How do you serve your pregnant patients? Do you serve them at all? Do you educate them to debunk the myths surrounding pregnancy and oral health? My hope is to provide you with a few compelling reasons to be proactive in treating these patients, because dentistry is not just about teeth anymore.
Our patients are more aware of their health and are more discriminating about taking care of their bodies than ever before. Of particular interest to dental professionals is that the media and researchers are making the public more aware of the possible connection between active periodontal disease and systemic health concerns. One in particular is the connection between periodontal disease and preterm labor and/or low-birth-weight babies.
In a recent study, researchers at the University of Alabama, Birmingham, found that women with generalized periodontal disease are four to seven times more likely to deliver prematurely than mothers with healthy gums.1 As hygienists, we are responsible for being a contributing part of the healthcare team. In order to be proactive, we must be knowledgeable about current health topics and ready to offer help to our patients.
Zeeman et al2 recently noted that the connection between periodontal disease and low birth-weight has not been reported in OB/GYN and medical journals. Popular women’s magazines are, however, reporting the possible connection between gum disease and preterm labor. What do you think will happen next? Our female patients, especially, will ask their hygienists what they can do to prevent problems with their pregnancies, related to their dental health.
There is a lot we need to know about this very important issue. First and foremost, we need to know that in educating our patients about the risk of low birth-weight, we are protecting the next generation. What more reward could we ask for than the health of our children? The significance of this particular health issue, risk factors for preterm labor, and the current research findings are all things of which we, as hygienists, must be aware. This is definitely a significant health issue affecting women and children.
According to a 1999 report from the National Center for Health Statistics,3 preterm labor and low birth-weight are the second leading cause of infant mortality in the United States, and resulted in over 4,000 infant deaths that year. Jared et al4 noted that preterm infants are nearly seven times more likely to die before their first birthdays than are term infants.
Generally, preterm labor is defined as labor occurring at 36 weeks or earlier. Low-birth-weight babies weigh approximately 5.2 pounds or less. The risk factors for preterm labor include the mother’s age, race, extent of prenatal care, smoking, alcohol and drug use, and infections during pregnancy. When we look at risk factors in an effort to reduce the risk of a disease, we look for factors that can be modified. Periodontal infection is a modifiable risk factor.
Let’s think about the following myths: for each pregnancy a woman loses one tooth; bleeding, swollen, and tender gums during pregnancy are normal; dental treatment during pregnancy is dangerous. What do all these myths have in common? Tooth loss and bleeding gums are a sign of disease and the need for dental treatment, other than preventive care, indicates some type of dental disease. Because the public believes these myths, periodontal disease is allowed to progress, increasing the risk of poor pregnancy outcomes. Granted, it is not prudent to do major, invasive dental treatment with heavy anesthetic during the first trimester. I am neither promoting excessive treatment nor being casual with the fragility of pregnancy. These are the very reasons I urge you to be proactive. It is our job, as dental healthcare providers, to properly identify, educate, and treat oral disease in order to reduce the risk. More importantly, we must educate our patients in prevention and be aggressive in treating gingivitis and the earliest stages of periodontal disease.
Dental researchers are finding greater amounts of evidence to support the theory of periodontal disease as a risk factor for systemic health problems, including poor pregnancy outcomes. These studies gather information in many different ways. One way is by gathering periodontal pocket readings and gingival crevicular fluid (GCF) samples from study participants. The pocket depths give an indication of the severity of the disease. The GCF samples allow scientists to study the biological information held in that fluid. These bits of information give us the key to unlocking a connection between periodontal disease, preterm labor, and low birth-weight.
PERIODONTAL DISEASE IS AN INFECTION
Periodontal disease is an inflammatory response brought about by bacterial invasion of the periodontium. During the inflammatory response, there is a cascade of biological events that controls its progression. Cytokines and other inflammatory mediators control these events. Inflammatory mediators, which include cytokines, are molecules that control one or more aspects of the inflammatory response. Cytokines are soluble polypeptide mediators that are involved in cellular growth, function, and healing. They are signaling proteins that control local and systemic immune and inflammatory response.5
The inflammatory mediators associated with periodontal disease are prostaglandin E2 (PGE2), tumor necrosis factor-alpha (TNF-a), interleukin-1 (IL-1), interleukin-6 (IL-6), and interleukin-1b (IL-1b).4 These mediators are found in high concentrations in the GCF in the presence of periodontal disease and tend to increase with the level of gram-negative bacteria and inflammation. The aforementioned mediators are also found in high levels during labor6 because they play a role in the onset of labor. Studies have shown that the risk for preterm labor increases with the severity of periodontal disease.6
Hence, the connection is made. Studies are not conclusive, but they are continuing. The latest results of ongoing research have been published in the 2001 edition of the Annals of Periodontology.7 There are many other articles packed with the scientific data to further explain this connection. (Please consult list of recommended reading.)
THE HYGIENIST’S ROLE
Hygienists can have an impact in several ways. The first is being very thorough and delivering outstanding customer service within their practices. The second is helping to spread the word in their communities.
As you know, the ultimate in customer service is to provide what the customer needs before she even knows she needs it. This holds true in the world of dentistry, also. Tools are needed to determine these needs. One such tool is the patient interview. This tool should be utilized with every patient: new or existing, male or female, pregnant or not. It can be done by the dentist or any auxiliaries who are properly trained. Hygienists can train other team members in this process in order to ensure continuity of care. The interview includes questions about why the patient chose to be a part of your practice, what things he or she expects of you and the dentist, and how you are doing in meeting those expectations.
