1. Maternal and Pediatric Oral Health Care
Presentation to University of Medical Sciences of Bhutan
Faculty of Nursing and Public Health
March 18, 2015

2. In the US and worldwide, dental caries (tooth decay) is the most common chronic disease of childhood.
Dental caries is almost entirely preventable.
Highly related to lifestyle factors (high sugar diet and protective factors like fluoride, oral hygiene).
Untreated disease results in pain, nutritional problems, poor appearance, malodor, lost school days, other disruption of normal activities.
Socially disadvantaged children are especially vulnerable.
Nearly half of US children 5 to 17 have decayed, missing or filled teeth (DFMT)
51 M lost school days (1989)

3. Oral Health and Global Burden of Disease
Dental caries is a major though declining disease in developed nations and a growing disease in countries with increasing consumption of sugar and inadequate exposure to fluorides.
Survey of child oral health in nine countries showed 65% children had decayed, filled or missing teeth (DFMT), with untreated decay in 47% of children age 1-2 and 97% of children over age 8
Morocco, Cambodia, Greece, Indonesia, Kenya, Myanmar, Vietnam, India, Phillipines--baseline assessment before FDI and Unilever sponsored project

4. Measures Disease prevalence: Access to dental care:
Decayed, missing or filled permanent tooth (DMFT)
Untreated decayed teeth
Access to dental care:
Number of dentists per 1,000 population
Dental services utilization:
Claims for care from a dental care professional, preventive services, treatment
American Dental Association format for claims does not include diagnosis codes

5. Why Oral Health is Important for Mothers and Young Children
Often neglected area of public health policy and health care delivery system
In childhood, oral health has a significant effect on normal growth and development, nutrition, learning and social function.
Periodontal disease may affect birth outcomes.
Oral diseases and chronic diseases share common risk factors
Traditional separation of medical and dental practice may limit effective health promotion
Diamonte Driver
Cardiovascular disease, cancer, chronic respiratory disease, diabetes, obesity

6. Oral Health in Early Childhood

7. BACTERIA + FOOD + TOOTH = DECAY

8. Dental Decay is an Infectious Transmittable Disease
Cariogenic bacteria: Streptococcus mutans
Bacteria is transmitted from mother or caregiver.
Mothers with high levels of bacteria have:
High levels of decay
Poor oral hygiene
High frequency of sugar intake

9. Early Childhood Caries (ECC)
Severe rapidly developing form of tooth decay in infants and young children
Affects teeth that erupt first, at about 6 months, and are least protected by saliva
Formerly called Baby Bottle Tooth Decay or nursing caries

10. Impact of Severe Early Childhood Caries
Extreme pain
Under-nutrition, low weight & height
Spread of infection
Poor self-esteem
Speech development problems
Lost school days and difficulty learning
High risk of dental decay and crooked bite in adult teeth

11. Contributing (Modifiable) Factors
Feeding habits such as high sugar snacks or nighttime bottle formula or juice
Beliefs about child care and teeth:
“Baby teeth are not that important.”
“It is cruel to deny my baby the bottle.”
“The bottle and snacks keep my baby quiet.”
“Decay will happen anyway.”
Changing feeding practices can health prevent other conditions like childhood obesity.

12. Maternal Oral Health

13. Good Oral Health for Mothers
Good oral health is important for pregnant women and for the future health of their children.
A child’s oral health begins in uteroandpoor maternal oral health and malnutrition may may disrupt enamel formation.
Most infants and young children acquire cariogenic bacteria from their mothers during ordinary caregiving.
Gingivitis: inflammatory condition of soft tissues surrounding a tooth or gingiva
Perodontitis: destrux of supporting strux such as ligament, bone, or soft tissues
Gram-negative, anaerobic bacteria mainly
Results of observational studies are mixed
Results of trials with low SES mothers show reduced risk of PT birth, LBW, but non-randomized
However, large body of evidence links infection to adverse outcomes (non-specific role):
Oral mechanical manipulation can cause bacteremia
Chronic periodontal infection can produce transient bacteremia
Local inflammatory process can activate maternal inflammatory response at cellular level and may be involved in preterm labor, etc.
No universally accepted standard for periodontal disease diagnosis
Causal relationship or confounded by other variables such as low SES, smoking, other infections, obesity, other maternal disorders, history of adverse pregnancy outcomes. Studies in Europ and Canada (universal HC) do not find association between disease and outcomes--effect modification?
Maternal health affects infant health, risk of early childhood caries?
Treat during pregnancy and early motherhood—but difficult to find willing providers

