Periodontal Disease and Preterm Delivery: From Research to Practice

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Periodontal Disease and Preterm Delivery From
Research to Practice

• Joan Wightkin, DrPH, Director
• Louisiana Title V-MCH Program

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Preterm Low Birth Weight Deliveries

• Preterm deliveries and low birth weight leading
  perinatal problem in the United States.
• Louisiana persists in ranking 49th of all the
  states in low birth weight rate (10.3 Louisiana
  vs 7.6 U.S.)
• 32.5 of the states population and 41 of all
  births are African American with large racial
  disparities in low birth weight 14.4 for
  African Americans and 7.0 for Whites.

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Prevention of Low Birth Weight High Priority in
Louisiana

• Approach the problem by addressing
• Aggressive outreach for early prenatal care
• Smoking cessation programs for pregnant women
• Public and professional education and information
  campaigns for adequate weight gain during
  pregnancy
• Prenatal care, case management, home visiting for
  low income high risk pregnant women

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Another Approach Fight Bacteria

• The potential impact of periodontal diseases on
  premature delivery was initially demonstrated by
  the research of Offenbacher et al. which
  documented that women who have preterm low birth
  weight infants as a result of either preterm
  labor or premature rupture of the membranes tend
  to have more severe periodontal disease than
  mothers of full-term, normal birth weight
  infants.

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Offenbacher, et al Study

• Case control study of 124 pregnant women found
  that after controlling for known risk factors,
  severe periodontitis was associated with a 7.5 to
  7.9 times increase in the risk of premature
  delivery.
• Source Annals of Periodontology, 1998

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Jeffcoat, et al Study

• The University of Alabama Perinatal Emphasis
  Research Center documented an association between
  generalized periodontitis and preterm delivery.
  This prospective study of 1,313 pregnant women
  found that those exhibiting clinical signs of
  generalized periodontitis were 4.5 times more
  likely to have a preterm birth compared with
  women who were periodontally healthy.
• Source Journal of American Dental Association,
  2001

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Jeffcoat Study

• For very preterm births (lt32 weeks), the risk
  among women exhibiting clinical signs of
  generalized periodontitis was 7 times greater
  than that of periodontally healthy women.

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What is Periodontal Disease?

• Periodontal disease is an oral infection caused
  by bacteria in the bio-film (plaque) that forms
  on the oral surfaces.
• These bacteria have the ability to colonize
  sub-gingival plaque and generate by-products that
  directly injure tissue and elicit inflammatory or
  immune responses.

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Basic Types of Periodontal Disease

• Gingivitis infection of the gingival tissues
  (gums surrounding the teeth) usually presents as
  bleeding and/or swollen gums.
• Periodontitis infection that usually involves
  the all the soft tissue and bony support of the
  teeth (often teeth are mobile).

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Whats the Link?

• Researchers are focusing on the possibility that
  periodontal infections interfere with normal
  physiological regulation of labor and delivery.
• Throughout pregnancy, levels of prostaglandins
  and cytokines steadily increase until a critical
  threshold level is reached inducing, labor,
  cervical dilation and delivery.

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Whats the Link?

• The bacteria associated with periodontal disease
  are capable of stimulating excessive production
  cytokines and prostaglandins, potentially causing
  pre-term birth.
• Source Offenbacher, et al., Annals of
  Periodontology, 1998

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Jeffcoat, et al., Intervention Study

• Randomized, controlled study comparing preterm
  births among 4 treatment groups of pregnant women
  with periodontisis
• Dental prophylaxis placebo (N123)
• Scaling and root planing placebo (N123)
• Scaling and root planingantibiotic (N120)
• No treatment (N723)

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Results Preterm Birthsby Treatment
Group(Jeffcoat, et al., J Periodontology, Aug
2003)
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Getting the Word Out

