gandara, Univ. of WA
Periodontal disease
• Can be detected in 37–46% of women of
reproductive age and in up to 30% of
pregnant women.
Photo: Robert Henry, DMD, MPH
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Caries: Maternal-Child Linkage
Mothers/primary caregivers are the main source
of the bacteria responsible for causing caries.
How are the bacteria transmitted?
• Normal essential behavior, including kissing
and playing with baby.
• Via saliva contact such as tasting food, licking
spoons, or pacifiers.
Mutans Streptococci
Upstream prevention
• If colonization is delayed until after two years
of age, children have less dental decay.
• Optimizing mothers’ oral health prevents
caries in young children.
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Current Unacceptable Outcomes
• 30–40% of pregnant women have some form of
periodontal disease.
• > 50% of women receive no dental care
(including cleaning) during pregnancy.
• This is directly related to income level.
• Hispanic and African-American women are only
half as likely to get their teeth cleaned during
pregnancy.
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Barriers to Care
Personal barriers
Dental barriers
• Finding a dentist.
• Getting to a dentist.
• Poor understanding
of oral health
importance.
• Uncertainty that
x-rays and dental
treatments, e.g.,
fillings, lidocaine, and
nitrous oxide, are
safe.
• Lack of dental training.
• Past teaching to avoid
dental care in
pregnancy.
• Unsubstantiated
liability concerns.
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ACOG Recommendations
• Oral health assessment should be done at first
prenatal visit.
• Dental x-rays (with proper shielding) are safe
during pregnancy.
• Treatments, e.g., fillings, root canals, cleaning,
and extractions, are safe. They may and should
be done at any time during pregnancy.
• Stomach acid can be neutralized by rinsing
mouth with baking soda solution and using
oral antacids.
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The Overview
• Goal: Dramatic reduction in caries and
periodontal disease in pregnant women.
• Strategy: Extend preventive care in partnership
with dentistry with systematic primary care
screening for:
• Risk factors coupled with risk reduction action.
• Oral disease coupled with referral for treatment.
• Tactic: Oral Health Delivery Framework.
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Extending the Reach of Oral Healthcare
Pregnant Women
Receiving Regular
Prenatal Care
Pregnant Women
Receiving Regular
Dental Care
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Oral Health Delivery Framework
Five actions primary care teams can take to protect and promote
their patients’ oral health. Within the scope of practice for primary
care, possible to implement in diverse practice settings.
Preventive interventions: Fluoride therapy, dietary counseling to protect teeth and
gums, oral hygiene training, therapy for substance use,
medication changes to address dry mouth.
Citation: Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential Component of Primary Care.
Seattle, WA: Qualis Health; June 2015
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Primary Care’s Role in Oral Health
The Oral Health Screening
Assessment: Ask and Look
Decide and Act
• Identify risk factors:
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Adjust medication list.
Fluoride for caries risk.
Printed education material.
Coaching.
• Identify signs of disease:
• Referral to dentistry.
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Oral Health Screening in Primary Care
Risk assessment
Identifying high-risk patients:
• Tobacco use
• Diabetes
• No recent dental care
• Poor oral hygiene
• High dietary sugar content
• Frequent snacking
• Inadequate fluoride
• Meds affecting saliva
Case finding
Detecting signs of disease:
• Gums
• Gingival inflammation
• Epulis
• Periodontitis
• Teeth
• Loose teeth
• Erosion
• Caries
Treatment: Referral,
in-clinic therapy
Treatment: Reduce risk
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Oral Structures and
Oral Disease
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The Healthy Mouth
Photo: UKCD, Robert Henry DMD, MPH
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Saliva
Teeth
Gums
Oral mucosa
Tongue
Photo: UKCD, Robert Henry DMD, MPH
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The Primary Threat Is Bacterial
Infection
Teeth and/or gums
Bacteria
UKCD, Robert Henry DMD, MPH
Substrate:
carbohydrate
Over time
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Saliva
• Secretion: Autonomic
nerve stimulation
• Components:
• Antimicrobial proteins
• High calcium concentration
• Role:
• Physical barrier, lubrication, and cleansing
• pH buffer for acid: food, bacteria, and
gastric reflux
• Remineralization
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The Salivary Glands
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Saliva Repairs Enamel
• Demineralization
• Acid dissolves enamel.
• pH drops with eating and drinking
(except water).
• Stimulation of bacterial growth by sugar.
• Acid in food and beverages.
