Discomforts, Lifestyle & Oral Health2012

• Discomforts– Nausea and vomiting– Heartburn

• Lifestyle concerns with nutritional implications:– alcohol– caffeine– smoking– Illicit drugs– Non-nutritive sweeteners– physical activity

• oral health

Nausea & Vomiting: Cochrane Intervention Review, 2010 Quinlan et al, Am Fam Phys, 2003

Background

• 70-85% of women experience nausea with pregnancy

• ~ ½ experience vomiting• 35% of women with employment lose

time from work due to nausea – an average of 62 hours

• Almost 50% of women report that their work efficiency is reduced by n&v

•Lack of understanding and support from others• Inability to take vitamins or eat healthy• Taking medications perceived as risky• Missing out on the “fun” of being pregnant• Loss of a “normal” pregnancy• Lost work days or quitting work• Putting life “on hold”• Longing to eat and drink normally• Money expended on care and support• Lack of energy, fatigue• Irritability and lack of enjoyment of life• Memory loss or inability to think clearly• Burden of care and time on others• Lack of socialization, isolation

Stress Associated with N&V

cont…

• Inability to prepare for birth and arrival of baby• Inability to care for family and home•Wanting pregnancy over or to end the misery• Others’ perception that hyperemesis is only in her mind• Reluctance of doctors to treat because of cost or liability• Weight loss or inadequate weight gain for gestational age of baby• Sense of inadequacy and failure at being unable to cope or function• Difficulty bonding with infant• Lack of energy and socialization with other children• Lack of excitement about infant’s arrival

Etiology

• Unknown – appears to have some association with rising levels of human chorionic gonadotropin (hCG) or estrogens– Nausea less common in those who

subsequently experience miscarriage– More common in twin pregnancies

Hyperemesis Gravidarum

• Severe nausea and vomiting• Affects one in 200 pregnancies• Most common reason for hospitalization in early

pregnancy• Clinical features: Persistent vomiting, dehydration,

ketonuria, electrolyte disturbances, weight loss• 159 per million pregnant women died in England

between 1931-1940 (before IV fluid replacement therapy was available)

• (Charlotte Bronte died of hyperemesis in her fourth month of pregnancy)

Use of non-pharmacological treatments

• Commonly recommended by health professionals without evidence of effectiveness

• Safety unknown and unregulated– “women and professionals are more likely

to underestimate their possible risks”

Cochrane 2010

• Interventions for nausea and vomiting in early pregnancy

• 27 studies with 4041 women included– 22 studies excluded

AcupressureComparison & studies Results

P6 vs vitamin B6– one study, 66 women

No sig difference, but more “satisfied” with P6

P6 vs “Placebo”–4 studies- 408 women

No sig differences

Auricular (metal balls taped to point on ear) vs “placebo”

–I study, 90 women

No sig difference

Acustimulation (low-level nerve stimulation therapy over the volar aspect of the wrist at the P6 point) vs placebo

–one study, 230 women

Data “not simple to interpret”

Acupuncture

• Acupuncture versus placebo (sham acupuncture and no treatment)

• two studies with 648 women

• No sig difference or data not interpretable

GingerComparison & studies Results

Ginger versus placebo–4 studies, 283 women

Studies suggest benefit, but meta-analysis that controlled for study deficits found no benefit

Ginger versus vitamin B6 –4 studies, 624 women

Pooled results show no benefit

Ginger versus Dimenhydrinate (Dramamine)

–1 study, 170 women

Data not “easily interpreted”

Vitamin B6 versus placebo

• 2 studies, 416 women

• Results favored vitamin B6 for reduction in nausea after three days

• Comparing the number of patients vomiting post-treatment, there was no strong evidence that vitamin B6 reduced vomiting

Anti-emetic medication versus placebo

• 6 studies, 803 women• Hydroxyzine, Debendox (Bendectin)

Thiethylperazine,Fluphenazine-Pyridoxine

• Review found substantial methodological problems with most studies and could not reach meaningful conclusion

Adverse Outcomes

• Acupressure: reports of pain, numbness, soreness and hand-swelling

• Ginger: few studies reported adverse impacts, one statement about heartburn

• Antiemetic drugs: primary complaint was drowsiness.

