Maternal and Early Childhood Oral Health

A 2-year project:

Bring together stake holders

Create tools and resources

Increase awareness and understanding

Promoting oral health among

pregnant women is a powerful

window of opportunity for

lifelong oral health for mothers and their children.

Maternal Oral Health Project

• Formed sub-committee of the SK Oral Health Coalition

• Focused on raising awareness that the oral health of pregnant women requires greater attention

• Project strategies:

Compile Evidence-Based Research

Saskatchewan Consensus Document

Social Marketing Campaign to ↑

Knowledge among Pregnant Women

Continuing Education for Oral Care and Prenatal

Care Providers

Maternal Oral Health Project Team

Dr. Alyssa Hayes College of Dentistry, University of Saskatchewan

Christine Thompson Saskatchewan Prevention Institute

Janet GrayPopulation Health Unit, Mamawetan Churchill River Health Region, Keewatin Yatthé Health Region & Athabasca Health Authority

Kellie WatsonSaskatchewan Dental Hygienists’ Association

Leslie Topola Saskatoon Health Region, Oral Health Program

Megan Clark Saskatchewan Prevention Institute

Marcella Ogenchuk College of Nursing, University of Saskatchewan

Saskatchewan Consensus Document

Goals:

Oral and prenatal care providers in Saskatchewan have an

understanding of the importanceand safety of oral care during

pregnancy

Oral care becomes part of routine prenatal care, contributing to the overall health of pregnant women

and their children.

Full document available at www.skprevention.ca/oral-health

Target Audiences

Oral care providers

Ministry of Health

Health professional associations

Prenatal care

providers

Primary health care managers

Academics

Groups/Organizations Supporting the Consensus Document

Oral Heath Organizations/Groups

• Canadian Dental Hygienists Association

• Saskatchewan Dental Assistants’ Association

• Saskatchewan Dental Hygienists’ Association

• Saskatchewan Dental Public Health Network

• Saskatchewan Dental Therapists Association

Health Organizations/Groups

• Breastfeeding Committee for Saskatchewan

• Medical Health Officers’ Council of Saskatchewan

• Nurse Practitioners of Saskatchewan

• Saskatchewan Association of Licensed Practical Nurses

• Government of Saskatchewan Ministry of Health - Primary Health Services

• Saskatchewan Public Health Nurse Managers Committee

• Saskatchewan Registered Nurses’ Association

Health Regions

• Athabasca Health Authority

• Cypress Health Region

• Five Hills Health Region

• Kelsey Trail Health Region

• Prairie North Health Region

• Prince Albert Parkland Health Region

• Regina Qu’Appelle Health Region

• Saskatoon Health Region

• Sun Country Health Region

Public Education Materials

Poster

Information Cards

Materials are available for order from:www.skprevention.ca

Small counter display

Large floor display (for loan)

Evaluation of Public Education Material

• Response rate was 54% (30% were prenatal care providers)

• Overall, the materials were found to be both appealing and useful

• High interest in ordering more of the materials

• 95% indicated they would recommend the materials to other care providers

• > 80% thought the campaign was effective in increasing knowledge and awareness of oral health during pregnancy and early childhood

Pregnancy is a Time for Smiling…

and a time to pay extra attention to your teeth and

mouth

Oral Health for Moms and Babies

Your thoughts?

Do you think of these materials are useful?

Will you distribute them to pregnant women and

families?

How would you distribute them?

Continuing Education for:

Oral Health Professionals

Prenatal Health Professionals

Oral Health during PregnancyPractice Opportunities for Oral Health Professionals

Project Partners:

Northern Saskatchewan Population Health Unit

Saskatchewan Dental Hygienists’ Association

Saskatchewan Oral Health Coalition

Saskatoon Health Region, Oral Health Program

University of Saskatchewan College of Dentistry

University of Saskatchewan College of Nursing

Overview

• Why oral health during pregnancy is important

• Oral disease and pregnancy

• Treating the pregnant patient

• Barriers to oral care during pregnancy

• Maternal oral health and ECC

• Practice opportunities

• Available guidelines on oral health during pregnancy

The following guidelines and documents informed the

development of this presentation

California Dental Association Foundation (2010). Oral Health

During Pregnancy & Early Childhood Guidelines.