• Remineralization
• Saliva restores pH balance and remineralizes
enamel between meals/snacks.
• Time is required for remineralization.
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Saliva: The Protective Balance
Protective Factors
Saliva
Peptides (defensins)
Oral hygiene
Prudent diet
Fluoride
No Caries
Pathologic Factors
Acid-producing bacteria
e.g., Strep mutans
Frequent carbohydrates
Reduced saliva
Caries
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Remineralization Takes Time
Regular Meals
Regular Meals
Plus Frequent
Snacks
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Medications Causing Oral Dryness
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Diuretics
Antihistamines
Antipsychotics
Antidepressants
ADD medications
Anti-anxiety medications
Anticholinergics
Proton pump inhibitors
Many others
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Drugs That Cause Oral Dryness
Caffeine
Alcohol
Amphetamines
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Assessing for Oral Dryness
• Ask
• Dry mouth.
• Not enough saliva.
• Look
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Dry-appearing mucosa and tongue.
Enlargement of the parotid glands.
Tongue blade sticking to oral mucosa.
Lack of saliva pooling under the tongue.
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Loss of Protective Saliva
• Patient’s experience:
• Mouth feels dry
• Difficulty:
• Swallowing
• Tasting food
• Speaking
Photo: Dr. Bea Gandara, Univ. of WA
• Untreated, leads to infection:
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Tooth decay
Periodontal disease
Angular cheilitis
Yeast infection of the tongue
Photo: Dr. Bea Gandara, Univ. of WA
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Consequences of Dry Mouth
Dry mucosa
Tooth loss
Root caries
Gum recession
Photo: Dr. Bea Gandara, Univ. of WA
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Managing Patients with Dry Mouth
Avoid:
• Medications causing dry mouth.
• Alcohol, caffeine, and tobacco.
• Sugary drinks and snacks.
Suggest:
• Frequent sips of water.
• Sugar-free products with xylitol.
• Saliva substitutes and stimulants.
Saliva
substitutes
Saliva
stimulants
Sugar-free
gum and mints
Prevent infection:
• Daily oral hygiene.
• Protect teeth with fluoride.
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Dry Mouth Leads to Caries
• Plaque deposits build up on teeth.
• Dietary acid and acid-producing
bacteria erode enamel.
• Caries-producing bacteria invade enamel.
• Progression to dentin causes deep decay.
• Progression to pulp causes tooth death:
• Need for expensive root canal therapy and
crown to save tooth, or
• Tooth loss.
• Bacteria spread to other teeth.
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What Is Plaque?
• Initially a film, which turns into hard deposit
on the teeth.
• Protein precipitate from saliva, food, and
bacteria adheres to teeth.
• Calcium deposits from saliva turn it
into calculus.
• Substrate for bacterial growth.
• A place acid and bacteria have prolonged
contact with enamel and roots.
• Barrier to protective effects of saliva.
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Anatomy of a Tooth
Periodontal
ligaments
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Tooth Decay Progression
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Assessing for Caries
• Ask
• Do you experience tooth pain or bleeding gums
when you eat or brush your teeth?
• Has anyone in the immediate family (including a
caregiver) had tooth decay, or lost a tooth from
tooth decay, in the past year?
• Look
• White discoloration of the enamel.
• Dark discoloration of enamel or root.
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The Spectrum of Caries
Root
caries
Early
caries
Advanced
caries
Plaque setting
the stage for
caries
Photo: Dr. Bea Gandara, Univ. of WA
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Actions to Prevent Tooth Decay
Remove bacteria daily.
• Brush twice daily for two minutes
with fluoridated toothpaste.
• Floss daily, preferably at night.
Limit sugar, and sweet, sticky, or
sugary foods and drinks.
Fluoride Toothpaste
• Use xylitol (a natural sweetener).
• Rinse with water after meals.
Use fluoride.
• Use fluoridated toothpaste.
• Drink fluoridated water.
• Apply fluoride varnish.
Regular dental care.
Fluoride Varnish
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The Impact of Fluoride
• Inhibits bacterial metabolism and limits pH drop
associated with eating and drinking.
• Makes enamel and dentin more resistant to
demineralization and dissolution in acid.
• Enhances remineralization by attracting calcium
to demineralized enamel.
