21 minute read
Oral Health Intervention Before Pregnancy: A Preconception Approach
Rachel Anderson, BS, is a medical student at the University of Massachusetts Chan Medical School. Conflict of Interest Disclosure: None reported.
Hugh Silk, MD, MPH, FAAFP, is a professor in the department of family medicine and community health at the University of Massachusetts Chan Medical School. He also teaches at the Harvard School of Dental Medicine. Conflict of Interest Disclosure: None reported.
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Oral disease is prevalent and has wide-ranging ramifications that have an important impact on overall health across the lifespan. [1] Almost 100% of adults will suffer from caries, which can be complicated by abscesses, hospitalization and death, [2] and 50% of adults will suffer from periodontitis, which has been linked to numerous poor health outcomes. [3] The devastating effects of poor oral health are experienced disproportionately by communities of color and those who are impoverished. These disparities are provoked by limited access to care, systemic racism and competing priorities of health and social needs. [4] Efforts have been made at nearly every stage of the lifecycle to reduce the burden of oral disease including prenatal, pediatric and geriatric care. However, interventions in the preconception phase, which encompasses the entire lifecycle during which a woman is not but could become pregnant, beginning at menarche and concluding with menopause, have been limited, and this could represent an untapped opportunity to improve oral and systemic health outcomes for women of childbearing age and their offspring. [5]
Importance of Oral Health in the Preconception Phase
The preconception phase, prior to a pregnancy, may be particularly important for caries prevention in children born to mothers with significant oral disease (FIGURE). Oral disease begins early in life as soon as teeth begin to erupt, and early caries affect a child’s growth, selfesteem and long-term dental outcomes in adulthood. [6–8] Studies have shown that caries-causing bacteria are passed from caregivers to offspring around the time of tooth eruption in infants. [9] If women received oral health care prior to pregnancy and their bacterial load was decreased at this time, caries rates in children would likely be reduced. [10]
In addition to increasing caries risk in offspring, oral disease during pregnancy can be harmful for the pregnant individual’s health. Periodontal disease has been linked to adverse pregnancy outcomes including preeclampsia, gestational diabetes, preterm delivery and low birth weight. [11–13] As such, treatment of oral disease prior to pregnancy could be conducive to nurturing healthy mothers, healthy pregnancies and healthy infants. There are numerous barriers to dental care during pregnancy, and pregnant individuals are less inclined to be seen by dentists during pregnancy and in the 12 months after pregnancy. [14] In fact, only 46% of pregnant people receive any dental care. [9] However, even for those who do receive treatment for periodontal disease during pregnancy, the treatment has failed to decrease adverse outcomes such as preterm birth, fetal growth restriction and preeclampsia. [15] It has been hypothesized that treating periodontal disease during pregnancy is too late, as the disease-related inflammatory cascade has already begun. [16] As such, it may be favorable to take a more upstream approach, addressing oral health needs in the preconception phase.
The importance of oral health education in the preconception phase may have added benefits for women trying to get pregnant. Emerging research suggests that oral disease negatively impacts fertility. Studies have shown that women with periodontal disease take longer to conceive, even when controlled for factors known to affect fertility such as age, BMI and smoking status. [17] Further, women with infertility have higher numbers of advanced caries and higher indicators of dental disease such as the percentage of bleeding on probing, gingival index and probing depth. [18]
Addressing Oral Health in Preconception
An effective approach to preconception oral health requires a multidisciplinary approach that involves both dentists and medical providers including family physicians, internists, obstetricians and gynecologists (OB- GYNs), midwives and their nurse practitioner (NP) and physician assistant (PA) counterparts providing consistent messaging and synergistic care. The SAMHSA-HRSA Center for Integrated Health Solutions proposes a six-tier approach to oral health integration. [19] Level one begins with medical providers addressing oral health needs in their own settings. Level two adds an aspect of communication between medical and dental providers in individual patient care. Level three requires increased communication and level four incorporates sharing of records and face-to-face interactions. In level five, medical and dental providers often share an electronic health record (EHR) and seek ways to work together through regular meetings. Finally, in level six, medical and dental providers work seamlessly together to provide continuous multidisciplinary care. Integrated medical-dental care, at any level, includes providing education, mitigating risk factors, delivering preventive care and treating active disease.
To better understand the challenges of achieving such a high level of integrated care, one must acknowledge that the U.S. health care system is complex, consisting of a wide variety of medical and geographical settings. Level six medical-dental integration will be achievable only in ideal settings. As such, providers must have a broad range of options for oral health care delivery so that they can provide such care in a way that works best within the confines of their practice and their community.