Summary Statements

• No acceptable studies of dietary or other lifestyle interventions

• Limited evidence regarding acupressure – acupuncture not effective

• “The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent.”

• “There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting.”

Cochrane Conclusions:

“Given the high prevalence of nausea and vomiting in early pregnancy, health professionals need to provide clear guidance to women, based on systematically reviewed evidence. There is a lack of high-quality evidence to support that advice. The difficulties in interpreting the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies.”

Nausea and vomiting of pregnancy: an evidence-based review (Davis, J Perinat Neonatal Nurs. 2004)

• First step is dietary & lifestyle changes

American Gastroenterological Association Institute Medial Position Statement on the Use

of Gastrointestinal Medication in Pregnancy (2006)

• Metoclopramide, prochlorperazine, promethazine, trimethobenzamide and ondansetron* are considered low-risk drugs based on studies in pregnant women and can be used for nausea and vomiting and for hyperemesis gravidarum. Granisetron and dolasetron have not been studied in human pregnancies.”

*Reglan, Compazine , Phenergan , Tebamide, Zofran

Interventions for Heartburn in PregnancyCochrane, 2008

• Up to 80% of women in third trimester• Not well understood – pregnancy

hormones influence• Lower esophageal sphincter• Gastric clearance

• 3 studies, 286 women• “little information to draw conclusions about the

overall effectiveness of interventions to relieve heartburn in pregnancy.”

Adverse effects of substance use determined by:

• Timing

• Dosage

• Duration

• Number of substances

• Environment (nutrition, health status)

• Individual susceptibility

Effects of substance abuse include:

• Increased health problems, including risk of AIDS

• Compromised nutritional status/weight gain

• Higher rates of OB complications

• Psychosocial/economic/legal problems

• Parenting difficulties

• Higher rates of child abuse/neglect

Interrelationships of undernutrition and neurotoxicity: Food for thought and

research attention (Spencer & Palmer, Neurotoxicoloty6, 2012)

• “undernutrition can modify risk …and in some cases may be a prerequisite for neurotoxicity to surface.

• combined effects of undernutrition and neurotoxicity are most relevant to people with low incomes who experience chronic hunger, parasitism and infectious disease…”

• …also important in high-income societies in the setting of drug and alcohol abuse… food faddism…

• Nutritional demands of pregnancy and lactation increase the risk of fetal and infant undernutrition and chemical interactions”

Alcohol: Background Per capita alcohol consumption has risen

through the second half of this century in the US

70% of individuals between the ages of 20 and 34 consume alcohol

Alcohol consumption peaks in the 20-40 year old group

Percentage of women aged 18--44 years who reported any alcohol use or binge drinking, by pregnancy status

--- Behavioral Risk Factor Surveillance System (BRFSS) surveys, United States

MMWR: May 22, 2009 / 58(19);529-532

Alcohol: Background, cont. Women are at disadvantage because less

gastric first pass metabolism due to lower levels of alcohol dehydrogenate in intestinal mucosa

Fetus has no alcohol dehydrogenase activity Alcohol crosses placenta easily by passive

diffusion – fetal levels mimic maternal levels The amniotic fluid acts as a reservoir for

alcohol.

FAS Diagnostic Criteria- Fetal Alcohol Study Group of the Research Society on Alcoholism

• Prenatal and/or postnatal growth retardation (<10th % ca)

• Central nervous system involvement (neurologic abnormality, developmental delay or intellectual impairment)

• Characteristic facial dysmorphology with at least 2 of these 3 signs: Microcephally ( OFC < 3rd %ile) Micoopthalmia and/or short palpevral fissures Poorly developed philtrum, thin upper lip, and or

flattening of the maxillary area

FAS, cont.