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Periodontal Disease
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The Pathway to Periodontal Disease
and Tooth Loss
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Early Periodontal Disease
Gingivitis
Redness
Bleeding
Puffiness
Photo: Dr. Bea Gandara, Univ. of WA
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Advanced Periodontal Disease
• Gum retraction
• Bone loss
• Spaces between teeth
• Loose teeth
• Tooth loss
Gum puffiness
masking spaces
between teeth and
bone loss
Gum
recession
Photo: Dr. Bea Gandara, Univ. of WA
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Periodontitis Accelerators
• Poor oral hygiene
• Medication side effects
• Malnutrition
• Eating disorders
• Alcohol
• Tobacco
• Chemical dependency
• Hormonal effects of pregnancy
• Diabetes
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Periodontal Treatment Reduces Medical
Costs for People with Chronic Conditions
Lower Annual Medical Costs
Reduced Hospital Admissions
$1,090
(10.7%)
$2,840
(40.2%)
21.2%
$2,433
28.6%
(73.7%)
$5,681
39.4%
(40.9%)
Diabetes
Stroke
Heart Disease
Pregnancy
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Assessing for Periodontal Disease
• Ask:
• Find out if patient experiences tooth pain or bleeding
gums when eating or brushing.
• Look:
• Gum inflammation, bleeding, gum recession.
• Root exposure.
• Decide/Act:
• Refer to dentist for intensive treatment.
• Address the accelerators.
• Apply fluoride to protect roots.
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How is Oral Health
Different in Pregnancy?
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Endocrine Changes
• Estrogen increases 10-fold.
• Capillary permeability and gingival hyperplasia.
• Progesterone increases 30-fold.
• Reduced inflammatory response: numbers of
neutrophils and antibody response.
• Increased bacterial growth.
• Gram negative bacteria in gums: periodontitis.
• Strep mutans and lactobacillus: caries.
• Fusobacterium nucleatum: pre-term delivery.
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Pregnancy Gingivitis
Clinical characteristics:
• 30‒80% of women.
• 2nd‒8th months,
anterior areas.
• Changes in gingival
vascularity result in
greater bleeding.
• Preexisting gingivitis
may predispose to
pregnancy gingivitis.
• Treatment is safe.
Photo: Dr. Robert Johnson, Univ of WA
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Pregnancy Granuloma (Epulis or
Pregnancy Tumor)
Photo: Dr. Robert Johnson, Univ of WA
Clinical characteristics:
• Occurs in up to 5%
of women.
• Starts in the 2nd or
3rd month.
• Single, tumor-like growth
(up to 2 cm) in an area of
gingivitis or recurrent
irritation (usually maxillary
buccal anterior).
• Usually regresses
spontaneously
after delivery.
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Pre-term Births and Periodontitis
• Severe periodontitis leads to high levels of
prostaglandins in the blood.
• High levels of prostaglandins are associated with
early uterine contractions, early birth, and low
birth weight.
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Preeclampsia and Periodontitis
• Periodontal disease may be associated
with preeclampsia.
• PGE2, IL-1, and TNF- levels from
gingival cervicular fluid are higher in women
with preeclampsia.
• Oral pathogens have been found in placentas
of women with preeclampsia. This implies a
possible contribution of periopathogenic
bacteria to the pathogenesis of this syndrome.
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Increased Exposure to Acid
• Vomiting.
• Gastroesophageal
reflux (GERD).
• Craving acidic foods.
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Gastric Reflux
• Pressure on the stomach from fetus.
• Lower esophageal sphincter pressure falls
33%–50%.
• Progesterone affects GI smooth muscle
(decreased motility and prolonged intestinal
transit time).
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Erosion of Tooth Enamel
Photo: Dr. Bea Gandara, Univ. of WA
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Tooth Mobility
• Transient increase in
tooth mobility.
• Gingivitis and ligament
relaxation not correlated
with hormone changes.
Photo: Dr. Bea Gandara, University of WA
Note: pregnancy does not
result in demineralization
of teeth because of fetal
calcium needs.
Women don’t lose a tooth for each pregnancy.
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Primary Care Oral Health Interventions
• Oral hygiene coaching:
• Brushing with fluoride
twice daily
• Flossing once daily
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Dietary counseling
Topical fluoride
Medication review
Antacids
Referral
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Case 1
• A 36-year-old female comes in for her 16-week
prenatal visit.
• She has been suffering from hyperemesis since her
sixth week, and while it has begun to get better, she still
vomits three to four times a day.
• Her nausea is helped a bit by sipping on Coke and
sucking on ginger candies. She has not been to the
dentist in the past year, and she has not been able to
regularly brush her teeth since the onset of hyperemesis,
since the toothbrush in her mouth triggers vomiting.