New York State Dept. of Health (2006). Oral Care

During Pregnancy & Early Childhood Practice

Guidelines.

Maternal & Child Health Bureau, American Dental

Assoc., American Congress of Obstetricians &

Gynecologists (2011). Oral Health Care During

Pregnancy: A National Consensus Statement.

“In many cases, neither pregnant women nor health professionals understand that oral

health care is an important component of

a healthy pregnancy.”

Why Oral Health during Pregnancy is Important

• Potential adverse pregnancy outcomes

• Pregnant women are at higher risk of tooth erosion and periodontal disease

• Untreated oral infections can further complicate pregnancy - especially for those with chronic conditions such as diabetes

• Untreated maternal tooth decay increases risk for tooth decay in child

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Research shows a possible connection between periodontal disease and adverse birth outcomes including preterm birth and low birth weight.- Offenbacher, S. et al. (1996). Periodontal infections as a possible risk factor for preterm low

birthweight. J Periodontol, 67(S10), 1103-13.

Pregnancy increases the risk for oral

disease.

This is due to hormonal changes

and changes in eating patterns (such

as increased snacking).

Oral Disease and Pregnancy

• Prevalence of gingivitis during pregnancy ranges from 30% to 100% (depending on the study)

• An estimated 5% to 20% of pregnant women have periodontal disease

• An estimated 25% of women of childbearing age have at least one untreated cavity

“A sizable number of women may enter

pregnancy with active oral disease, or

pregnancy may trigger the progression of the

disease process”.

- U.S. Department of Health and Human Services (2000). Oral Health in America: A Report of the

Surgeon General.

Why it is Critical to Treat the Pregnant Patient

• Acid erosion

• Immunocompromised status

• Pregnancy gingivitis

• Increased risk of periodontal disease

• Reduce risk of self-medication for pain management

• Reduce bacterial transmission from mother to infant

• Establish good oral hygiene

Source: California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Maternal Oral Health and ECC

“Vertical transmission of MS from mother to infant is well documented.”

“Along with maternal salivary levels of MS, the mother’s oral hygiene, periodontal disease, snack

frequency, and socio-economic status also are associated with infant colonization.”

- American Academy of Pediatric Dentistry (2011). Guideline on Perinatal Oral Health Care.

There is well-established evidence that caregivers (primarily mothers) with high levels of mutans streptococci have a high likelihood of infecting the child before the second birthday.

- Berkowitz, R. J. (2003). Acquisition and transmission of mutans streptococci.

J Cal Dent Assoc, 31(2), 135-138.

Early colonization in an infant’s mouth by MS is a major risk factor for early childhood caries as well as future dental caries.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy and Early Childhood.

Cariogenic or decay-causing bacteria are typically transferred from the mother or caregiver to child by behaviours that directly pass saliva, such as sharing a spoon when tasting baby food or cleaning a dropped pacifier by mouth.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy and Early Childhood.

Key strategies to reduce the risk for future cavities for the child:• Minimize the MS levels in the mother in order to delay the colonization of

MS in the infant as long as possible; and

• Minimize the sharing of MS from mother to child.

- American Academy of Pediatric Dentistry, Clinical Affairs Committee (2011).

Guideline on Infant Oral Health Care.

Women with poor oral health affect their children’s oral health through the influence of their beliefs, knowledge, and skills.

- Huebner, C. E. & Riedy, C. A. (2010). Behavioral determinants of brushing young children’s teeth:

implications for anticipatory guidance. Pediatr Dent, 32(1), 48-55.