Other organ systems often involved. Some with nutritional implications:

Cleft palate Eustachian tube dysfunction Array of cardiac, renal, and skeletal defects that

may require surgical repair

FAE – Fetal Alcohol Effects or PFAE

• Exhibit some components of FAE, but not all

• Most common sign is retarded growth both pre and postnatal

• Can have significant developmental and behavioral components

Fetal Alcohol Spectrum Disorders (FASD)

• Surgeon General’s Advisory (2005)– “FASD is the full spectrum of birth defects caused

by prenatal alcohol exposure.”– “The spectrum may include mild and subtle

changes, such as a slight learning disability and/or physical abnormality, through full-blown Fetal Alcohol Syndrome, which can include severe learning disabilities, growth deficiencies, abnormal facial features, and central nervous system disorders.”

FAS/FAE Incidence

FAS – 1.9 per 1000 births, 25 per 1000 among women who drink heavily

FAE – 3 to 5 per 1000 births, 90 per 1000 among women who drink heavily

FASD is leading cause of mental retardation in the western world

Pathophysiology

• Combination of – Toxic effects of ethanol and its derivatives– Nutritional factors– Genetic predisposition

Toxic effects• Both alcohol and derivative acetaldehyde directly

damage developing and mature nervous systems• Impair nucleic acid synthesis• Disrupts protein synthesis• Cell membrane narcosis• High maternal alcohol levels associated with

dehydration, fetal hypoxia and acidosis, placental pathology and dysfunction, and endocrine disturbances.

Nutrition & Alcohol• Poor nutritional status of mother –

underweight/undernourished • Reduced placental transfer of zinc and folic

acid associated in animal models• Alcohol impairs absorption, utilization, and

metabolism of nutrients• Effects of etoh more severe with malnutrition:

– Zn supps can protect against fetal effects – Clinical phenotype of FASD more likely with low

maternal weight & BMI

The effects of alcohol on fetal development. Jones. Birth Defects Research. 2011

Surgeon General’s Advisory (2005)

• Science: – Alcohol consumed during pregnancy increases the risk

of alcohol related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development.

– No amount of alcohol consumption can be considered safe during pregnancy.

– Alcohol can damage a fetus at any stage of pregnancy. Damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.

– The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure are lifelong.

– Alcohol-related birth defects are completely preventable

Surgeon General’s Advisory (2005)

Recommendations:1. A pregnant woman should not drink alcohol during

pregnancy. 2. A pregnant woman who has already consumed alcohol

during her pregnancy should stop in order to minimize further risk.

3. A woman who is considering becoming pregnant should abstain from alcohol.

4. Recognizing that nearly half of all births in the United States are unplanned, women of child-bearing age should consult their physician and take steps to reduce the possibility of prenatal alcohol exposure.

5. Health professionals should inquire routinely about alcohol consumption by women of childbearing age, inform them of the risks of alcohol consumption during pregnancy, and advise them not to drink alcoholic beverages during pregnancy.

Caffeine• History:

– Rat based studies with high levels of caffeine found adverse pregnancy outcomes

– Early 1980s US FDA issued advisory about adverse effects of caffeine in pregnancy

– Further research found little association, FDA concludes that no strong evidence, urges moderation

– 1996 IOM review for WIC advised removing excessive caffeine intake from WIC risk criteria

– 1998 - USDA removed as WIC risk criteria

The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al.

Nutrition Review, 1996)

• Metabolism– methylxantines cross the placenta to the

fetus where an equilibrium is achieved between maternal and fetal plasma

– half-life of caffeine in pregnancy changes from 5.2 to 18.1 hours in T2 and T3 and returns to non-pg levels a few weeks pp

Caffeine Metabolism, Genetics and Perinatal Outcomes (Ann Epidemiol 2005)

• Wide individual variation in caffeine metabolism– Due to variation in CYP1A2 enzyme

activity• “Measuring maternal, fetal and neonatal

caffeine metabolites may allow for a more precise measure of fetal caffeine exposure.”

