Periodontal Disease and Pre-term Delivery: From Research to Policy

Joan Wightkin: Good morning. So I’ll be talking to you this morning about periodontal disease and pre-term delivery, how we move in Title V from research to practice. Pre-term deliveries and low birth weight, as we’ve heard this morning, are the leading perinatal problem in the U.S. Louisiana has a large share of this problem. We persist in ranking 49^th of all the states in low birth weight with 10.3 percent of our births low birth weight compared to the nation at 7.6%. Thirty-two point five percent of our states population and 41 percent of all births in our state African-American, with large racial disparities in low birth weight, 14.4 percent for African-Americans, and 7 percent for whites. So, of course, prevention of low birth weight in our state is a very, very high priority. We struggle with this all the time. And how we approach the problems is through aggressive outreach for early prenatal care, media campaigns, and outreach workers, smoking cessation programs for pregnant women, public and professional education and information campaigns for adequate weight gain during pregnancy, and gap filling prenatal care, case management, home visiting for low income high risk pregnant women.

More recently, we have looked toward another approach: fighting bacteria. With the recent research in the last few years, it’s really caught our attention and Offenbacher initially showed that there was an impact of periodontal disease on premature delivery, in that women who had more extreme periodontal disease, had a higher risk of pre-term delivery than other women. Offenbacher did a case control study of a 124 pregnant women and found that after controlling for known risk factors, severe periodontal disease was associated with almost eight times increase in the risk of premature delivery. Marjorie Jeffcoat, formerly of the University of Alabama, also showed that generalized periodontitis and premature delivery were related. She did a perspective study of over 1,300 pregnant women and found that those exhibiting signs of periodontitis were 4.5 times more likely to have a pre-term birth than women without periodontal disease. For very pre-term births, those under 32 weeks, the risk among women exhibiting these signs were seven times greater than women without periodontal disease. What is periodontal disease? It’s an oral infection caused by bacteria and plaque that forms on the oral surfaces, and these bacteria have the ability to injure tissue and elicit inflammatory and immune responses. The basic types of periodontal disease are gingivitis, which is an infection of the gums, usually presenting as bleeding or swollen gums, and periodontal disease, an infection that involves all the soft tissue and bony support of teeth, and often the teeth are mobile. Here’s an example of periodontal disease.

So what’s the link? Researchers are focusing on the possibility that periodontal infections interfere with the normal physiological regulation of labor and delivery. Throughout pregnancy, levels of prostaglandins and cytokines steadily increase until the critical threshold level is reached, inducing labor, cervical dilation, and delivery. The bacteria associated with periodontal disease are capable of stimulating excessive production of cytokines and prostaglandins, potentially causing pre-term birth. Now we look at all the data on the relationship and it looks pretty well established that there is a relationship. The next question is, does an intervention work to prevent the problem? And this past August Marjorie Jeffcoat published an article about her randomized controlled study comparing pre-term births of four different groups of women with periodontal disease, and these groups were divided as a dental cleaning or a dental prophylaxis plus a placebo, scaling and root planning, which is the deep below the gum cleaning, plus a placebo, the scaling and root planning plus an antibiotic, and no treatment. And her results showed that those with no treatment had over six percent pre-term delivery rate, those with a cleaning and placebo had almost a five percent, those with the deep cleaning below the gum had less than one percent, and those with the deep cleaning plus an antibiotic had over three percent. We’ve been fortunate enough to hear the research and to learn about this through different mechanisms in the MCH community.

At our Region VI Title V Directors meeting in 2002, Marjorie Jeffcoat presented her work. Around the same time, the Women and Children’s Health Policy Centers at Johns Hopkins issued “Improving Women’s Health and Perinatal Outcomes: The Impact of All Diseases.” And I personally in the last year attended four different presentations by dentists, hygienists, *perinatalogists and so forth on this issue, so it keeps coming out fast and furious. So we took it upon ourself, in Louisiana, to start adding to spreading that word, and last December we held our first oral health summit, which included 125 dentists, hygienists, other health providers, policymakers, head start directors, school nurses, and others, and we strategically selected the Medicaid Director and the Secretary of the Department, which houses Medicaid in the health department, to be speakers at that summit. Our Oral Health Director presented the research on the relationship between periodontal disease and pre-term delivery, and there was very strong interest and we sort of added to that strong interest by talking it up at breaks and at lunch with our Medicaid officials and our department secretary. And by fueling that fire, so to speak, the secretary did invite me to send additional information which we of course put together along with a couple of the key articles. In addition, we’ve put together an oral health policy brief which was the work of Louisiana’s Children’s Oral Health Initiative, which was a coalition of advocates addressing access to oral health services funded by the Head Start Collaboration Project and Title V provided the printing for the distribution. One of the priority recommendations was coverage of dental care for Medicaid eligible women, and was distributed widely to policymakers and legislators in our state. So timing is everything.

