Oral Healthcare for Pregnant Women | Maneesh Gupta
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It's essential for you to take excellent care of your tooth and gums while pregnant.Listed below are some guidelines to support you manage good oral health before, throughout, and after pregnancy.
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Oral Healthcare for Pregnant Women | Maneesh Gupta
- 1. Promoting Oral Health Care for Pregnant Women | Maneesh Gupta
- 2. Overview • Importance of Oral Health • Current CA Availability Issues • National and Situation Updates • Possible Solutions to Enhance Access • Local Program Examples
- 3. Oral Health as Part of Prenatal Care
- 4. Improving the Oral Health of a Pregnant Woman 1. Prevents problems of dental diseases during pregnancy 2. Has the potential to decrease beginning youth caries 3. May decrease preterm and low starting weight deliveries
- 5. Are Pregnant Women Getting Dental Care in CA? • 34.5% of members visited a spoken professional or oral hospital during their pregnancy • Most were non-Hispanic white, English talking about, experienced beyond school, and had insurance
- 6. Are Expecting Females Getting Oral Proper care in CA? • 40% of females with higher education educations or in maximum earnings classification did not have a oral check out during pregnancy • 62% of females confirming oral issues did not get good care during pregnancy • 21% of females confirming a oral issue considered they didn’t need to go to a dentist
- 7. Primary Reason for not Getting Oral Care among each woman sampled • Did not understand a need to go (38%) • No insurance plan or it cost too much (21%) • Didn’t want to go or too active (19%) • Believed oral treatment was risky (14%) • Provider guidance against getting proper care (8%)
- 8. Factors Dental practitioners May Not Be Dealing with Expecting Women • Therapy often prevented and misinterpreted by health professionals • Fear of hurting either the girl or the fetus • Failure of recommendation due to deficiency of training • Pregnant females more likely to search for healthcare care/advice • Lack of suppliers who will cure females with community insurance policy (Denti-Cal)
- 9. 9 Expecting Individual Population: Nearly all interviewed are currently dealing with pregnant sufferers, and recognizing new sufferers who are pregnant. A little community (15%) only agree to new sufferers with a pre-natal provider’s launch. Few cure pregnant sufferers under condition applications. 96% 4% 82%, always 15%, with provider release Currently treat pregnant patients Accept new patients who are pregnant Yes No Yes, with pre-natal provider's release 20% say they treat pregnant patients insured by state programs
- 10. Why is it challenging to relate a customer to a Medi-Cal oral provider?
- 11. So how do we enhance dental medical care for pregnant women?
- 12. Cash is an Issue!
- 13. Recent Access Reports • Two IOM reports on accessibility this year • Advancing Oral Wellness in American • Improving Access Oral Wellness Care for Vulnerable and Underserved Populations • Pew Children’s Oral Campaign • Children’s Partnership – Oral Wellness Agenda • ADA/CDA efforts
- 14. ADA Access to Dental Care Summit – March, 2009 “What are we going to do, in rapid and the long phrase, both independently and jointly, to assure maximum dental wellness through prevention and strategy to underserved people?”
- 15. CDA’s Access Report Phased Strategies for Reducing the Barriers to Dental Care in California • Developing State Oral Health Management and Improving Current Sources (Years 1-3) • Focusing on Protection and Early Involvement for Children (Years 3-5) • Innovate the Oral Distribution System to Increase Potential (Years 4-7)
- 17. Solutions
- 18. Integrate Oral Health Care into Overall Health Care
- 19. 19 Usage of Prenatal Care Guidelines: Two-thirds of dental practitioners say they currently use some sort of recommendations when dealing with expecting sufferers. Almost all would use such recommendations if they were available from a reliable resource. Yes, 68% DK, 10% No, 22% Do you currently utilize clinical guideline/s for pregnant women? If recommendations on appropriate take good care of expectant mothers were easily obtainable from a reliable resource, how likely would you be to use them? Very Likely: 90% Somewhat Likely: 7%
- 20. Dental Wellness During Maternity and Early Childhood: Evidence-based Recommendations for Wellness Professionals
- 21. Improve Oral Health Literacy
- 22. Enhance the Delivery System within Dental Profession
- 23. Health Collaborations • CHDP • WIC • Head Start • Home visitation • Obesity and nutrition • Diabetes and other serious disease • Substance abuse • Childhood injury • First 5 Commissions
- 25. Ask Questions During Prenatal Exam • Do you have loss of blood vessels gum area, teeth discomfort, area, decrease teeth or other issues in your mouth? • Have you had a dental check out in the last 6 months?