Pregnant women who may not be concerned about their own oral health are generally very receptive to information about the consequences it can have on their children.

Many people do not realize that dental caries is the most common infectious disease in childhood, that it has health and developmental consequences, and that it is preventable.

- Kowash, M. B., et al. (2000). Dental health education: effectiveness on oral health of a long-term health education programme for mothers with young children. British Den J,

188, 201-205.

Where does Saskatchewan rank among Canadian provinces/territories for day surgery rates to treat cavities among children?

A. 8th highest rate

B. 5th highest rate

C. 3rd highest rate

D. 2nd highest rate

“One-third of all day surgery operations for preschoolers

in Canada are done to perform substantial dental work, making it the leading

cause of day surgery for children this age.”

“Saskatchewan has the third highest rate in Canada for

day surgery operations performed to treat cavities among children aged 1-5 years, after Nunavut and

NWT.”

- CIHI (2013). Treatment of Preventable Dental Cavities in Preschoolers, A Focus on

Day Surgery Under General Anesthesia.

Safety of Dental Care During Pregnancy

• No evidence of early spontaneous miscarriage in 1st trimester as a result of dental procedures

• Women in dental pain tend to self medicate themselves

• Periodontal treatment during pregnancy• Is safe

• Doesn’t increase risk for preterm or low birth weight

• Dental care is not contraindicated for women with preeclampsia

• Dental X-rays & anesthesia present no additional fetal & maternal risk compared to no treatment for oral diseases

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

“Pregnancy is not a reason to defer routine dental care or treatment of

dental problems”.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Diagnostic Radiation

• Radiographic imaging of oral tissues is not contraindicated in pregnancy and should be utilized as required to complete a full examination, diagnosis and treatment plan.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Positioning the Pregnant Patient

• Place the patient in a semi-reclining position (especially in the 3rd

trimester), encouraging frequent position changes, and/or place a small pillow or folded blanket underneath one of her hips to displace the uterus.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Use of Nitrous Oxide

• Because pregnancy is associated with decreased anesthetic requirements, lower concentrations of nitrous oxide may be adequate for sedation and patient comfort.

• Prolonged dental treatments and nitrous oxide exposure should be avoided if possible.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Restorative Materials

• Given the risks associated with untreated dental caries in pregnant women, oral health professionals should recommend prompt treatment of dental caries and, in consultation with the pregnant woman, determine the appropriate options for treatment and restorative materials.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Pharmacologic Considerations

• Pharmacologic treatment during pregnancy is of concern as the maternal metabolism of drugs is altered by the normal physiologic changes of pregnancy, and certain medications can reach the fetus and cause harm.

• The physiologic changes of pregnancy influence absorption, plasma levels, drug distribution, half-lives and elimination of drugs.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Pharmacological Considerations for Pregnant and Breastfeeding Women

Drug FDA Classification Teratogenic Risk Evidence

Quality

Restrictions/Special Considerations

ANALGESICSAspirin C Minimal Good Short duration of use

Avoid in 1st and 3rd trimester

Avoid if breastfeeding

Acetaminophen B None to minimal Good Analgesic and antipyretic of choice

Ibuprofen B Minimal Fair to good Short duration of use

Avoid in 1st and 3rd trimester

Do not use for >48-72 hours

Compatible with breastfeeding

Naproxen B Minimal Fair Short duration of use

Avoid in 1st and 3rd trimester

Do not use for >48-72 hours

Compatible with breastfeeding

Codeine C Unlikely Fair to good Compatible with breastfeeding

At high maternal doses, may cause

depression/ drowsiness in breastfeeding

infants

Morphine B/D Unlikely Fair to good Withdrawal symptoms in neonate may

occur with prolonged or chronic use

At high maternal doses, may cause

depression/ drowsiness in breastfeeding

infants

Category D with prolonged use

Meperidine B/D Unlikely Fair Category D with prolonged use

Compatible with breastfeeding

- California Dental Association Foundation (2010). Oral Health During Pregnancy & Early Childhood Guidelines.

