May 11th 2015

1. Maternal and Early Childhood
Oral Health
A 2-year project:
Bring together stake holders
Create tools and resources
Increase awareness and
understanding

2. Promoting oral
health among
pregnant women
is a powerful
window of
opportunity for
lifelong oral health
for mothers and
their children.

3. 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

4. Maternal Oral Health Project Team
Dr. Alyssa Hayes
College of Dentistry, University of Saskatchewan
Christine Thompson
Saskatchewan Prevention Institute
Janet Gray
Population Health Unit, Mamawetan Churchill River Health Region, Keewatin
Yatthé Health Region & Athabasca Health Authority
Kellie Watson
Saskatchewan Dental Hygienists’ Association
Leslie Topola
Saskatoon Health Region, Oral Health Program
Megan Clark
Saskatchewan Prevention Institute
Marcella Ogenchuk
College of Nursing, University of Saskatchewan

5. Saskatchewan
Consensus Document
Goals:
Oral and prenatal care providers in
Saskatchewan have an
understanding of the importance
and 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

6. Target
Audiences
Oral care
providers
Ministry of
Health
Health
professional
associations
Prenatal
care
providers
Primary
health care
managers
Academics

7. 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

8. Public Education
Materials
Poster

9. Information Cards

10. Materials are available for order
from:
www.skprevention.ca
Small counter display
Large floor display (for loan)

11. 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

12. Pregnancy is a
Time for
Smiling…
and a time to pay extra
attention to your teeth and
mouth
Oral Health for
Moms and Babies

13. Your thoughts?
Do you think of these materials are useful?
Will you distribute them to pregnant women and
families?
How would you distribute them?

14. Continuing Education for:
Oral Health Professionals
Prenatal Health Professionals

15. Oral Health during Pregnancy
Practice 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

16. 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

17. The following guidelines and
documents informed the
development of this
presentation

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

19. New York State Dept. of
Health (2006). Oral Care
During Pregnancy & Early
Childhood Practice
Guidelines.

20. 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.”

22. 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.

23. 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.

24. Pregnancy increases
the risk for oral
disease.
This is due to
hormonal changes
and changes in
eating patterns (such
as increased
snacking).

25. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

34. “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.

35. 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.

36. “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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. Pharmacological Considerations for Pregnant and Breastfeeding Women
Drug FDA Classification Teratogenic Risk Evidence
Quality
Restrictions/Special Considerations
ANALGESICS
Aspirin 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.

43. ANTIBIOTICS
Penicillin 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.

44. 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.

45. 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.

46. 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.

47. 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.

48. 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.

49. 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?

50. 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

51. 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?