The interview also includes a review of the patient’s medical and dental history. During the interview, ask about her past experiences with dentistry. How long has it been since her last dental exam and cleaning? Do her gums bleed at any time? Do her gums feel puffy or tender? Are there any concerns about her oral health? Has the patient noticed any unusual lumps or bumps in the mouth or head and neck region? Talk to the patient about her home care.
Now, move into the medical history. Thoroughly question the patient about the prescription and /or over-the-counter medications, vitamins, and herbal supplements she is taking. Be aware of the possible reactions between her medications and/or supplements, and educate her to the best of your ability. Consult the Physician’s Desk Reference or Mosby’s Drug Reference whenever necessary. Ask why they are taking these medications. Discuss her health concerns. Ask about recent surgeries, chronic pain, and systemic health problems. As she tells you about her health concerns, LISTEN. This is the perfect time to educate your patient on the need for optimal oral health. Then you can say, “You know, I’m glad you shared that with me. Every day, research is finding that infections in our mouths can affect the rest of our body. Did you know that having periodontal disease could increase the risk for having a low-birth-weight baby or having a heart attack or stroke?” Being knowledgeable about such issues is essential to increasing the value of the dental hygiene profession. Being a true healthcare provider increases the value of our services with patients, co-workers, and employers.
GETTING THE MESSAGE OUT
Getting the message out in your community can be accomplished in several ways. Be creative and serve your neighbors. Contact the local hospital to find out how you can contribute to the health of the community’s mothers. The obstetrics department can help guide you to the right place. Conduct a 10-minute workshop at the beginning of a Lamaze class. Print material from the ADA website (www.ada.org) and the American Academy of Periodontology website (www.perio.org) to share with the participants. Each of these websites has consumer pages with easy-to-read explanations of research findings regarding the relationship between periodontal disease and preterm labor. Contact the public health department in your county or city. They often offer free prenatal classes. The women attending often are referred by their doctors very early in their pregnancies. This is the perfect time to educate them before it is too late. This is also a great opportunity to talk about infant dental care. My experience has been that the directors of these programs are thrilled to have an expert deliver this information.
After researching this issue yourself, it would be great to write an article for your practice newsletter reporting this information to your patients. These newsletters are an informative and subtle marketing tool used during the workshops you deliver. Be sure to include your name, your doctor’s name, and the office phone number. A survey could be included in the articles and workshops asking questions pertaining to prevention, signs and symptoms of periodontal disease, and the common myths surrounding pregnancy and dental health. Another opportunity is to deliver this information to your local dental hygiene society, making sure the hygienists in your community are armed with the knowledge they need to properly educate their patients. The bottom line is to get this information out there. Once you feel comfortable sharing this with others, you may want to learn more about other systemic conditions that are affected by periodontal disease and share that knowledge as well.
This article is intended to pique your interest in the relationship between periodontal disease and our country’s leading health concerns. I also hope it triggers thoughts about how to better serve your patients and be a true healthcare provider. My greatest desire, however, is that it will inspire you to raise your personal standard of care, the level of care you deliver to those who seek it. Every day, researchers are learning more about the mouth-body connection. It is time for those of us “in the field” to put this knowledge to practical use. Don’t compromise your standard of care because of resistance from a patient or a co-worker. Educate your patients with what you know in your heart and mind to be true, and they will know that you care and that the treatment you recommend is in their best interest. Be honest and use all the educational tools at your disposal during the clinical evaluation. Whether this is a diagram, intraoral photographs, x-rays, or a simple hand mirror, create an interactive experience for the patient, and he or she will respond with appreciation and compliance.
Webster’s Dictionary defines health as “freedom from disease.” This implies that healthcare providers are not merely obligated to treat disease; we must guide those we care for in the search for health and in the prevention of disease. As we become increasingly enlightened about the connection between oral and systemic health, we must share this knowledge with our patients. We must be proactive in providing them with the tools to prevent disease.
Chronic maternal gum disease strongly linked to premature birth. American Dental Association news release; July 19, 2001. Available at: www.ada.org/public/media
. Accessed on 1/15/02.
Zeeman G, Veth E, Dennison D. Periodontal disease: implications for women’s health. Obstetrical Gynecological Survey. 2001;56:43-49.
Infant Mortality Rate 1999; National Center for Health Statistics. Available at: www.cdc.gov/nchs/fastats
. Accessed on 1/15/02.
Jared H, Lieff S, Wilder R, et al. Periodontal disease and low birth weight: a critical link? Access. 1999;3:32-37.
Stites D, Terr A, Parslow T. Basic and Clinical Immunology. 8th ed. Norwalk, Conn: Appleton and Lange; 1994;:42-47,105,137-147.
Jeffcoat M, Geurs N, Reddy M, et al. Periodontal infection and preterm birth. J Am Dent Assoc. 2001;132:875-880.
- American Academy of Periodontology Adverse Pregnancy Outcomes. In: Annals of Periodontology. Chicago, III; December, 2001.
Gaffield M, Gilbert B, Malvitz D, et al. Oral health during pregnancy. J Am Dent Assoc. 2001;132:1009-1016.
Jackson C. Moms-To-Be, Brush Up! Available at: www.WebMD.com
, Search: Pregnancy and Periodontitis. June 5, 2000. Accessed on 2/4/02.
Mosby’s Drug Reference. 5th ed. St Louis, Mo: Mosby, Inc; 2001.
American Academy of Periodontology. Parameter on systemic conditions affected by periodontal diseases. J Periodontol. 2000;71(Suppl):880-883.
Website of the American Academy of Periodontology. Available at: www.perio.org.
Website of the American Dental Association. Available at: www.ada.org.