- 26. Guidelines for Health Care Professionals • Advise that dental proper care is safe and effective during pregnancy • Can be done any time while pregnant with no additional risk as compared to not providing care • Don’t delay treatment
- 27. Safety Concerns in the Dental Office • Analytic x-rays can be used during pregnancy • Xylocaine with epinephrine can be used during pregnancy
- 28. Tips to Keep Mom Healthy • Sweep tooth 2 X day with fluoride tooth paste, especially before bed time, and get flossing daily • Chew xylitol gum 4 to 5 X day, especially after meals • http://www.first5oralheal th.org/ • Drink fluoridated water
- 29. Reduce Risk of Decay in Children • Decrease the decay-causing bacteria in the mouth • Reduce the visibility of these bacteria to fermentable carbohydrate food and sugars • Increase the corrosion level of resistance of the teeth
- 30. Client Brochures Cavity Keep Away Two Healthy Smiles cdafoundation.org mchoralhealth.org
- 31. Examples of Local Efforts • Alameda – lead venture with Early Head Start focusing on expecting teens • Contra Costa – markets company details and prescribed design to CPSP suppliers, designed customer brochure • Imperial/Plumas – manager provides outreach and education • Siskiyou – 100 OH packages through OB providers • Stanislaus – attention campaign
- 32. Summary • Continue to do the best we can with the sources we have • Educate medical/dental providers • Watch for and improve nationwide dental health knowledge campaign • Create new ways to use workforce • Collaborate and system with OH advocates • Enhance customer knowledge to improve prevention
- 33. Thank You!
Editor's Notes
- Solutions you may want to consider to increase access in your own location.
- Why? Nutrition, healthy weight gain, substance abuse and oral health – foundation of prenatal care. Reduce oral infection. It could be argued that a child’s oral health care begins during pregnancy. OH status of children is linked to OH status of their mothers, and children’s use of services is higher when mothers have regular access to care Current recommendation from CA Perinatal OH Guidelines – encourage all women at the first prenatal visit to schedule a dental exam if one has not been performed in the past 6 months, or if a new condition has developed or is suspected. However women are unaware of the importance of maintaining oral health during preconception and pregnancy. Stories from survey of low-income pregnant women and new moms about their knowledge and behaviors– “When I was pregnant, my teeth hurt so bad, during all my pregnancies. So I actually went to the dentist at 8 months…it was terrible…after I had my son, I had 2 teeth pulled because the calcium was all gone.” “I am petrified of going to the dentist. I hate going and I’ve had really bad experiences.” “I haven’t been to the dentist since middle school…I probably should have gone, but I just didn’t. We didn’t have insurance and it’s hard to pay for.” “I read somewhere if you drink from other people it can cause gingivitis.” “I’ve noticed when I brush my teeth at night my gums are sore…I thought the blood was from flossing too much.” “I brush my teeth but sometimes I’m too tired”.
- 1) Improving the oral health of the woman will improve the overall health of the woman (such as gingivitis, tooth mobility, tooth erosion, dental pain causing overmedication, etc.). 2) Evidence suggests that most young children acquire caries-causing bacteria from their mothers. No evidence to show that repairing a woman’s dental lesions will reduce numbers/types of oral bacteria in her mouth. 3) Periodontal disease in a pregnant woman may cause preterm and low birth weight babies, but treating pregnant women with periodontal disease has no effect on reducing adverse birth outcomes.
- Only 1/3 of CA women have had a dental visit during pregnancy. (MIHA Study 2002-2007, almost 22,000 responses) Maternal Infant Health Assessment
- 40% of women who did not see a dentist were educated or higher income. 62% with dental problems did not receive care - (74% had Medi-Cal). Dental problems mean red, swollen gums, toothache, cavity, missing fillings, need tooth pulled, loose tooth. 21% lacked a perceived need to get care. (same MIHA Study as previous slide)
- Women were asked to select the main reason for not seeing a dental while pregnant-38% didn’t see a need, 21% had financial reasons (>25% on Medi-Cal sited financial reasons), 19% had attitudinal reasons, 14% thought it unsafe, 8% told it was unsafe by a provider. Do these reasons sound familiar to you? Can we do anything to make a change? (need, safety, provider advice)
- Misinformation, very little training centered around treating pregnant women, fear, reimbursement issues.
- CDA member questionnaire survey in 2008 by Edge Research – random sampling of membership. Approx. 68% of CA dentists are members of CDA.
- What are some of the reasons you have heard why Medi-Cal dentists won’t see pregnant patients? New vs existing (established) patient? Insurance – cuts to Medi-Cal(fees, adult dental benefits, admin. hassles) – Most dentists do not take Medi-Cal, esp. in N. CA. Limited window of time to treat a pregnant woman on Medi-Cal. Costs – low reimbursement for dentists $40 vs. $102(average private insurance fee) for prophy. It now costs over $326,000 to get a dental degree at UCSF, not counting room and board. High office overhead expenses, including administrative costs for Medi-Cal. Fewer than 4000 dentists (25%) in CA that accept Medi-Cal patients. HRC is expected to add 1 million additional children. 4 quads of scaling/root planing – a benefit often disqualified by Denti-Cal. Must have required pocket depths, significant amount of bone loss, presence of calculus deposits, have arch integrity and shall meet “Medi-Cal Dental Program criteria for the requested procedure.” $40 vs $30-$50 per quad depending on number of teeth. Safety concerns for fetus/malpractice. Want medical provider release from prenatal provider prior to treatment.