Historically, oral health education has been well-integrated into pediatric well-child visits, and the American Academy of Pediatrics’ Bright Futures practice guidelines provide topics for relevant anticipatory guidance for each age group, including adolescents who are in the beginning of the preconception phase. [20] Anticipatory guidance for adolescents includes making regular dental appointments, brushing teeth twice daily with fluoridated toothpaste, flossing daily, limiting sugary snacks and drinks, drinking fluoridated water, using protective gear such as mouthguards to prevent traumatic dental injuries and avoiding smoking. [20] Similar education and anticipatory guidance should continue to be addressed at well/annual visits into adulthood. Well visits also provide an opportunity to address risk factors for oral disease. Some risk factors such as poverty, racial discrimination and access to dental care can be extremely challenging to effectively address. Other risk factors such as poor personal dental hygiene and high-sugar diets can be more easily addressed with education and consistent messaging. Preventive oral health care should be offered during primary care office visits as indicated by age and risk. This may include applying fluoride varnish, prescribing oral fluoride supplements or offering xylitol gum and chlorhexidine rinses when appropriate. Annual physical exams are an ideal time to perform an oral exam to look for active disease. Those with active periodontal disease and/or demineralization and caries should be referred for treatments such as scaling, root planing, restorations, root canals and extractions respectively.
Primary care providers must approach oral health in the preconception period much like cervical cancer or heart disease by proactively educating, screening, preventing and treating early disease. Oral health is a component of systemic health and must be taken seriously and addressed routinely. To ensure healthy mothers, healthy pregnancies and healthy infants, this preventive approach to oral health must be used to address and treat oral disease in preconception.
Next Steps
While medical-dental integration in the preconception phase is theoretically simple, the reality of incorporating oral health into preconception care can be quite challenging. Lasting changes in medical education and practice typically occur through a combination of incentives and mandates. Incentives can include readily available curricula, efficient workflow designs and financial reimbursement, while mandates often include national education accreditation requirements, quality improvement standards and public reports of clinician outcomes.
Involving Trusted Medical Organizations
If providers who care for women during the preconception phase are serious about changing their practices, they must expand upon their current collaborations with trusted organizations to evolve and promote clinical guidelines and recommendations, such as the American Academy of Family Physicians (AAFP), American College of Obstetrics and Gynecology (ACOG) and American Academy of Pediatrics (AAP) as well as their NP, PA and midwifery counterparts.
This should occur concurrently with dental organizations such as the American Dental Education Association (ADEA) and the Commission in Dental Accreditation (CODA). Providers must encourage these organizations to continue to emphasize the importance of oral health, publish preconception oral health guidelines for clinical practice and set standards for the inclusion of preconception oral health in medical and dental education as part of an emphasis on oral-systemic health. Further, they must utilize the guidelines to their fullest extent in clinical practice and encourage their peers to do the same.
Many trusted medical organizations have already taken tremendous steps in promoting preconception oral health. The AAFP is editing its original preconception care position paper to include advice for oral health promotion. [21] The ACOG’s committee opinion “Oral Health in Pregnancy and Through the Lifespan,” which was created in 2013 and reaffirmed in 2017, includes the importance of oral health for a woman’s general health throughout her life and the importance of reducing the transmission of caries-producing oral bacteria from mothers to their infants. [22] A consortium of oral health advocates have recently submitted oral health as a topic for The Women’s Prevention Services Initiative to consider including as one of their recommended health topics for women. [23] The Center for Integration of Primary Care and Oral Health (CIPCOH) is carrying out a project called the 100 Million Mouths campaign to recruit and train educational oral health champions in each state to engage health schools, programs and residencies to teach oral health promotion and disease prevention. [24] The American Academy of Pediatrics already has oral health champions to engage pediatric clinicians around oral health. [25] The Primary Care Collaborative has created a report entitled “Innovations in Oral Health and Primary Care Integration” promoting mechanisms and scope of integration efforts. [26] Sharing these efforts, endorsed by these organizations that providers already trust for clinical guidelines, will be fundamental in the integration of oral health into preconception care.
Providing Easily Accessible Curricula
Easy access to oral health curricula for providers is essential to incorporating oral health into medical education and clinical practice. Smiles for Life is an existing national resource that consists of a comprehensive oral health curriculum targeted at primary care providers and includes a module focused specifically on
pregnancy and women’s oral health, which promotes addressing oral health at all women’s well visits. [27] In addition to Smiles for Life, there are other proven curricula including the American Academy of Pediatrics Tiny Teeth and the Association of American Medical Colleges’ (AAMC) Oral Health Collection of MedEdPortal touching on a range of oral health topics for women. [24,28,29] Of course this curricula should be edited as new evidence becomes available and efforts should be made to promote these curricula that many schools and programs are unfamiliar with. [30] Most health care providers have continuing education requirements to maintain their licensure. Incorporation of oral health education into continuing education requirements for physicians and their PA/NP counterparts would increase awareness of the importance of oral health, especially in preconception.