ANTIBIOTICSPenicillin B None Good No restrictions

Amoxicillin B Unlikely Good No restrictions

Cephalosporins B Unlikely Fair to

limited

No restrictions

Clindamycin B Unlikely Limited

Erythromycin B Minimal Fair Erythromycin estolate is avoided due to

potential maternal hepatotoxicity

Tetracycline D Moderate for

tooth staining

Good Avoid during pregnancy; use after 25

weeks may result in staining of teeth and

possible effects on bone growth

Fluorquinolones C Unlikely Fair Avoid during pregnancy and lactation due

to toxicity to developing cartilage in

animal studies

Clarithromycin Undetermined Limited Alternative antibiotics are recommended

because number of cases of pregnancy

exposure is too small to conclude no risk

- California Dental Association Foundation (2010). Oral Health During Pregnancy & Early Childhood Guidelines.

ANESTHETICS

Lidocaine (local) B None Fair No restrictions

MISCELLANEOUS

Chlorhexidine mouth

rinse

C Unlikely Poor Has not been evaluated for possible

adverse pregnancy effects

Xylitol Undetermined Unlikely Not

available

No references available on possible

adverse pregnancy effects

- California Dental Association Foundation (2010). Oral Health During Pregnancy & Early Childhood Guidelines.

Dental Care Utilization During Pregnancy

“Only about one-quarter to one-half of women receive dental care during their pregnancy”.

“The likelihood of low-income and uninsured women receiving such care is even lower.”

- Gaffield, M.L., et al. (2001). Oral health during pregnancy: an analysis of information collected by the pregnancy risk assessment monitoring system. J Amer Dent Assoc, 132(7),

1009-1016.

Barriers to Oral Care During Pregnancy

• Women often do not seek or are not referred for oral care by their doctors

• Many oral care and prenatal care providers have only a limited knowledge of the safety and benefits of oral care during pregnancy

• Many oral care providers delay or withhold treatment fearing:• Potential harm to the mother or fetus

• Liability

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Practice Opportunities for Oral Health Professionals

• Ask the woman if she has any concerns/fears about getting dental care while pregnant.

• Advise the pregnant woman that prevention, diagnosis and treatment of oral diseases, including needed dental X-rays and use of local anesthesia (when necessary for the care of the patient), are acceptable and can be safely undertaken.

• Perform a comprehensive periodontal examination.

• Plan definitive treatment based on customary oral health considerations.

• Develop and discuss a comprehensive treatment plan that includes preventive, treatment, and maintenance care throughout pregnancy. Discuss the benefits, risks, and alternatives to treatments.

• Provide emergency/acute care at any time during pregnancy as indicated by oral condition.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Practice Opportunities for Oral Health Professionals cont’d

• Encourage women to learn more about oral health during pregnancy and early childhood.

• Provide health education or anticipatory guidance about oral health practices for her children to prevent ECC.

• Recommend strategies to decrease maternal cariogenic bacterial load (i.e., tooth brushing, flossing, treating caries, mouth rinses, fluoridated water, healthy diet, regular dental visits).

• Support the development of provincial guidelines on oral care during pregnancy.

• Engage in training and continuing education opportunities on oral health during pregnancy.

- California Dental Association Foundation (2010).

Oral Health During Pregnancy & Early Childhood Guidelines.

Discussion

What are you already doing?

What barriers or challenges do you face in providing oral care to pregnant women?

What supports would be helpful to enhance your practice?

Dental-Medical Collaboration

• Connection between oral health and systemic health

• Prenatal care providers play a key role in preventing oral disease, especially among those who have limited access to dental services

• Interprofessional learning and practice opportunities

• Collaborative relationships for case management & dental referral network

Discussion

Do you collaborate with prenatal health care providers?

What are/might be the benefits of collaborating?

What are/might be some challenges with collaborating?