- -For providers, clients and for public health programs. California does not have an adequate state oral health infrastructure to successfully promote, fund, or coordinate public oral health programs – no oral health “state plan”. In CDPH, the Office of Oral Health was downgraded to a “Unit”. Staffing was reduced from 4-5 with 33 contractors in 2006 to 1 staff today. All state funding was suspended for the children’s dental disease prevention program in July 2009. Denti-Cal Adult dental benefits were cut except for emergency only (FRADS-Federally required adult dental services) in July, 2009. However dental benefits for children under the age of 21 (EPSDT), and certain pregnancy-related services have been retained. Also at the national level – As of August - reduction in HRSA MCHB funding will impact ASDTT funding – a non-profit representing state oral health programs, providing TA on public health programs. ASTDD must reduce by more than 40% its capacity to support perinatal and early childhood programs. ASTDD's Perinatal and Early Childhood Committee provides states with expertise to analyze data and direct early childhood and perinatal oral health activities to encourage the integration of oral health into early childhood and perinatal health programs. ASTDD also supports attendance at comprehensive fluoridation trainings designed for state officials
- IOM report recommendations: Integrating oral health care into overall health care; creating optimal laws and regulations; improving dental education and training ; reducing financial and administrative barriers; and expanding capacity The Pew Children’s Dental Campaign works with states on four efficient, cost-effective solutions: ensure that Medicaid and the Children’s Health Insurance Program – the programs that serve low-income children – work better for kids and for providers so that insurance coverage translates into real access to needed care; expand sealant programs for kids who need them most; help expand access to optimally fluoridated water; expand the number of professionals who can provide dental care to low-income children Pew also produced a report last year addressing workforce issues; Most private-practice dentists who hire new types of dental providers can serve more patients, including Medicaid-enrolled children, while maintaining or improving their financial bottom line. Key findings: In solo private dental practices—where most dentists work—adding new types of providers and dental hygienists produced gains in productivity and increased earnings by a range of 17 to 54 percent. Dentists who operate a practice by themselves can increase their pre-tax profits by six or seven percent by accepting more Medicaid-enrolled children and hiring either a dental therapist or a hygienist-therapist. Children’s Partnership - California Children’s Dental Workforce Campaign: A Project to Increase Access to Dental Care for Children. Documenting gaps in care; Developing a workforce model for underserved children; Seeking collaboration /educating the media; Policy advocacy campaign Next slide for ADA/CDA details
- Quote from the proceedings – consider this question… In a 3-day summit ADA brought together a broad spectrum of stakeholders in order to consolidate information about current efforts focused on improving access to care activities, to develop a coordinated strategy for addressing access to oral health care challenges, and to establish metrics for activities related to the defined strategies. The participants broke up into separate workgroups and came up with short-term and long-term goals that the group could agree one. The topical areas included: Workforce development strategies Reorganization of the dental delivery system Financing models Population-based prevention strategies and strengthening the public health infrastructure Improving oral health literacy through social marketing Collaboration between the medical and dental communities Developing metrics for measuring and defining access Building a sustainable infrastructure for communication and collaboration The summit proceedings is considered a foundation for future efforts.
- “Capacity to provide care for additional families does not currently exist within the dental delivery system in California.” To help meet this need, in November 2008 the CDA House of Delegates directed the association to undertake a comprehensive study aimed at improving access to dental care for underserved populations. Per this directive, the Access Workgroup and the Workforce and Forecasting Research Task Force were created to identify ways to improve access to dental care for the nearly 30 percent of the population that experiences barriers to care while preserving the dental delivery system that serves the majority of Californians. No mention of services for pregnant women but would like to expand adult dental benefits under Medi-Cal CDA has applied for a grant to create a state plan and build infrastructure.
- While all children covered by Medicaid and the Children’s Health Insurance Program (CHIP) have coverage for dental services, ensuring access to these services remains a concern. National oral health goals announced in 2010: To increase the rate of children ages 1-20 enrolled in Medicaid or CHIP who receive any preventive dental service by 10 percentage points over a 5-year period; and • To increase the rate of children ages 6-9 enrolled in Medicaid or CHIP who receive a dental sealant on a permanent molar tooth by 10 percentage points over a 5-year period (this goal will be phased in during year 2 or 3 of the initiative). These goals will be detailed in a “Call to Action” letter to State Health Officials (SHO) and State Medicaid Directors. The letter ( which is delayed) will ask each State to develop specific action plans for submission to CMS that outline strategies for breaking down barriers to oral health for children enrolled in Medicaid or CHIP. The action plans are a tool that States and CMS can use in planning efforts to achieve the goals. CMS will provide technical assistance to States in developing their action plans, which will ultimately be posted on the CMS web site. The CMS’ oral health strategy is designed to support efforts to achieve these goals. States will have 6 months to develop a plan.