We decided we were on a roll; we would setup the meeting after we sent the information to our secretary back in January, but that wasn’t going to happen because we were just going into a legislative session and it was going to be a terrible budget year. As a matter of fact, the state budget presented on February 14 was referred to as the St. Valentines Day Massacre, so nobody wanted to hear about expanding Medicaid. But the legislative session turned out much, much better than expected, and we did have a unique opportunity to talk to the Secretary. Right around that time, our agency--the Health Commissioner changed leadership, and the Secretary attended one of our small staff meetings to show his support for our new Assistant Secretary, and invited us to ask questions. And, you know, since many people had not seen him before, folks were relatively shy, but there were a few of us that said, “You know, this is the time to seize an opportunity,” and we talked about periodontal disease, and he was reminded of it because he had heard it, seen it, and asked his assistant to follow up on it and see what we can do about this problem. The back drop is we’re going through a gubernatorial election in a couple weeks and this particular Secretary has been there for the past eight years and it takes time to build that relationship, so we feel like we’ve got to hurry up in case there’s a change. So within the next day or two, the Secretary did talk to our Medicaid officials, and those folks were really already knowledgeable about this.

They had been to the oral health summit. They had read the reports, some articles, and they really saw this as part of their mandate. They cited this Medicaid regulation that states that mandatory Medicaid coverage for pregnancy related services, and services for other conditions that might threaten the carrying of the fetus to full term. So they really see that this is something that they be irresponsible to not at least consider. So what are the services that are needed? The oral health program recommended that all pregnant mothers receive dental evaluation and oral cleaning during pregnancy. I think we all would agree that that should happen every place, but how many places really is it? And then pregnant women exhibiting signs of periodontal disease should receive the necessary treatment such as deep cleaning and to eliminate or control this disease. So our first step was to conduct a cost analysis and propose a schedule of services, which our oral health program did, estimated the utilization rate, which, I don’t know about other states, but we based it on our EPSDT utilization rate which is around the 30 percent range, and these are children that already have coverage, so it’s not a well-utilized service. And then we projected the Medicaid program cost to cover an oral exam, cleaning, and x-rays, and then to set up some controls for containing costs by having prior authorization for the scaling and root planing, and tooth restoration or extraction as needed. So again we have another fiscal year coming up that will--everyone is extremely nervous. It’s in the newspaper, you know, weekly about how bad the budget could be this coming year as many of you, I’m sure, feel the same way.

And so rather than opening up the service to all pregnant women, it was decided that we would screen those with periodontal problems, those at risk for periodontal disease, and it would be up to the prenatal provider, the OB’s, the nurse midwives, our maternal child health clinics, to find women who had bleeding or swollen gums, loose teeth, inability to chew or swallow, pain, teeth with obvious decay, teeth that appear longer and spaces between teeth that were not there before. So that’s a challenge to try and get this sort of gate keeping approach in place, but we felt like it’s a foot in the door. And really, you know, as you get closer to a fiscal year that looks very bad, you get a little more nervous. So while Medicaid and our Secretary really are interested in doing this service, they want to see that it’s contained, that it’s not only cost neutral but that hopefully there’ll be a savings. And of course, that’s based on the huge Medicaid expenditures in every state related to low birth weight and premature delivery. March of Dimes reports $50,000.00 dollars for the needy and treatment cost for very low birth weight birth, and in Louisiana for our 1,366 very low birth weight births that comes out to about $68 million, which, of course, all the related costs related to the after care for very low birth weight babies really grows and grows. So we’re going to start the program and this is all being decided in really the last few weeks and months is when we’ve started really getting active on this, and the decision has been to have an evaluation plan that tracks all women that are eligible for the service.

And what I mean is that the prenatal provider sending in the bill to Medicaid will need to put as one of the diagnosis codes the periodontal disease. And that pool of women will be the study population and we will compare the birth weights and possibly the cost of treatment for these women, comparing those that got the service and those that did not get the service. But again, for this to just happen in the next few months, have to do an aggressive outreach to dentists and the prenatal providers to make this thing happen. First of all, just to increase knowledge and raise awareness about the importance of dental care during pregnancy, and then inform all the OB’s and nurse midwives and so forth about the process, how they would have to screen and fill out the bill, and so forth. And then to try and reach out to women as they become Medicaid eligible with a pamphlet that tells them about the importance and the safety of receiving dental care during pregnancy and how they can access this service and to ask their provider if they have those 10 conditions that I mentioned earlier. So in summary, how do you move research to practice? In our experience, you know, we keep abreast of the research in the ways that I’ve outlined. Try to select one issue at a time to advocate. Relationship, relationship, relationship; you know, after eight years you feel like you have some good relationships with those folks, you know, maybe the in the last four or five you’re really building, and the last two you have, you know, finally make your mark and get some things in there, and then you have to start over in the next administration. But talking to the policymakers directly if you have a relationship with them, or find someone who’s trusted by that Medicaid Director, by that Department Secretary, and then just keep talking, don’t shut up. In small groups, large forums, get everybody talking about it; your advocates, just everywhere, and then be patient. It takes time, set backs, more set backs; you’ll just have to keep trying. So thank you.