Coffee and Health: A Review of Recent Human Research (Higdon and Frei; Crit

Rev Food Sci and Nutrition, 2006)

Conception

• Many studies find > 300 mg/d associated with delay in time to conception (some do not find this effect)

• Author’s conclusions: “it may be prudent for women who are having difficulty conceiving to limit caffeine consumption to less than 300 mg/d in addition to eliminating tobacco use and decreasing alcohol consumption.”

Spontaneous Abortion

• Conflicting studies • Women who decrease Caffeine due to N&V,

more likely to have viable pregnancies.• “Most studies that observed significant

associations between self-reported coffee or caffeine consumption and the risk of spontaneous abortion did so at intake levels of at least 300 mg/d of caffeine.”

Fetal Growth

• “Several studies found that maternal caffeine intakes ranging from 200-400 mg/d were associated with decreases in mean birth weight of about 100 g.”

• “A meta-analysis that combined the results of eight epidemiological studies found that maternal caffeine consumption greater than 150 mg/d increased the risk of low birth weight by approximately 50%.”

Preterm Delivery

• “Most epidemiological studies have not found coffee or caffeine consumption to be associated with the risk of preterm delivery.”

Birth Defects

• “At present, there is no convincing evidence from epidemiological studies that maternal caffeine consumption ranging from 300-1000 mg/d increases the risk of congenital malformations in humans.”

Coffee and Health: A Review of Recent Human Research (Higdon and Frei; crit

rev food sci and nutrition, 2006)

• “Currently available evidence suggests that it may be prudent for pregnant women to limit coffee consumption to 3 cups/d providing no more than 300 mg/d of caffeine to exclude any increased probability of spontaneous abortion of impaired fetal growth.”

Smoking

• 25-30% of US women smoke during pregnancy; down from 40% in 1967

• Cochran review found that 30 trials of intensive intervention programs in pregnant women lead to smoking cessation in 6.6-9.2% of women.

Interventions for promoting smoking cessation during pregnancy. Cochran Database Syst. Rev. 2009

Trends in Smoking Before, During, and

After Pregnancy, MMW; May 29, 2009

Trends in Smoking Before, During, and

After Pregnancy, MMW; May 29, 2009

Trends in Smoking Before, During, and

After Pregnancy, MMW; May 29, 2009

Trends in Smoking Before, During, and

After Pregnancy, MMW; May 29, 2009

Adverse Outcomes of Maternal Smoking

• Cigarette smoking is the single most important factor affecting birthweight in developed countries (DiFranza, Pediatrics, 2004)

– Twice the risk of LBW– Lower birthweight (~200g)

• Perinatal: Moderately increased risk of preterm delivery, perinatal mortality, spontaneous abortion

• Long term: modest reduction in long term growth and intellectual development of fetus.

Nutritional Risks Associated with Smoking

• No breakfast (38% of smokers vs. 18% of non-smokers)

• Lower dietary intakes of fruits and vegetables, protein, zinc, riboflavin, thiamin, iron

Nutritional Risks Associated with Smoking, cont.

• Smoking appears to:– decrease the availability of dietary energy– increase requirement for iron– reduce availability of B12, amino acids,

vitamin C, folate, and zinc

• Lower serum vitamin C, B6, E, folate, beta carotene

Norkus et al. FASEB, 1989 and Ann NY Acad Sci 1987

Smokers Non-Smokers

Cord vit. C (mg/dl) 0.61 1.68

Placental vit. C(mg/dl)

10.1 20.9

Cord vit. E (mg/dl) 0.2 0.3

Maternal plasmacarotene (g dl

19 44

Cord carotene(g dl

7 20

Vitamin C and PROM

• PROM occurs in 8-10 % of all pregnancies

• Vitamin C is required for collagen synthesis

• Maternal plasma and placental vitamin C is lower in women with PROM

Nutritional Risks Associated with Smoking, cont.