• Marjorie Jeffcoat presented her research at the
  Region VI Title V Directors meeting in 2002
• Womens Childrens Health Policy Center, Johns
  Hopkins School of Public Health issued Improving
  Womens Health Perinatal Outcomes The Impact
  of Oral Diseases
• Heard this research referred to in 4 different
  presentations by dentists, hygienists,
  perinatologists in past year

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Spread the Word

• In December 2002 Oral Health Program held a
  statewide summit on oral health
• 125 dentists, hygienists, other health providers,
  policy makers, Head Start directors, school
  nurses and others attended
• Speakers included the Medicaid Director and the
  Secretary of the Department which houses Medicaid
  and the State Health Department

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Oral Health Summit

• Oral Health Director presented the research on
  the relationship between periodontal disease and
  preterm delivery
• Strong interest and discussion on this issue with
  Medicaid officials and Department Secretary
• Secretary asked Title V Director to send
  additional information on this issue. Summary of
  information sent with articles

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Oral Health Policy Brief

• The work of the Louisiana Childrens Oral Health
  Initiative, a coalition of advocates addressing
  access to oral health services funded by the
  state Head Start Collaboration Project and Title
  V
• Included as priority recommendation coverage of
  dental care for Medicaid eligible pregnant women.
  
• Distributed to state policy makers and legislators

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Timing is Everything

• Attempted to set up a meeting with the DHH
  Secretary after the Oral Health Summit and
  information sent Jan 2003
• Going into legislative session where no one
  wanted to discuss expansion of Medicaidstate
  budget presented on February 14, 2003 was
  referred to as St. Valentines Day Massacre

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Rare Opportunity

• After Legislative session ended with less cuts
  then expected, had an opportunity to raise this
  issue in a health department staff meeting with
  the Secretary.

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Medicaid

• Secretary met with Medicaid officials who support
  adding dental services
• According to 42 CFR 440.210 (a) (2), mandatory
  Medicaid servicesinclude, Pregnancy-related
  services and services for other conditions that
  might complicate the pregnancy. include(s) those
  (services) for diagnoses, illnesses, or medical
  conditions which might threaten the carrying of
  the fetus to full term or the safe delivery of
  the fetus

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What Services Are Needed?

• Oral Health Program recommends all pregnant
  mothers receive a dental evaluation and oral
  prophylaxis during pregnancy.
• Pregnant women exhibiting signs of periodontal
  disease should receive the necessary treatment
  (scaling, root planing) to eliminate and/or
  control this disease.

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Cost Analysis

• Oral Health Program proposed a schedule of
  services, estimated utilization rate by level of
  service, and projected Medicaid Program costs to
  implement this service
• Oral exam, prophylaxis, x-rays
• Prior authorization for
• Scaling and root planing
• Tooth restoration and extraction

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Cost Containment

• Target women with periodontal disease via
  screening/referral process by prenatal provider
• Bleeding or swollen gums
• Loose teeth
• Inability to chew or swallow properly
• Pain
• Teeth with obvious decay
• Teeth that appear longer
• Spaces between teeth that were not there before

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Cost Effectiveness, Savings?

• Large Medicaid expenditures related to low birth
  weight and premature delivery
• March of Dimes reports 50,000 median treatment
  costs per very low birth weight infant
• Estimated at 68 million for the 1366 very low
  birth weight infants annually in Louisiana

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Evaluation Plan

• Track all women eligible for periodontal services
  by prenatal provider (diagnosis code indicated on
  billing form)
• Compare birth weight and gestational age of those
  who accessed dental services vs to those who did
  not by birth certificate linkage

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Outreach to Dentists and Prenatal Providers

• Increase knowledge about the importance of dental
  care during pregnancy for medical providers.
• Inform providers about the screening and referral
  process
• Increase knowledge about the importance and
  safety of dental care during pregnancy for
  patients and how to access this new service.

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Summary Research to Practice

• Keep abreast of research
• Select 1 issue at a time to advocate
• Relationship, relationship, relationship
• Talk to policy makers directly and/or via someone
  trusted by that policy maker
• Keep talkingin small groups and in large forums
• Be patienttakes time and setbacks