Engaging Upstream Learners
While incorporating oral health into continuing education is a step toward educating clinicians on this important topic, it would be best to take a more upstream approach and highlight the importance of oral health during preconception to medical learners beginning in medical, PA, NP and midwifery school. Midwifery is an excellent example of successful integration of oral health. Midwifery education has core requirements for oral health teaching, and 100% of programs currently teach oral health to students. [31] Schools can use CIPCOH’s Entrustable Professional Activities (EPAs) for oral health to calibrate their offerings. [32] Other resources for ensuring a comprehensive curriculum would be the AAMC’s Oral Health Core Competencies or Smiles for Life’s comprehensive list of objectives. [27,33] Schools and programs should be encouraged to have a spiral curriculum with small amounts of oral health offered in many courses and rotations to normalize oral health as part of overall health and wellness. For preconception oral health, topics to teach would include oral anatomy, risk history, oral exam, dental hygiene promotion and awareness of referral resources. Curricular evaluation could be performed by multiple choice and short-answer questions, oral reports and observed feedback in clinical encounters.
The importance of oral health should be further emphasized in residency programs that train physicians who care for preconception-age women — family medicine, internal medicine, OB-GYN and pediatrics. Existing curricula must be promoted widely to program directors at national academic conferences and relevant academic journals. For true universal integration, accreditation standards must be developed. OB-GYNs are often the primary point of contact with health care for women in the preconception phase, but less than half of OB-GYN physicians receive oral health training during residency. 30 Because oral health is so neglected in their training, less than 12% of OB-GYN physicians have referred preconception women for dental care. [34] While 81% of family medicine residencies include oral health education, only 31% include four hours or more of oral health education, [35] leaving significant room for improvement. Pediatric residencies tend to include more appropriate amounts of oral health education, which can be largely attributed to the importance placed on oral health by the AAP, but specific coverage of preconception oral health is unknown. [36] Lastly, over 100,000 internists in the U.S. provide primary care, yet oral health education in an internal medicine residency is essentially nonexistent. [37,38]
Facilitating Incorporation Into Clinical Practice
One of the largest challenges to incorporating oral health care into preconception well visits is the significant time constraints that primary care providers face. As such, it is crucial to provide tools to ease the integration of oral health care with a minimal time burden.
Electronic health records (EHRs) have been found to improve the quality of preventive care by reminding providers when preventive care is due and generating feedback to determine if preventive care targets are being met. [39] Oral health screening is preventive care and can be incorporated into the EHR in this way with simple prompts.
Other measures to ease clinical incorporation of oral health include dividing tasks from the front staff to the clinician, having handouts available and setting up billing codes as needed (e.g., fluoride varnish). This requires an office champion, some basic in-service training and periodic reports on quality. It is not difficult but does require an initial investment of time and energy. Qualis Health and others have created very clear documents with examples and case studies. [40]
Educating Preconception Women Directly
In addition to training medical providers, public outreach campaigns directly targeting women of preconception age can empower them to self-advocate for their oral health. Addressing the oral health of other caregivers, including fathers and adoptive parents, during this same time period prior to the introduction of a newborn could further decrease the risk of passing caries-causing bacteria to infants. Social media campaigns have shown promising results in the public health realm, particularly in motivating users to take small, concrete actions. [41] Social media campaigns have been utilized in this manner by large medical organizations, including the World Health Organization (WHO) and Center for Disease Control (CDC). The AAFP, AAP, American College of Physicians (ACP) and the American Dental Association (ADA) together have over 150 million Instagram followers, representing a significant opportunity for a wide-reaching oral health education campaign.
In an age of rampant misinformation, it is important to create easily accessible resources for those looking for accurate information. Oral health fact sheets written at a variety of different health literacy levels and directed at the general population should be published in a central online location. Information should include the effects of oral disease on overall health, pregnancy and newborn health. The AAP and ADA have such resources; however, they need to be more widely promoted on popular medical consumer sites. [42,43]
Conclusion
Oral health is an important yet frequently neglected component of overall health and as such should be a focus of primary care providers. Oral disease can cause or is associated with systemic illness such as infection, heart disease and diabetes. During pregnancy, oral disease has been linked to poor outcomes. Infants born to mothers with oral disease are more likely to have early childhood caries, putting them at greater risk of oral disease later in life. Because oral disease is detrimental to mothers, newborns and pregnancy itself, interventions during pregnancy have been attempted to decrease the adverse outcomes but have been ineffective, as pregnancy appears too late to stop the complications. As such, experts have suggested a more upstream approach to identifying, preventing and treating oral disease prior to conception. Such an approach requires coordinated care between dentists and medical providers who treat preconception women. To foster clinical practice changes, we must gather support from trusted medical and dental organizations, provide easily accessible mandated curricula for providers, integrate oral health into medical education at all levels and create workflows and EHR shortcuts to ease clinical practice incorporation. We must also educate women and other caregivers directly about the importance of oral health to promote healthier mothers, pregnancies and infants.
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THE CORRESPONDING AUTHOR, Rachel Anderson, BS, can be reached at rachel.anderson@umassmed.edu.