• Increased carboxyhemoglobin in smokers blood leads to requires increased cutoff point for anemia in smokers.

• Women who smoke may have lower prepregnancy weights and may have lower pregnancy weight gains.

Maternal smoking during pregnancy and child overweight: systematic review and

meta-analysis (Oken, 2008)

Maternal smoking during pregnancy and child overweight: systematic review and

meta-analysis (Oken, 2008)• “The pooled estimate from unadjusted

odds ratios (OR 1.52, 95% CI: 1.36, 1.69) was similar to the adjusted estimate, suggesting that sociodemographic and behavioral differences between smokers and nonsmokers did not explain the observed association.”

Maternal smoking during pregnancy and child overweight: systematic review and

meta-analysis (Oken, 2008)

• In parts of the world undergoing the epidemiologic transition, the continuing increase in smoking among young women could contribute to spiraling increases in rates of obesity-related health outcomes in the 21st century.

Prenatal exposure to maternal cigarette smoking, amygdala volume, and fat intake

in adolescence. (Haghight et al. Arch Gen Psyc. 2012)

• N-378, aged 13-19• Exposed to prenatal maternal cigarette smoking (180),

not exposed (198) – matched by maternal education, school attended to control for SES effects.

• Exclusions: preterm, DM, placental problems, alcohol use in pregnancy.

• “Prenatal exposure to maternal cigarette smoking may promote obesity by enhancing dietary preference for fat, and this effect may be mediated in part through subtle structural variations in the amygdala.” (reward center possibly with role in limiting fat intake).

Date of download: 10/9/2012Copyright © 2012 American Medical

Association. All rights reserved.

From: Prenatal Exposure to Maternal Cigarette Smoking, Amygdala Volume, and Fat Intake in Adolescence

Arch Gen Psychiatry. 2012;():1-8. doi:10.1001/archgenpsychiatry.2012.1101

Figure. Association of prenatal exposure to maternal cigarette smoking with amygdala volume (A) and fat intake (B) in individuals with above median and below median body mass index (BMI). The median split was performed separately in exposed (E) and nonexposed (NE) individuals on age-adjusted and sex-adjusted BMI. The data are presented as age-adjusted and sex-adjusted means and standard deviations.

Figure Legend:

Illicit Drugs: Nutritional Implications

• Estimates of 4-10% of US newborns exposed to one or more illicit drugs in utero

• Illicit drug use strongly associated with inadequate maternal weight gain, anemia, poor dietary habits

• Knight et al. (FASEB, 1992) found lower serum ferritin, folate, vitamin C and B12

levels in women when cord blood reflected illicit drugs

Illicit Drug Use & Infant Outcomes: March of Dimes fact sheet

• In utero: Slowed fetal growth, reduced head circumference

• Perinatal: higher risk of CP, placental abruption

• Infancy: difficult to sooth and feed

Illicit drug use and adverse birth outcomes: is it drugs or context?

(Schempf & Stobino, J Urban Health, 2008)• In unadjusted results, marijuana, cocaine, and

opiates were related to increased odds of LBW. • No drug was significantly related to LBW when

adjusted for social, psychosocial, behavioral, and biomedical factors.

• About 70% of the unadjusted effect of cocaine use on continuous birth weight was explained by surrounding psychosocial and behavioral factors, particularly smoking and stress.

• Most of the unadjusted effects of opiate use were explained by smoking and lack of early prenatal care.

Illicit Drugs: Nutritional Implications

• Cocaine:– associated with fewer meals, increased alcohol and

caffeine and fat intake– 32% also classified as eating disordered

• Methadone– Higher birthweights than women who continue to

use heroine– diarrhea, constipation, nausea, anorexia, and dry

mouth• Heroin

– altered glucose tolerance - delayed glucose response

Position of the Academy of Nutrition and Dietetics: Use of nutritive and nonnutritive

sweeteners (2012)

• “All FDA-approved nutritive sweeteners and NNS are approved for use by the general public, which includes pregnant and lactating women.”