• She reports pain when drinking hot tea or
cold ice cream.
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Case 2
• A 28-year-old woman comes in for her 32-week
prenatal visit.
• She was recently diagnosed with gestational diabetes so
is trying to change her diet, but was previously eating a
lot of carbohydrates and sugary snacks.
• She reports bleeding while brushing her teeth and pain
while eating, as well as a feeling that a few of her teeth
are “wiggling.”
• She has not been to the dentist in a few years and
intended to go when the bleeding started a few months
ago, but a friend told her it wasn’t safe to get a cleaning
when pregnant.
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Group Discussion
• Who will ask the questions that give you
this information?
• Who will look in the mouth and look for
the key findings?
• Who will order preventive actions?
• Who will deliver preventive actions?
• How will you set up the referral?
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Addressing Oral Health for
Pregnancy in an Already Busy
Primary Care Practice
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Building Oral Health into the Process
• Structure visits and use the entire team to
ensure oral health isn’t overlooked.
• Use health IT to organize information so that risk
factors are easily identifiable and education
interventions are automated.
• Share the care among team members and let
the clinician focus on the reason for the visit.
• Used structured referrals to dentistry.
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Teamwork to Share the Care
• Identify target
population patients
before visit.
• Ask about symptoms
while rooming patient.
• Set up orders for the
clinician to sign.
• Arrange for oral
health protocol at the
end of the visit.
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Prevention Through Counseling
Most important topics:
• Oral hygiene best practices:
• Brush twice daily for two minutes with
fluoride toothpaste.
• Floss at least once daily.
• Diet:
• Reduce sugar and carbohydrates, rinse with water.
• Allow sufficient intervals between snacks.
• Recognize dry mouth as a sign of trouble:
• Teach patients to ask about medication side effects.
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Prevention Through Counseling
Technique depends on team resources:
• Synergy with general health messages:
• Teach-back
• Motivational interviewing
• Patient education:
• Handouts
• Videos
• Peer support
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Summary
• Oral health in pregnancy is a major unmet need.
• Maternal oral health directly benefits the baby.
• Primary care strengths:
• Risk factor identification and reduction through
behavior change.
• Case finding and referral.
• Pathophysiology of caries and periodontal
disease are familiar to primary care.
• Integration into primary care workflow works
using the Oral Health Delivery Framework.
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Source: Developed by Qualis Health for the Washington Dental
Service Foundation “Oral Health Preventive Services in Primary Care
Project.” 1st ed. Seattle, WA. November 2014.
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About the Oral Health Integration in Primary Care Project
The Organized, Evidence-Based Care Supplement: Oral Health Integration joins the Safety Net Medical Home Initiative Implementation
Guide Series.
The goal of the Oral Health Integration in Primary Care Project was to prepare primary care teams to address oral health and to
improve referrals to dentistry through the development and testing of a framework and toolset. The project was administered by
Qualis Health and built upon the learnings from 19 field-testing sites in Washington, Oregon, Kansas, Missouri, and Massachusetts,
who received implementation support from their primary care association. Organized, Evidence-Based Care Supplement: Oral Health
Integration built upon the Oral Health Delivery Framework published in Oral Health: An Essential Component of Primary Care, and was
informed by the field-testing sites’ work, experiences, and feedback. Field-testing sites in Kansas, Massachusetts, and Oregon also
received technical assistance from their state’s primary care association.
The Oral Health Integration in Primary Care Project was sponsored by the National Interprofessional Initiative on Oral Health, a
consortium of funders and health professionals who share a vision that dental disease can be eradicated, and funded by the
DentaQuest Foundation, the REACH Healthcare Foundation, and the Washington Dental Service Foundation.
For more information about the project sponsors and funders, refer to:
• National Interprofessional Initiative on Oral Health: www.niioh.org.
• DentaQuest Foundation: www.dentaquestfoundation.org.
• REACH Healthcare Foundation: www.reachhealth.org.
• Washington Dental Service Foundation: www.deltadentalwa.com/foundation.
The guide has been added to a series published by the Safety Net Medical Home Initiative, which was sponsored by The Commonwealth Fund,
supported by local and regional foundations, and administered by Qualis Health in partnership with the MacColl Center for Health Care Innovation.
For more information about the Safety Net Medical Home Initiative, refer to www.safetynetmedicalhome.org.
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