14. Physiologic Changes During Pregnancy
Pregnancy gingivitis: increased inflammatory response to dental plaque during pregnancy causing gingivae swell and bleed more easily.
Tooth mobility: Ligaments and bone that support the teeth may loosen during pregnancy
Erosion of tooth enamel: Due to exposure to gastric acid from vomiting due to morning sickness or gastric reflux
Dental caries: Due to increased acidity in the mouth, increased sugar intake (cravings), decreased attention to oral health maintenance

15. Periodontal Disease During Pregnancy
Untreated gingivitis can lead to periodontitis, an inflammatory response in which a film of bacteria (plaque) adheres to teeth and releases bacterial toxins that create pockets of infection in gums and bones.
Studies have linked periodontal disease and preterm birth; however, subsequent studies have not shown any reduction in preterm birth or low birthweight from treating periodontal disease during pregnancy.
Theoretically, blood borne gram negative anaerobic bacteria or inflammatory mediators may be transported to the placental tissues as well as to the uterus and cervix. This results in increased inflammatory modulators that may precipitate preterm labor.

16. Maintaining Good Oral Health In Pregnancy: Advice for Mothers
Practice good oral hygiene (brushing twice daily, flossing daily)
Eat healthy foods.
Get oral health care:
Oral health care is an important component of prenatal care.
Oral health care is safe throughout pregnancy.
Oral hygiene is especially important for those with vomitting, bleeding gums,
Source: Dr. Alex Rose, surgicorps.org

17. Program and Policy Options

18. Strategies for Increasing Access to Oral Health Care
Co-locate dental clinics in medical care facilities.
Locate dental clinics in schools.
Expand dental provider workforce.
Train pediatric primary care providers (doctors and nurses) in providing oral health evaluation and hygiene instruction for patients under 3 and topical therapeutic fluoride varnish application for children at risk for dental caries.
Policy development…
outreach materials
Eff. October 2008

19. Other Options for Improving Oral Health in the Community
Community water fluoridation
Steps to reduce craniofacial injuries from accidents and sports injuries
Reducing smoking
9% of children 3-19 had at least one sealant placed (average 4.4 per child)

20. Oral Health Research

21. Build on Bhutan National Health Survey
Oral health indicators:
Percent who brush teeth at least once a day
Percent have never received dental care
Risk factors for oral disease and other diseases:
Percent who currently smoke
Percent who use smokeless tobacco
Percent who eat doma/betel quid
Percent who use chewing tobacco
Add examination survey to track DFMT prevalence
Add survey questions of child health, nutrition, infant feeding practices
A topic ripe for public health research!
Current smokers: 53.5% smoke on a daily basis
Betal nut, especially when mixed with tobacco, is RF for oral cancers

22. Recommendations for Oral Health Research Agenda
International Association for Dental Research Global Oral Health Inequalities Task Group on Dental Caries recommends that research should:
Integrate health and oral health, using common risk factors
Respond to and influence international developments
Exploit the potential for novel funding partnerships with industry and foundations
Translation of research into policy and practice should be a priority for all.

23. For further information: MaryAlice Lee, Ph.D. Lecturer
Yale School of Public Health
Special thanks to Joanna Douglass DDM, University of Connecticut, and Connecticut Department of Public Health for photos of children with early childhood caries.