• One study completed after review: Among 59,000 Danish women, those who consumed one or more NNS-sweetened soft drinks per day were significantly more likely to deliver preterm.

Exercise

• Benefits:– improved or maintained fitness– reduces anxiety and depression– eases pregnancy discomforts such as

constipation, backache, fatigue and varicose veins

Exercise

• Contraindications– previous experience of preterm labor– ob complications including vaginal

bleeding, incompetent cervix, ruptured membranes, compromised fetal growth

– Hx of medical problems (hypertension, heart disease, etc.) requires health care provider approval

Exercise

• Changes with pregnancy– tolerance for strenuous exercise decreases

as pregnancy progresses• work of breathing increases as enlarging uterus

crowds the diaphragm• oxygen needs increase

– if lying flat on back after the 4th month, risk of compression of vena cava with dizziness and interference with blood flow to the uterus

Exercise

Changes with pregnancy, cont.– may have increased efficiency of heat

dissipation– altered sense of balance with shift in center

of gravity– high hormonal levels associated with lax

connective tissue and increased joint susceptibility

Postpartum

• Physiological changes persist 4 to 6 weeks postpartum

• Return to vigorous exercise should be gradual

• Return to physical activity may be protective against postpartum depression if exercise is stress relieving- not inducing

Cochrane: Aerobic Exercise for Women During Pregnancy (2006)• 11 trials involving 472 women• “The trials were not of high methodologic quality.”• Results:

– Regular aerobic exercise during pregnancy appears to improve (or maintain) maternal physical fitness

– Non significant, but concerning increased risk of preterm birth in exercise groups. From 7 trials: Pooled RR 1.82 (95% CI 0.35-9.57).

– Data insufficient to infer important risk or benefits for mother or infant

Continuous, Strenuous, Vigorous Activity Throughout Pregnancy

(Gunderson, Clin Obstet gynecology, 2003)

• Can reduce birth weight & length of gestation

• Additional carbohydrate recommended before activity

• Increased need for B vitamins• Careful screening for nutritional &

herbal supplements• Athletes at higher risk for Fe depletion.

Oral Health & Pregnancy: Major Concepts (Academy of General Dentistry)

• Increased risk for gingivitis (red,swollen, tender gums that are more likely to bleed) associated with increased estrogen and progesterone

• Frequent consumption of high cho foods may be used to combat nausea

• Cariogenic bacteria may be passed from mother to infant

• Periodontal disease is associated with preterm birth

Position of the American Dietetic Association: Oral Health and Nutrition, 2009

• Periodontal Disease: nutrient deficiencies increase susceptibility & compromise systemic response to inflammation & infection

• Primary determinants of cariogenic, cariostatic, and anticariogenic properties of the diet:– food form (liquid, solid or sticky, slowly dissolving)– frequency of consumption of sugar and other fermentable

Carbohydrates– nutrient composition,– potential to stimulate saliva,– sequence of food intake, and combinations of foods

Pregnancy Gingivitis

• 30-75% of women experience gingival changes such as edema, hyperplasia, redness, and bleeding

• Hormonal changes cause greater reaction to dental plaque

• Women who are plaque and inflammation-free at beginning of pregnancy have only 0.03 chance of gingivitis

Periodontitis• Definition: an infection caused by specific

bacterial plaque that involves loss of bone, fiber, and gum tissue attachment for the tooth.

• Smoking associated with increased prevalence and severity of periodontitis

• Periodontal infections caused by gram-negative pathogens are associated with increase in preterm delivery and/or PROM - one mediating factor is prostaglandin production triggered by bacterial products.

• Women with diabetes are at higher risk

Periodontitis (cont.)

• Pathogens and bacterial products may translocate and inhibit normal clearance of enteric organisms from genitourinary tract.

• Overgrowth of gram negative bacteria and infection can be associated with preterm birth.