- Dentistry is the first medical specialty – separated from Medicine almost 200 years ago in US. Medicine has since become very specialized as well. Oral-systemic connection – heart disease, respiratory disease, diabetes. Bring back OH training and education to non-dental health providers (MDs, nurses, PAs, etc.) – how to prevent oral disease, assess risk, screen for disease, and deliver preventive services such as fluoride varnish. AAP has OH information – two web sites Smiles for Life National Oral Health Curriculum – Module on oral health and the pregnant patient. CA Perinatal OH Guidelines; Prescription forms for dental care from OB provider. We need more oral health advocates.
- Use of Guidelines - CDA member questionnaire survey in 2008 by Edge Research. Despite not feeling particularly informed, majority of dentists believe they are currently utilizing some type of clinical guidelines for pregnant women; and almost all are interested in such guidelines should they be available from a trusted source. Professional organizations/conferences appear to be the best distribution channels for these guidelines. 72% of ACOG members say they currently use guidelines; 85% were likely to use from a trusted source, with 13% somewhat likely.
- Educate the public. Educate the community. Educate the clients. They have to know about services and why they are needed. IOM concluded that oral health literacy of parents is low. Efforts to include: infectious nature of dental caries, effectiveness of fluoride and sealants, role of diet and nutrition, how oral disease affects other health conditions. Can you answer these questions yourself? Ad Council will soon launch a major oral health public awareness campaign over a 3 year period.
- Expand the dental team – New visions of mid-level providers and dental therapists. Teledentistry. Use existing dental professionals with expanded duties. Current California RDHAP model can currently bill Medi-Cal. Need demonstration projects in CA that produce evidence to change SOW. Minnesota’s law allows the creation of two new types of licensed oral health professionals: a dental therapist who will work with a dentist on-site and an advanced dental therapist who will work under a collaborative practice agreement with an off-site dentist. Although dental therapists are not well-known in the lower 48 states, they have been employed by Alaska Native tribes since 2004, and in Great Britain, Canada, New Zealand and many other countries for decades. Organized dentistry is fighting all mid-level provider proposals and demonstration projects doing “irreversible procedures”. ADA proposed community workers. Very difficult for organized dentistry to think in public health terms; the vast majority of members are private practice clinicians. Public health dentists are in favor of mid-level.
- CHDP dental subcommittee – a representative in most LHJs WIC/OH initiative in CA– project with RDHAPs, etc Head Start - AAP was awarded a $3 million contract to run Office of Head Start National Center on Health will focus on health, oral health, mental health and nutrition for pregnant women and children birth to five as well as their families. The Center will be instrumental in disseminating the latest evidence based tools, techniques, and research to local grantees to assist them in providing high quality, comprehensive services to the one million children and their families enrolled in Head Start, Many health departments have home visitation programs. More will soon be implemented through a grant to MCAH. Nurse and paraprofessional visit can provide education. How about risk assessments, screenings, referrals, and even fl varnish applications (which are billable to Medi-Cal for children under 6 years old) Rethink your Drink campaign – recent study of rural Alaskan Native children showed lack of water fluoridation and soda pop consumption were associated with dental caries severity. Smoking, alcohol, meth – cleft lip/smoking association Oral injuries – sports, etc. First 5 – State Level still supporting oral health projects, activities like current fluoridation projects (no new ones) and ‘Drink water, said the otter’.
- Cornerstone to any health program. Treating the existing disease without educating the patient is a wasted opportunity, making it likely that the disease will recur. Influencing behavior of an individual. We have to maximize our dollars. We need to lessen the demand on treatment and increase the demand for prevention. Help parents to help their children. Steps to Take under Health Education Section
- Reduce saliva-sharing behaviors, wipe gums, brush teeth with own toothbrush – use of xylitol, chlorhexidine Reduce sugar (fermentable carbohydrates) in diet, beverages, medicines – baby bottle at night – use of cup – less juice, more whole fruit Fluoride in toothpaste, fluoride treatments, fluoridated water, supplements, rinses
- Recommended brochures for pregnant women.
- Alameda – looking for funding to promote guidelines and recruit dentists to provide services. Imperial/Plumas – educate parents and providers, outreach activities at pre-natal and parenting classes. Siskiyou – kits with toothbrush, paste, floss, brochure, and referral list. Stanislaus – “Teeth Matter” bus ads, CPSP client brochure and Roundtable on OH and pregnancy.