Can preterm birth be prevented by periodontal treatment?

• NIDCR funded two large RCT – women assigned to treatment or no treatment – Oral Therapy to Reduce Obstetric Risk

(OPT) – results published in 2006– Maternal Oral Therapy to Reduce Obstetric

Risk (MOTOR) – results published in 2009

• Other large trial reports

OPT: Treatment of Periodontal Disease and the Risk of Preterm Birth

(Michalowicz et al. NEJM, Nov. 2006)

• 823 women with periodontal disease, enrolled between 13-17 weeks gestation, randomized to:– Scaling and root planing before 21 weeks; monthly

polishings– Scaling and root planing after delivery

• Major Outcomes: – no difference in rates of preterm birth or low

birthweight– no adverse outcomes associated with treatment

MOTOR: Effects of periodontal therapy on rate of preterm delivery: a randomized controlled

trial (Offenbacker et al, Obstet Gynecol, 2009)

• 3 site RCT, 1,760 women with periodontal disease, assigned to:– Scaling, root planing early in T2– Treatment after delivery

• No significant differences with regard to adverse events or major obstetric and neonatal outcomes

2 Recent Trial Reports

• Australia RCT, 1,000 women (Newnham et al, Evid Based Dent. 2001): – No differences in preterm birth, fetal growth restriction,

preeclampsia– Periodontal tx not hazardous to women or pregnancies

• US Periodontal Infections and Prematurity Study (PIPS), 750 women (Macones et al, Am J Obstet Gynecol, 2010)– TX did not reduce risk of spontaneous preterm delivery

(SPTD) – “Suggestion” of increased risk in SPTD < 35 weeks with

active tx (RR 3.01, 95% CI, 0.95-4.42)

All Periodontal Treatment Impacts are not the Same:

• Periodontal infection and preterm birth: successful periodontal therapy reduces preterm birth (Parry et al, BJOG, 2010)– At 20 week FU treated women categorized

as successful (no periodontal disease) or not successful (ongoing disease)

– Successful treatment protected against preterm birth (OR 6.02, 95% CI 2.57-14.03)

American Academy of Periodontology Statement Regarding Periodontal

Management of the Pregnant Patient (2004)

• Achieve a high level of oral hygiene prior to becoming pregnant and throughout pregnancy

• Periodonal treatment (eg; scaling and root planing) is usually scheduled in second trimester

• Emergencies such as acute infection and abcess may require immediate treatment regardless of stage of pregnancy)

• Consultation with prenatal care provider

Oral Health: Recommendations

• Frequent dental cleanings (3 to 6 months)• Daily oral care routines including brushing

and flossing at least twice daily and after eating

• Use of toothpastes and rinses with fluoride• Consider cariogensis in food choices and

patterns.• Offer smoking cessation programs

Improving Access to Perinatal Oral Health Care: Strategies & Considerations for Health Plans

(Issue Brief July 2010)

• National Institute for Health Care Management Foundation – http://nihcm.org/pdf/NIHCM-OralHealth-Final.pdf

“Research has exhibited an association between periodontal disease in pregnant women and adverse birth outcomes, such as low birth weight, preterm birth, preeclampsia and gestational diabetes. Because studies have shown conflicting results on the relationship between periodontal disease and birth outcomes, and there is no general consensus on this association, further research is needed to explore and confirm this possible correlation. However, research does universally support the safety of dental treatment during pregnancy and confirms that maintaining good oral health prior Improving Access to Perinatal Oral Health Care: Strategies & Considerations for Health Plans to and during pregnancy remains a key factor in achieving overall health and well-being for women and their infants.”

“Mother-to-child transmission of bacteria is the primary vehicle through which children first acquire dental caries, the disease process that causes cavities. These bacteria are transmitted through saliva that is passed from a caregiver’s mouth to achild’s. The healthier the mother’s mouth, and the longer the initial transmission of caries-causing bacteria is delayed, the more likely children are to establish and maintain good oral health.”